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Original Article |

Multi-institutional Experience Using Human Acellular Dermal Matrix for Ventral Hernia Repair in a Compromised Surgical Field FREE

Jose J. Diaz Jr, MD; Anne M. Conquest, MD; Steven J. Ferzoco, MD; Daniel Vargo, MD; Preston Miller, MD; Yi-Chen Wu, BS; Rafe Donahue, PhD
[+] Author Affiliations

Author Affiliations: Division of Trauma and Surgical Critical Care, Department of Surgery (Drs Diaz and Conquest), and Department of Biomedical Statistics (Ms Wu and Dr Donahue), Vanderbilt University Medical Center, Nashville, Tennessee; Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Ferzoco); Division of General Surgery, University of Utah Health Science Center, Salt Lake City (Dr Vargo); and Division of Trauma and Surgical Critical Care, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina (Dr Miller).


Arch Surg. 2009;144(3):209-215. doi:10.1001/archsurg.2009.12.
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Published online

Background  A complex ventral hernia repair (CVHR) involves a compromised surgical field where gastrointestinal, biliary, and genitourinary procedures are performed. Complex ventral hernia is a significant problem in trauma, emergency, and elective general surgery in which prosthetic material is contraindicated. In this clinical scenario, primary fascia closure carries a 50% risk of developing a hernia. The other option is a planned ventral hernia with delayed repair.

Hypothesis  Human acellular dermal matrix is a suitable implant for CVHR in a compromised surgical field.

Design  Multi-institutional, 5-year retrospective review.

Setting  Four academic medical centers.

Patients and Methods  Each center obtained institutional review board approval. Patients included in the review had undergone CVHR with human acellular dermal matrix. Data collected included age, body mass index (calculated as weight in kilograms divided by height in meters squared), comorbidities, size of fascial defect, wound classification, hospital length of stay, length of follow-up, and mortality. Primary outcomes were surgical site infection, fistula recurrence, and hernia recurrence. Both χ2 and logistic regression analyses were performed.

Results  Two hundred forty patients met the study criteria. Their mean (SD) age was 52.2 (15.0) years, and 132 (55.0%) were men. The most common comorbidity was hypertension (115 patients [47.9%]), and the mean defect size was 201 cm2. The mean hospital length of stay was 17.2 days, and the mean follow-up was 317 days. The overall mortality was 2.9%. The hernia recurrence rate was 17.1% (41 patients). Repair of a fistula or stoma was associated with hernia recurrence (P = .03) and with fistula recurrence (P < .001). Logistic regression analysis demonstrated surgical site infection and body mass index of greater than 30 to be independent risks of hernia recurrence.

Conclusions  Human acellular dermal matrix is a suitable alternative for CVHR in a compromised surgical field. The hernia recurrence rate with human acellular dermal matrix in a compromised surgical field is less than that seen with primary repair, offering additional and improved surgical options for CVHR in this group of patients. Stoma or fistula takedown at the time of CVHR continues to be associated with significant complications.

Repair of a ventral hernia is one of the most common general surgical procedures. A prosthetic mesh repair during a clean case (ie, with no bacterial contamination) remains the standard of care for optimal long-term results.15 Patient selection and comorbidities are important factors in identifying patients who may be at risk of a recurrent hernia or a complication.6,7 Ventral hernia repair on a patient with significant comorbidities or in conjunction with another surgical procedure, with the potential for bacterial contamination, makes the use of a prosthetic mesh contraindicated.8,9 An infected prosthetic mesh usually needs to be removed and may result in a hernia defect.10,11

An increasing number of patients are surviving surgery performed after trauma or peritonitis that occurs as a result of general surgery.1215 This patient population is at a higher risk of the development of a complex ventral hernia (CVH). There are no classification systems that define a CVH, which can be described as a ventral hernia in a patient with a significant comorbidity or comorbidities or multiple previous operations or hernia repairs; in a patient with a planned ventral hernia after trauma with or without a split-thickness skin graft; or in a patient with a compromised surgical field in which gastrointestinal tract, biliary, or genitourinary procedures might contaminate the surgical field. Patients with an ostomy, infected prosthetic mesh, or an enterocutaneous fistula with or without a hernia represent a surgical dilemma.

