Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects

Abstract

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.

Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis

“…The choice of mesh to strengthen the reconstruction of the abdominal wall in all the patients was an acellular porcine dermal matrix (Strattice™). Mesh placement techniques employed in our patient population were: sublay (retro-rectus), underlay (intraperitoneal), onlay or bridge However, since 2017 our group has changed the mesh placement technique from intraperitoneally (underlay) and anterior component separation [18,19] to posterior component separation (PCS) with or without transversus abdominis release (TAR) and sublay (retro-rectus) mesh placement [20][21][22]. During PCS we ensure the sparing of all neurovascular bundles.…”

Fasciocutaneous anterolateral thigh flaps for complex abdominal wall reconstruction after resection of enterocutaneous fistulas and the role of indocyanine green angiography: a pilot study

“…abdominal cavity [3,4]. A biological mesh consists of an extracellular collagen matrix that is gradually replaced with a collagen framework.…”

“…This allows for cellular regeneration, neovascularization and remodulation of the mesh into a neofascia which should withstand mechanical forces. Evidence suggests that biological meshes are less sustainable and are associated with higher abdominal hernia and bulging rates when compared to synthetic material [4]. However, biological meshes are associated with higher salvage rates in cases of infection [5].…”

“…Moreover, component separation may not be sufficient to restore abdominal integrity in large abdominal wall defects. Therefore, autologous tissue flaps are recommended in these cases [4,[7][8][9].…”

New Surgical Strategy for Abdominal Wall Defects. A Successful Swine Model Experiment

“…Due to the high risk of mesh infection or mesh rejection that could lead to dramatic consequences [2]. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds [3].…”