Prelamination of Vascularized Tensor Fascia Lata for Complex Abdominal Wall Reconstruction

Abstract

There are 2 to 5 million laparotomies performed in the United States annually. Of these, 250,000 to 350,000 will undergo a ventral hernia repair. Repairs are often complicated by recurrence and infection. These risks are significantly increased in previously infected repairs, with reported recurrence rates varying from 17% to 28% after repair of infected ventral hernias, double the rates reported for first-time uninfected repairs. We describe here a novel treatment strategy involving the creation then use of bilateral prelaminated permanent mesh-reinforced tensor fascia latae flaps for abdominal wall reconstruction in patients who have recurrent ventral hernias and had undergone previous repairs complicated by infection. Previous repairs included anterior components separation, thereby making subsequent fascial release techniques and achievement of a reinforced repair extremely unlikely. Three patients were treated by a single surgeon using this 2-stage technique. There have been no incidences of recurrence and no infections after 2 to 10 years. In these patients, the only conventional option would have been a bridged repair with absorbable mesh. Combining the advantages of permanent mesh and well-vascularized autologous tissue optimizes the repair's tensile strength while mitigating the chance of recurrent infection associated with the use of permanent mesh. We propose that this strategy may be an appropriate treatment option for patients with recurrent ventral hernias that have not responded to other conventional modalities of treatment.

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

“…They additionally posit that the deeper layer protects the viscera from inflammation [30]. Another publication describes a two-stage procedure involving the creation of bilateral prelaminated tensor fascia lata flaps reinforced with permanent synthetic mesh during the first stage, and eight weeks later the flaps elevated, tunneled, and inset mesh-up during the second stage [31]. This procedure was performed on three patients who had previously failed reconstructive attempts and purposefully did not include the repair of their rectus fascia [31].…”

“…Another publication describes a two-stage procedure involving the creation of bilateral prelaminated tensor fascia lata flaps reinforced with permanent synthetic mesh during the first stage, and eight weeks later the flaps elevated, tunneled, and inset mesh-up during the second stage [31]. This procedure was performed on three patients who had previously failed reconstructive attempts and purposefully did not include the repair of their rectus fascia [31]. The follow-up for these patients varied between two and ten years but no recurrence or infection occurred over that time; complications included only seroma and wound dehiscence treated successfully with negative pressure wound therapy [31].…”

“…This procedure was performed on three patients who had previously failed reconstructive attempts and purposefully did not include the repair of their rectus fascia [31]. The follow-up for these patients varied between two and ten years but no recurrence or infection occurred over that time; complications included only seroma and wound dehiscence treated successfully with negative pressure wound therapy [31]. The authors attribute their success to vascularized tissue combined with the permanent synthetic mesh, as prior studies have indicated that tensor fascia latae alone are insufficient for lasting repair [31].…”

“…The follow-up for these patients varied between two and ten years but no recurrence or infection occurred over that time; complications included only seroma and wound dehiscence treated successfully with negative pressure wound therapy [31]. The authors attribute their success to vascularized tissue combined with the permanent synthetic mesh, as prior studies have indicated that tensor fascia latae alone are insufficient for lasting repair [31]. A final new technique for consideration is using a fixation-free permanent synthetic mesh placement in the retromuscular plane for defects 15 cm or less in width [32].…”

“…This technique was used to repair large and complex ventral hernias given that prior techniques had recurrence rates anywhere between 20% and 50% [40]. While early studies showed that recurrence rates were less than 10% without the use of mesh, follow-up was limited, and long-term effects were not evaluated [30][31][32][33][34][35][36][37][38][39][40][41][42]. A significant disadvantage of ACS is wound complications from extensive lateral dissection.…”