The clinical options for treating a patient with actively infected mesh, an ostomy takedown, or repair of an intestinal fistula are limited in terms of performing gastrointestinal tract procedures and a hernia repair during the same operation. One option is to stage the procedures.1315 Initially, the contamination procedure, such as a colostomy takedown, would be performed. One accepts the planned ventral defect to be repaired at a later date. The patient must return 6 to 12 months later to undergo a clean ventral hernia repair. Staging the procedure requires that the patient undergo a temporary hernia repair, undergo 2 anesthetic procedures, and incur the risk involved with 2 surgical procedures. During the recovery period in a patient with a planned ventral hernia, the abdominal muscles begin to contract laterally and that results in the extrusion of the viscera out of the abdominal cavity. This causes the abdominal cavity to get smaller, resulting in loss of abdominal domain. The patient may be unable to return to work or care for his or her family.

Surgical site infection (SSI) remains a serious problem in this patient population. The biomedical industry has introduced biologic mesh that might be better able to tolerate bacterial contamination and have a lower incidence of SSI. Several companies have produced either porcine or human biologic mesh.16 Most are dermal matrixes that have been engineered so that only the biologic scaffolding remains and all of the cellular and immunologic elements have been removed.

We choose to study human acellular dermal matrix (HADM) (LifeCell Corporation, Branchburg, New Jersey) because this product has demonstrated the greatest success in the limited single-site studies to date.1719 Our hypothesis was that HADM is a suitable implant for complex ventral hernia repair (CVHR) in a compromised surgical field.

We performed a multi-institutional, 5-year (December 17, 2002, to January 27, 2006) retrospective study at 4 academic medical centers. Researchers at each center obtained institutional review board approval before beginning the study. Vanderbilt University Medical Center was the lead site, and all data analyses were performed there.

DEFINITIONS AND PATIENTS

A CVH was defined as a recurrent ventral hernia in a compromised surgical field in which gastrointestinal, biliary, and/or genitourinary procedures are performed. Removal of infected mesh and a plan to later repair the ventral hernia with or without a split-thickness skin graft represented a CVH in a compromised surgical field. Ostomy repair was defined as a formal ostomy takedown with a bowel anastomosis. Fistula repair was defined as a formal fistula takedown with a bowel resection and anastomosis.

Patients were included if they underwent a CVHR with HADM. Patients were excluded if they did not undergo repair of a midline, ventral fascial defect, or were prisoners. Human acellular dermal matrix is derived from the dermis of human donors and is harvested at tissue and organ banks. Preparation involves a multistep process in which the epidermis is separated from the dermis and all the cellular and immunologic elements are removed. This leaves a 3-dimensional matrix with all the mucoproteins and vascular channels intact. Via a proprietary process, the matrix is cryopreserved with a shelf-life of 2 years.

DATA COLLECTION

The data collected included age, sex, body mass index (calculated as weight in kilograms divided by height in meters squared), comorbidities, hospital length of stay, length of follow-up, and mortality. The cumulative size of the implants was used to estimate the size of the ventral defect. The clinical scenario during the procedure was divided into trauma, emergency general surgery, and elective general surgery.

From a procedural standpoint, wound classification, suture type, and repair type were recorded. There were 4 types of repair performed: (1) interpositional (the edge of the mesh was sewn directly to the edge of the fascia), (2) onlay (mesh was laid onto the fascia with 3-5 cm of overlap), (3) inlay (mesh was placed under the fascia with 3-5 cm of underlay from the fascial edge), and (4) component separation. Component separation was performed using either a separation of parts or an open book technique of the myofascial component and advancement of the components medially. Human acellular dermal matrix was used for additional support as an onlay repair of the fascial relaxing incisions and/or an underlay. If a fascial defect remained, the repair type was then a bridge technique (interposition, onlay, or underlay). Closed suction drains were universally used in potential spaces. The clinical examination at follow-up was used to determine hernia recurrence (HR).

PRIMARY AND SECONDARY OUTCOMES

Primary outcomes were SSI, fistula recurrence, and HR. Secondary outcomes included other infectious complications (urinary tract infections, bloodstream infections, and ventilator-associated pneumonia), wound dehiscence, seroma formation (a sterile postoperative fluid collection in the subcutaneous layers), and days receiving ventilator support. Surgical site infections included only wound infections. Intra-abdominal abscesses were recorded separately. The Centers for Disease Control and Prevention National Nosocomial Infections Surveillance definitions for SSI, urinary tract infection, bloodstream infection, and ventilator-associated pneumonia were used.

A complete data set of study variables was not available for all patients owing to the retrospective nature of the study and the multiple study sites.

STATISTICAL ANALYSIS

Data analysis was performed using χ2 test. Statistical significance was considered at P < .05. Logistic regression analysis was performed to identify the independent risk of HR for comorbidities. Multivariate logistic regression models were performed to determine the odds of HR, SSI, and fistula using PROC LOGISTIC in SAS version 9.1 (SAS Institute Inc, Cary, North Carolina). All intra-abdominal procedures were grouped and compared with ventral hernia repair only. Point estimates and 95% confidence intervals for odds ratios were reported. Confidence intervals not crossing unity were considered statistically significant.

