Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy

Abstract

BackgroundHyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy.Materials and methodsAll patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed.ResultsEight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula.ConclusionThe use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.

Systematic review of the stage of innovation of biological mesh for complex or contaminated abdominal wall closure

“…Distribution of IDEAL stage and GRADE quality of included studies are presented in Tables and respectively. Of the four prophylaxis studies, two evaluated biological mesh at the time of stoma closure, one following midline laparotomy after abdominal aortic aneurysm (AAA) repair, and one after cytoreduction and hyperthermic intraperitoneal chemotherapy. All four studies included only elective patients and the degrees of contamination were clean‐contaminated (2) and contaminated (2).…”

Biological mesh is a safe and effective method of abdominal wall reconstruction in cytoreductive surgery for peritoneal malignancy

“…In a series of eight patients undergoing CRS and HIPEC followed by abdominal wall reconstruction with a biological mesh, Boutros and colleagues reported one hernia recurrence during a much shorter follow‐up period of about 6 months. Nunez and co‐workers studied 213 consecutive patients undergoing CRS, HIPEC and abdominal wall reconstruction who had abdominal wall disease.…”

Chemotherapy does not adversely impact outcome following post‐incisional hernia repair with biomaterial mesh

“…The choice of this particular mesh was based on our institutional experience as well as other reports documenting that SIS mesh remodels into vascularized host tissue [13][14][15][16]. The main indication for the use of SIS biomaterial mesh was a contaminated field during gastrointestinal tract surgery or previous wound infection.…”