Revising Recommendations and Outcome Measurements after Complex Open Abdominal Wall Reconstruction

Abstract

Grading systems developed by the Ventral Hernia Working Group (VHWG) for complex open abdominal wall reconstruction rely on limited outcomes: surgical site occurrence (SSO) and hernia recurrence. This does not account for the longitudinal restoration of a functional abdominal wall and the ability to correct complications. We performed a single-site, retrospective review of consecutive complex open abdominal wall reconstruction interventions with 24-month minimum follow-up to establish reoperation rates and compare long-term results to the VHWG. About 125 midline hernia repairs (>200 cm2) were studied. All had loss of functional domain and 47-month average follow-up. Demographics included: mean age 57 years, 47 per cent male, 63 per cent obese, and 34 per cent with contamination. Rates of SSO per VHWG grade were 9 per cent grade I, 45 per cent grade II, and 55 per cent grade III. Forty-three of 59 patients who developed complications were eventually successful after reoperation leading to an 87 per cent restoration rate. Select factors independently associated with reoperation included biological mesh and clinical history of infection. Although rates of SSO were higher than the VHWG published, we experienced high salvage rates except in patients who underwent biologic repair. We recommend restricted use of biologic mesh in contaminated and clean fields as well as modifications to the VHWG grading and recommendations.

What Exactly is Meant by “Loss of Domain” for Ventral Hernia? Systematic Review of Definitions

“…Sixty-five articles described LOD in the context of ventral hernia patients, 9 articles described LOD caused by giant inguinal hernia, and 3 articles described giant diaphragmatic hernia. Sixty-seven articles were from the primary literature, comprising 44 case series, 17 case reports, 4 retrospective database analyses [ 18 , 33 – 35 ], and 2 retrospective interventional studies [ 36 ] [ 30 ]. Ten articles were from the secondary literature comprising seven editorials, two systematic reviews [ 20 , 37 ] and one consensus questionnaire [ 11 ].…”

Budget Impact Analysis of a Biosynthetic Mesh for Incisional Hernia Repair

“…Wounds classified as CDC class I (clean) may be classified as VHWG 2012 grade 1 (clean cases; no comorbidity) or 2 (clean cases + comorbidity, history of infection), while CDC clean-contaminated, contaminated, and infected wounds would be VHWG 2012 grade 3. 12 The VHWG 2010 classification suggests the use of synthetic mesh for low-risk defects (grade 1) and biological mesh for higher-risk defects (grade 2) and contaminated or infected wounds (grades 3 and 4). However, given the significantly higher acquisition cost of biological meshes compared to synthetic ones, often there is a shift toward choosing synthetic mesh even in case of wound contamination.…”

Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates

“…It has been suggested that combining these grades and stratifying contamination according to the Centers for Disease Control classification of wound contamination scale improves the accuracy of prediction of wound morbidity . However, others have supported the use of separate grades in cases of severe contamination .…”

“…The advent of biological mesh was hoped to provide the solution to this, and early results demonstrated satisfactory outcomes in contaminated settings . Some issues have arisen around the use of crosslinked meshes and the risk of fistula recurrence and the lack of data on long‐term outcomes . The variety of products available and a lack of randomized trials add to the confusion.…”