There were 240 patients who met study criteria. Their mean (SD) age was 52.2 (15.0) years, and 132 (55.0%) were men. Of the 240 patients, 190 (79.2%) underwent an additional surgical procedure (Table 1). In this study population, none of the comorbidities were statistically significant in terms of risk for HR or SSI. Fifty-one (21.3%) of the 240 patients underwent removal of old mesh, and 40 (16.7%) underwent removal of a split-thickness skin graft. The mean (SD) hospital length of stay was 17.2 (20.9) days. There were 165 patients (68.7%) who had follow-up data, with a mean follow-up of 317 days (range [SD], 9-1161 [269] days).

Table Graphic Jump LocationTable 1. Details of 240 Study Operative Procedures

The overall mortality was 2.9% (7 of 240). Four deaths occurred in patients who underwent emergency general surgery, 2 deaths occurred after elective surgery, and 1 death occurred in a trauma patient. Mortality during elective surgery occurred in patients who underwent successive attempts at repair of multiple atmospheric enterocutaneous fistulas (Table 2).

Table Graphic Jump LocationTable 2. Demographics of 240 Study Patients

The mean (SD) defect size was 201 (155) cm2 (median, 168; range, 21-896). When the defect size was divided into quartiles, there was no statistical significance in the rate of HR or SSI (Table 3).

Table Graphic Jump LocationTable 3. Defect Size Analysis by Quartiles in Relation to Hernia Recurrence (HR) and Surgical Site Infection (SSI)

The overall HR rate for the study was 17.1% (41 of 240). Most of the HRs occurred in patients in whom an additional procedure was performed (33 of 41 [80.5%]). Hernia recurrence was associated with a body mass index of greater than 30 (P = .02), mesh removal (P = .048), or ostomy or enterocutaneous fistula repair (P = .03). Postoperative factors associated with HR were SSI (P = .003) and fistula formation (P = .005). Component separation repair type had the lowest HR (2 of 31 [6.5%]), and inlay (17 of 91 [18.7%]), onlay (4 of 28 [14.3%]), and interpositional mesh repairs had the highest recurrence (18 of 89 [20.2%]), but these results did not reach statistical significance (P = .46). There was 1 patient for whom the repair type was unknown (Table 4).

Table Graphic Jump LocationTable 4. Risk Associated With 41 Hernia Recurrences

Surgical site infections occurred in 96 of the patients (40.0%). Surgical site infection was associated with the repair type (interpositional mesh repair; P = .003) and wound classification (clean-contaminated; P = .01) (Table 5).

Table Graphic Jump LocationTable 5. Risk Associated With 96 Surgical Site Infections (SSIs)

There were 28 postoperative fistulas (11.6%) among the 240 study patients. The fistulas occurred in the setting of ostomy or enterocutaneous fistula repairs (18 patients), bowel procedures (5 patients), and ventral hernia repair only (5 patients). Of the 5 cases of ventral hernia repair only, 1 patient underwent removal of old mesh. Fistula formation was associated with an ostomy or enterocutaneous fistula repairs (P < .001) and with removal of a split-thickness skin graft (P = .048) (Table 6).

Table Graphic Jump LocationTable 6. Risk Associated With 28 Fistula Formations (FFs)

Regarding other complications, postoperative ileus (34 of 240 [14.2%]) and wound seroma (31 of 240 [12.9%]) were the most common. Twenty-three of the 240 patients (9.6%) developed an intra-abdominal abscess, with 18 of the 23 abscesses (78.3%) occurring in cases in which a bowel procedure was performed. If an intra-abdominal abscess and a fistula developed, they were only counted as fistulas. There were 58 patients (24.2%) who required more than 1 day of ventilator support, with a mean (SD) of 4 (13) days receiving ventilator support. All of the pneumonia complications occurred in patients who required mechanical ventilation, except for 1 case (Table 7).

Logistic regression analysis was used to identify risk factors for HR. Body mass index greater than 30, SSI, and ostomy or fistula repair were independently associated with the development of an HR. Wound classification was associated with SSI. Ostomy or fistula repair and removal of a split-thickness skin graft during a planned ventral hernia were independent risk factors for fistula formation (Table 8).

Table Graphic Jump LocationTable 8. Multivariate Logistic Regression Analysis of Hernia Recurrence, Surgical Site Infection, and Fistula Formation

The repair of a CVH has baffled surgeons for many years, and the standard of care continues to require the use of prosthetic mesh.15,2022 Prosthetic mesh in a compromised surgical field is considered by many surgeons to be a contraindication.10,11 The wound infection rate is higher, and infection of a prosthetic mesh is a serious clinical problem.10,11 The clinical options when faced with such a scenario are to stage the procedures by initially performing the bowel procedure and then, at a later date, to repair the hernia defect.1215 Others have had success with the use of polypropylene mesh in ventral hernia repairs with an elective bowel procedure.21,22 However, polypropylene mesh is known to have the highest fistula formation of any prosthetic mesh, and the formation of a fistula can occur many years later.23,24

Recently, the biomedical industry has developed several biologic meshes for the repair of a ventral defect. Human and porcine matrixes have been the most common sources. We choose to study HADM because it most closely resembles the properties of native fascia.25 Once the matrix is implanted, it becomes revascularized into the wound with angiogenesis, bringing in the necessary fibroblasts to begin the incorporation process.2628 The process of early angiogenesis is thought to provide the matrix with the abilities to clear local bacterial contamination and to resist infection.

Only HADM has been demonstrated in animal models to allow adequate fibroblast infiltration with resultant angiogenesis into the matrix.29 Other porcine matrix demonstrates higher fibroblast proliferation but limited infiltration into the matrix.27,28 This seems to be more specific to the porcine matrixes that have been permanently cross-linked.30 There is still concern that a xerograph dermal matrix implant will elicit an antibody response, which could result in rejection.31

Our study population reflects an extremely complex group of patients; only 5.6% of the cases were clean cases (ie, no baterial contamination), 50% of the study group had at least 1 comorbidity, and 70% underwent an additional surgical procedure other than the hernia repair. Yet, the mortality was only 2.9%. In our study population, comorbidity did not demonstrate increased risk of HR or SSI, but patients with diabetes mellitus and morbid obesity are known to carry an increased risk of complications.5,6,32

The SSI rate in this population was 40%, which is high. The most recent Centers for Disease Control and Prevention National Nosocomial Infections Surveillance Report (1999-2004) of infection rates in elective ventral hernia repairs without bowel procedures gives a range of 1% to 3.8%, and colorectal procedures are listed in the range of 3.98% to 11.25% for SSIs,33 although dirty cases (with gross bacterial contamination) or infected cases historically have infection rates well above 50%. Recently, antibiotic studies for SSIs have provided more reliable data. For example, the PREVENT trial had an SSI rate, in elective colorectal surgery, in the range of 18% to 30%.34 Yet, even with our high infection rate for the study, the HR rate was only 17%. Our regression analysis demonstrated that SSI was an independent risk factor for HR. In general, SSI is a known risk factor of the development of a hernia in all laparotomies.6

The fistula recurrence for this population is high (12%). The study was not designed to tell if a biologic mesh contributed to the development of a fistula. Most of the fistulas (18 of 28 [64.2%]) occurred during an ostomy or a fistula repair. The group of concern is the 5 patients with postoperative fistula formation who underwent a hernia repair only. In review of the cases, 2 were trauma cases and 1 was an emergency general surgery case. The 2 elective cases in which a fistula occurred could be attributable to either a missed enterotomy or technical problem.

The HR rate for the study was 17%. These results are similar to the recently published reports with HADM.1719 The short follow-up period and the low follow-up rate for this patient population do not allow for an accurate assessment of long-term success. The study did confirm that like prosthetic mesh repairs, ostomy, fistula repair, SSI, and obesity (body mass index of >30) are independent risk factors for early HR.6,32

The ability to combine a ventral hernia repair and a “contaminated” procedure into 1 anesthetic procedure and a single hospital stay is extremely attractive. From the patient's perspective, recovering from 1 procedure, as opposed to 2, and returning to functional status are much more attractive. The study demonstrated that 123 of the 240 patients (51.2%) did not have an SSI, postoperative fistula, or HR in this complex patient population.

The question that has arisen from our study is, “Is there a subpopulation of patients for whom staging the repair of contaminated procedures and, at a later date, performing a ventral hernia repair is the better option?” Our study was not designed to answer this question, but clearly, owing to the high SSI and fistula formation rates, there is a group of patients for whom one should consider a staged approach.

STUDY STRENGTHS

There are several strengths to our study. It is a multi-institutional study with the study sites selected for their academic focus, large clinical experience with this complex patient population, and clinical expertise using the various available biologic mesh implants other than HADM for hernia repair. Our study is, to our knowledge, the largest series to date to study a complex patient population and the use of HADM for hernia repair. In addition, the results in this study parallel those seen in earlier single-site reports using HADM.1719

STUDY LIMITATIONS

There are several weaknesses to our study. This is a retrospective review with all the inherent associated problems. The multiple sites, multiple surgeons, and heterogeneity of the patient population make it difficult to accurately classify the results. In addition, the repair types and the suture used vary to the degree that HR rates are difficult to analyze. The trauma and emergency general surgery patient populations are known to have poor follow-up and resulted in incomplete study data capture. The clinical examination for defining an HR may have resulted in bias. Some of these “recurrences” could have been better defined as laxity of the repair vs a true hernia.

The study was not designed to examine the issue of laxity of the abdominal wall repair. Laxity of the abdominal repair has been described in the literature.35 Many of the early series of ventral hernia repairs with HADM were performed during an acute illness. At this point, the patient has gained a significant amount of weight owing to the volume resuscitation and lost domain of the abdominal cavity.36 Laxity of the repair can later develop into a problem when the patient has improved clinically and loses the weight. Human acellular dermal matrix does not elicit as significant an inflammatory response as do other porcine or prosthetic implants because minimal wound contracture occurs.37,38 Laxity of the repair should be an almost expected result. Also, during the implantation, HADM must be placed on a great deal of tension. This is contrary to ventral hernia repair with a prosthetic mesh. If the elasticity in HADM is inadequately addressed during the repair, laxity of the repair may occur.

This study describes the early 5-year history of HADM for the repair of CVHR. Patient selection, operative techniques, postoperative complications, and follow-up assessments have continued to be refined. Yet, in a field where the available data are severely lacking, this study begins to define the scope of the problem and the areas of future study.

In conclusion, HADM is a suitable alternative for the CVHR in a compromised surgical field. The HR rate with HADM in a compromised surgical field is less than that seen with primary repair, offering additional and improved surgical options for CVHR in this group of patients. Ostomy or fistula takedown at the time of CVHR continues to be associated with significant complications. A randomized, multi-institutional study is needed to help define the patient who would best benefit from the use of HADM for the repair of a CVH and the best operative technique to use.

Correspondence: Jose J. Diaz, Jr, MD, Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 404 Medical Arts Bldg 1211, 21st Ave S, Nashville, TN 37212 (jose.diaz@vanderbilt.edu).

Accepted for Publication: February 9, 2008.

Author Contributions: Drs Diaz, Conquest, and Miller had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Diaz and Vargo. Acquisition of data: Conquest, Ferzoco, Vargo, and Miller. Analysis and interpretation of data: Diaz, Conquest, Ferzoco, Wu, and Donahue. Drafting of the manuscript: Diaz, Conquest, Wu, and Donahue. Critical revision of the manuscript for important intellectual content: Diaz, Conquest, Ferzoco, Vargo, and Miller. Statistical analysis: Wu and Donahue. Administrative, technical, and material support: Diaz, Conquest, Vargo, and Miller. Study supervision: Diaz and Ferzoco.

Financial Disclosure: Drs Diaz and Vargo reported receiving research support and honoraria for speaking on behalf of LifeCell Corporation and for teaching courses on the use of their biologic matrix. Dr Ferzoco reported receiving consulting fees from LifeCell Corporation

Previous Presentation: This study was presented at the 115th Scientific Session of the Western Surgical Association; November 4-7, 2007; Colorado Springs, Colorado.

Le  HBender  JS Retrofascial mesh repair of ventral incisional hernias. Am J Surg 2005;189 (3) 373- 375
PubMed Link to Article
Chrysos  EAthanasakis  ESaridaki  Z  et al.  Surgical repair of incisional ventral hernias: tension-free technique using prosthetic materials (expanded polytetrafluoroethylene Gore-Tex Dual Mesh). Am Surg 2000;66 (7) 679- 682
PubMed
Bauer  JJHarris  MTGorfine  SRKreel  I Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients [published online July 13, 2002] Hernia 2002;6 (3) 120- 123
PubMed Link to Article
Bauer  JJHarris  MTKreel  IGelernt  IM Twelve-year experience with expanded polytetrafluoroethylene in the repair of abdominal wall defects. Mt Sinai J Med 1999;66 (1) 20- 25
PubMed
Vidović  DJurisić  DFranjić  BDGlavan  ELedinsky  MBekavac-Beslin  M Factors affecting recurrence after incisional hernia repair [published online May 17, 2006] Hernia 2006;10 (4) 322- 325
PubMed Link to Article
Hesselink  VJLuijendijk  RWde Wilt  JHHeide  RJeekel  J An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176 (3) 228- 234
PubMed
Burger  JWLuijendijk  RWBurger  JW  et al.  Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240 (4) 578- 585
PubMed
Basoglu  MYildirgan  MIYilmaz  I  et al.  Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 2004;104 (4) 425- 428
PubMed
Leber  GEGarb  JLAlexander  AIReed  WP Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133 (4) 378- 382
PubMed Link to Article
Diaz  JJ  JrGray  BWDobson  JM  et al.  Repair of giant abdominal hernias: does the type of prosthesis matter? Am Surg 2004;70 (5) 396- 402
PubMed
Paton  BLNovitsky  YWZerey  MSing  RFKercher  KWHeniford  BT Management of infections of polytetrafluoroethylene-based mesh. Surg Infect (Larchmt) 2007;8 (3) 337- 341
PubMed Link to Article
Fabian  TC Damage control in trauma: laparotomy wound management acute to chronic. Surg Clin North Am 2007;87 (1) 73- 93, vi
PubMed Link to Article
Jernigan  TWFabian  TCCroce  MA  et al.  Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003;238 (3) 349- 357
PubMed
Fabian  TCCroce  MAPritchard  FE  et al.  Planned ventral hernia: staged management for acute abdominal wall defects. Ann Surg 1994;219 (6) 643- 653
PubMed Link to Article
Cohen  MMorales  R  JrFildes  JBarrett  J Staged reconstruction after gunshot wounds to the abdomen. Plast Reconstr Surg 2001;108 (1) 83- 92
PubMed Link to Article
Buinewicz  BRosen  B Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair. Ann Plast Surg 2004;52 (2) 188- 194
PubMed Link to Article
Kim  HBruen  KVargo  D Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg 2006;192 (6) 705- 709
PubMed Link to Article
Diaz  JJ  JrGuy  JBerkes  MBGuillamondegui  OMiller  RS Acellular dermal allograft for ventral hernia repair in the compromised surgical field. Am Surg 2006;72 (12) 1181- 1188
PubMed
Patton  JH  JrBerry  SKralovich  KA Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg 2007;193 (3) 360- 363
PubMed Link to Article
Alaedeen  DILipman  JMedalie  DRosen  MJ The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields [published online November 28, 2006] Hernia 2007;11 (1) 41- 45
PubMed Link to Article
Kelly  MEBehrman  SW The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg 2002;68 (6) 524- 529
PubMed
Birolini  CUtiyama  EMRodrigues  AJ  JrBirolini  D Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 2000;191 (4) 366- 372
PubMed Link to Article
Halm  JAde Wall  LLSteyerberg  EWJeekel  JLange  JF Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg 2007;31 (2) 423- 430
PubMed Link to Article
Chew  DKChoi  LHRogers  AM Enterocutaneous fistula 14 years after prosthetic mesh repair of a ventral incisional hernia: a life-long risk? Surgery 2000;127 (3) 352- 353
PubMed Link to Article
Winkler  AAMilburn  MLHolton  LT  IIIGoldberg  NHSilverman  RP Effect of suture material on tensile strength and complication rate in abdominal fascial defects repaired with acellular dermal matrix Hernia 2008;12 (1) 33- 38
Link to Article
Silverman  RPLi  ENHolton  LH  IIISawan  KTGoldberg  NH Ventral hernia repair using allogenic acellular dermal matrix in a swine model. Hernia 2004;8 (4) 336- 342
PubMed Link to Article
Armour  ADFish  JSWoodhouse  KASemple  JL A comparison of human and porcine acellularized dermis: interactions with human fibroblasts in vitro. Plast Reconstr Surg 2006;117 (3) 845- 856
PubMed Link to Article
Helary  CFoucault-Bertaud  AGodeau  GCoulomb  BGuille  MM Fibroblast populated dense collagen matrices: cell migration, cell density and metalloproteinases expression. Biomaterials 2005;26 (13) 1533- 1543
PubMed Link to Article
Menon  NGRodriguez  EDByrnes  CKGirotto  JAGoldberg  NHSilverman  RP Revascularization of human acellular dermis in full-thickness abdominal wall reconstruction in the rabbit model. Ann Plast Surg 2003;50 (5) 523- 527
PubMed Link to Article
Jarman-Smith  MLBodamyali  TStevens  CHowell  JAHorrocks  MChaudhuri  JB Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation. J Mater Sci Mater Med 2004;15 (8) 925- 932
PubMed Link to Article
Ansaloni  LCambrini  PCatena  F  et al.  Immune response to small intestinal submucosa (surgisis) implant in humans: preliminary observations. J Invest Surg 2007;20 (4) 237- 241
PubMed Link to Article
Anthony  TBergen  PCKim  LT  et al.  Factors affecting recurrence following incisional herniorrhaphy. World J Surg 2000;24 (1) 95- 101
PubMed Link to Article
National Nosocomial Infections Surveillance System, National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004 Am J Infect Control 2004;32 (8) 470- 485
PubMed Link to Article
Itani  KMWilson  SEAwad  SSJensen  EHFinn  TSAbramson  MA Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006;355 (25) 2640- 2651
PubMed Link to Article
Gupta  AZahriya  KMullens  PLSalmassi  SKeshishian  A Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm Hernia 2006;10 (5) 419- 425[published online ahead of print August 22, 2006]
PubMed Link to Article
Scott  BGWelsh  FJPham  HQ  et al.  Early aggressive closure of the open abdomen. J Trauma 2006;60 (1) 17- 22
PubMed Link to Article
Truong  ATKowal-Vern  ALatenser  BAWiley  DEWalter  RJ Comparison of dermal substitutes in wound healing utilizing a nude mouse model [published online March 14, 2005]. J Burns Wounds 2005;4e4
PubMed
Walden  JLGarcia  HHawkins  HCrouchet  JRTraber  LGore  DC Both dermal matrix and epidermis contribute to an inhibition of wound contraction. Ann Plast Surg 2000;45 (2) 162- 166
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Details of 240 Study Operative Procedures
Table Graphic Jump LocationTable 2. Demographics of 240 Study Patients
Table Graphic Jump LocationTable 3. Defect Size Analysis by Quartiles in Relation to Hernia Recurrence (HR) and Surgical Site Infection (SSI)
Table Graphic Jump LocationTable 4. Risk Associated With 41 Hernia Recurrences
Table Graphic Jump LocationTable 5. Risk Associated With 96 Surgical Site Infections (SSIs)
Table Graphic Jump LocationTable 6. Risk Associated With 28 Fistula Formations (FFs)
Table Graphic Jump LocationTable 8. Multivariate Logistic Regression Analysis of Hernia Recurrence, Surgical Site Infection, and Fistula Formation

References

Le  HBender  JS Retrofascial mesh repair of ventral incisional hernias. Am J Surg 2005;189 (3) 373- 375
PubMed Link to Article
Chrysos  EAthanasakis  ESaridaki  Z  et al.  Surgical repair of incisional ventral hernias: tension-free technique using prosthetic materials (expanded polytetrafluoroethylene Gore-Tex Dual Mesh). Am Surg 2000;66 (7) 679- 682
PubMed
Bauer  JJHarris  MTGorfine  SRKreel  I Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients [published online July 13, 2002] Hernia 2002;6 (3) 120- 123
PubMed Link to Article
Bauer  JJHarris  MTKreel  IGelernt  IM Twelve-year experience with expanded polytetrafluoroethylene in the repair of abdominal wall defects. Mt Sinai J Med 1999;66 (1) 20- 25
PubMed
Vidović  DJurisić  DFranjić  BDGlavan  ELedinsky  MBekavac-Beslin  M Factors affecting recurrence after incisional hernia repair [published online May 17, 2006] Hernia 2006;10 (4) 322- 325
PubMed Link to Article
Hesselink  VJLuijendijk  RWde Wilt  JHHeide  RJeekel  J An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176 (3) 228- 234
PubMed
Burger  JWLuijendijk  RWBurger  JW  et al.  Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240 (4) 578- 585
PubMed
Basoglu  MYildirgan  MIYilmaz  I  et al.  Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 2004;104 (4) 425- 428
PubMed
Leber  GEGarb  JLAlexander  AIReed  WP Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133 (4) 378- 382
PubMed Link to Article
Diaz  JJ  JrGray  BWDobson  JM  et al.  Repair of giant abdominal hernias: does the type of prosthesis matter? Am Surg 2004;70 (5) 396- 402
PubMed
Paton  BLNovitsky  YWZerey  MSing  RFKercher  KWHeniford  BT Management of infections of polytetrafluoroethylene-based mesh. Surg Infect (Larchmt) 2007;8 (3) 337- 341
PubMed Link to Article
Fabian  TC Damage control in trauma: laparotomy wound management acute to chronic. Surg Clin North Am 2007;87 (1) 73- 93, vi
PubMed Link to Article
Jernigan  TWFabian  TCCroce  MA  et al.  Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003;238 (3) 349- 357
PubMed
Fabian  TCCroce  MAPritchard  FE  et al.  Planned ventral hernia: staged management for acute abdominal wall defects. Ann Surg 1994;219 (6) 643- 653
PubMed Link to Article
Cohen  MMorales  R  JrFildes  JBarrett  J Staged reconstruction after gunshot wounds to the abdomen. Plast Reconstr Surg 2001;108 (1) 83- 92
PubMed Link to Article
Buinewicz  BRosen  B Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair. Ann Plast Surg 2004;52 (2) 188- 194
PubMed Link to Article
Kim  HBruen  KVargo  D Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg 2006;192 (6) 705- 709
PubMed Link to Article
Diaz  JJ  JrGuy  JBerkes  MBGuillamondegui  OMiller  RS Acellular dermal allograft for ventral hernia repair in the compromised surgical field. Am Surg 2006;72 (12) 1181- 1188
PubMed
Patton  JH  JrBerry  SKralovich  KA Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg 2007;193 (3) 360- 363
PubMed Link to Article
Alaedeen  DILipman  JMedalie  DRosen  MJ The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields [published online November 28, 2006] Hernia 2007;11 (1) 41- 45
PubMed Link to Article
Kelly  MEBehrman  SW The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg 2002;68 (6) 524- 529
PubMed
Birolini  CUtiyama  EMRodrigues  AJ  JrBirolini  D Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 2000;191 (4) 366- 372
PubMed Link to Article
Halm  JAde Wall  LLSteyerberg  EWJeekel  JLange  JF Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg 2007;31 (2) 423- 430
PubMed Link to Article
Chew  DKChoi  LHRogers  AM Enterocutaneous fistula 14 years after prosthetic mesh repair of a ventral incisional hernia: a life-long risk? Surgery 2000;127 (3) 352- 353
PubMed Link to Article
Winkler  AAMilburn  MLHolton  LT  IIIGoldberg  NHSilverman  RP Effect of suture material on tensile strength and complication rate in abdominal fascial defects repaired with acellular dermal matrix Hernia 2008;12 (1) 33- 38
Link to Article
Silverman  RPLi  ENHolton  LH  IIISawan  KTGoldberg  NH Ventral hernia repair using allogenic acellular dermal matrix in a swine model. Hernia 2004;8 (4) 336- 342
PubMed Link to Article
Armour  ADFish  JSWoodhouse  KASemple  JL A comparison of human and porcine acellularized dermis: interactions with human fibroblasts in vitro. Plast Reconstr Surg 2006;117 (3) 845- 856
PubMed Link to Article
Helary  CFoucault-Bertaud  AGodeau  GCoulomb  BGuille  MM Fibroblast populated dense collagen matrices: cell migration, cell density and metalloproteinases expression. Biomaterials 2005;26 (13) 1533- 1543
PubMed Link to Article
Menon  NGRodriguez  EDByrnes  CKGirotto  JAGoldberg  NHSilverman  RP Revascularization of human acellular dermis in full-thickness abdominal wall reconstruction in the rabbit model. Ann Plast Surg 2003;50 (5) 523- 527
PubMed Link to Article
Jarman-Smith  MLBodamyali  TStevens  CHowell  JAHorrocks  MChaudhuri  JB Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation. J Mater Sci Mater Med 2004;15 (8) 925- 932
PubMed Link to Article
Ansaloni  LCambrini  PCatena  F  et al.  Immune response to small intestinal submucosa (surgisis) implant in humans: preliminary observations. J Invest Surg 2007;20 (4) 237- 241
PubMed Link to Article
Anthony  TBergen  PCKim  LT  et al.  Factors affecting recurrence following incisional herniorrhaphy. World J Surg 2000;24 (1) 95- 101
PubMed Link to Article
National Nosocomial Infections Surveillance System, National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004 Am J Infect Control 2004;32 (8) 470- 485
PubMed Link to Article
Itani  KMWilson  SEAwad  SSJensen  EHFinn  TSAbramson  MA Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006;355 (25) 2640- 2651
PubMed Link to Article
Gupta  AZahriya  KMullens  PLSalmassi  SKeshishian  A Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm Hernia 2006;10 (5) 419- 425[published online ahead of print August 22, 2006]
PubMed Link to Article
Scott  BGWelsh  FJPham  HQ  et al.  Early aggressive closure of the open abdomen. J Trauma 2006;60 (1) 17- 22
PubMed Link to Article
Truong  ATKowal-Vern  ALatenser  BAWiley  DEWalter  RJ Comparison of dermal substitutes in wound healing utilizing a nude mouse model [published online March 14, 2005]. J Burns Wounds 2005;4e4
PubMed
Walden  JLGarcia  HHawkins  HCrouchet  JRTraber  LGore  DC Both dermal matrix and epidermis contribute to an inhibition of wound contraction. Ann Plast Surg 2000;45 (2) 162- 166
PubMed Link to Article

Correspondence

CME


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