Soft Polypropylene Mesh, But Not Cadaveric Dermis, Significantly Improves Outcomes in Massive Midline Hernia Repairs Using the Components Separation Technique
Jason H. Ko, MD; Benjamin C. Paul, BA; David M. Salvay, BS, MS; Edward Wang, PhD; Gregory A. Dumanian, MD
INTRODUCTION: The use of acellular cadaveric dermis for reconstruction of abdominal wall defects has gained popularity over the past several years, especially for procedures in a contaminated field. Though cadaveric dermis promotes tissue ingrowth and neovascularization, recent literature, in conjunction withour experience, has led us to question the long-term tensile strength and durability of cadaveric dermisin abdominal reconstruction (1-3). We limited our internal database review to all consecutive patients who underwent a modified components separation procedure by a single surgeon using either an acellular cadaveric dermis or soft polypropylene mesh underlay for closure of a midline ventral hernia defect. Our goal is to determine the overall procedure success and complication rates of cadaveric dermis versus soft polypropylene mesh underlay in abdominal wall reconstruction.
METHODS: Between September 2004 and September 2007, 47 patients had a components separation technique where either acellular cadaveric dermis (n=19) or soft polypropylene mesh (n=21)was used as an underlay for fascial reinforcement but never as a “bridging material” at the time of primary or subsequent repairs (Figure 1). Additional patients (n=7) had cadaveric dermis placed during one procedure, followed by soft polypropylene in a subsequent surgery for the treatment ofrecurrence. In order to preserve periumbilical perforators and skin blood flow, the external oblique releases were performed through bilateral 6-cm transverse incisions that were made just inferior to the lowest aspect of the rib cage.
RESULTS: The cadaveric dermis and soft polypropylene groups were similar in terms of patient demographics (Table 1), the main difference being the presence of contamination at the time of surgery--31% for the cadaveric dermis group compared to only 7% for soft polypropylene (p=0.0366). The use of acellular cadaveric dermiswas associated with a42% “true” recurrence ratethat required re-operation (mean follow-up duration 15.4 months), whereas soft polypropylene mesh had a significantly lower recurrence rate of 11% (p=0.0124)during a mean follow-up period of 14 months. In patients where cadaveric dermis was used, the major complication rate was 15% with aminor complication rate of 12%, while soft polypropylene mesh was associated with a slightly lower rate of 11% for both major and minor complications. In terms of minor complications seen in both groups, cadaveric dermis demonstrated an increased incidence of post-operative cellulitis (11.1% compared to 3.3%). Two patients in the cadaveric dermis group required operative re-exploration for bowel obstructions, one of which was secondary to an incarcerated recurrent hernia. No patients in the soft polypropylene group have developed a bowel obstruction due to adhesive disease; however, one patient in the soft polypropylene group underwent a surgical revision at an outside hospital for undetermined reasons.
TABLE 1 – Patient Characteristics (N=47)aVariable / Patients where Cadaveric dermis was used (N=26) / Patients where Soft Polypropylene was used (N=28) / P valueb
Baseline Patient Characteristics
Sex, n (%)
Male / 16 (62%) / 14 (50%) / 0.4251
Female / 10 (38%) / 14 (50%)
Age (year) / 0.5285
Mean (Range) / 53.3 (24-75) / 55.4 (27-74)
S.D. / 12.0 / 12.2
Hernia size (cm) / 0.6548
No. of cases in which size was known / 16 / 16
Mean (Range) / 12.6 (6.0-19.7) / 11.9 (6.3-19.4)
S.D. / 4.3 / 4.0
Body-mass index (kg/m2) / 0.0528
Mean (Range) / 30.9 (19.9-47.9) / 34.6 (24.3-52.1)
S.D. / 6.9 / 7.0
Smoking, n (%) / 7 (27%) / 8 (29%) / 0.9999
Diabetes, n (%) / 7 (27%) / 7 (25%) / 0.9999
Contamination, n (%) / 8 (31%) / 2 (7%) / 0.0366
Post-Operative Follow-up
Hernia recurrence, n (%) / 11 (42%) / 3 (11%) / 0.0124
Major complication, n (%) / 4 (15%) / 3 (11%) / 0.6994
Minor complication, n (%) / 3 (12%) / 3 (11%) / 0.9999
aSeven patients had multiple consecutive operations using both cadaveric dermis and soft polypropylene.
bStatistical test using t-test (for continuous variables) or Fisher exact test (for categorical variables).
CONCLUSION: Our study demonstrates that soft polypropylene mesh exhibits markedly improved recurrence rates compared to acellular cadaveric dermis when used as a fascial underlay during components separation for abdominal wall reconstruction. Although the difference in recurrence rates may be partly due to the increased presence of contamination at the time of cadaveric dermis implantation, the long-term strength of the midline hernia repair, regardless of contamination, was not augmented by cadaveric dermis. Thelong-term strength and durability of intraabdominal soft polypropylene meshare superior to those seen with acellular cadaveric dermis, and to this point, late mesh infections, fistulas, and bowel adhesions have not been observed in the soft polypropylene group.
Figure 1. Components separation technique with midline approximation of the rectus abdominis muscles. (A) Acellular cadaveric dermis underlay. (B) Soft polypropylene mesh underlay.
REFERENCES
1. Gaertner WB, Bonsack ME, Delaney JP. Experimental evaluation of four biologic prostheses for ventral hernia repair. J Gastrointest Surg 11:1275-1285, 2007.
2. Gupta A, Zahriya K, Mullens PL, et al. Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm. Hernia 10:419-425, 2006.
3. Jin A, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: Does technique affect outcomes? J Am Coll Surg 205: 654-660, 2007.
Financial Disclosure and Products
This study was funded by the senior author, Gregory A. Dumanian, MD, and the Division of Plastic and Reconstructive Surgery at Northwestern University, Feinberg School of Medicine in Chicago, IL. None of the authors have any financial interest in this study or in any of the products listed in the manuscript--human acellular cadaveric dermis (Alloderm, LifeCell Co., Branchburg, NJ) and soft polypropylene mesh (Proceed Surgical Mesh and soft Prolene mesh, Ethicon Inc., Somerville, NJ). In addition, none of the authors of this study have any commercial associations or financial disclosures that may pose a conflict of interest with any information presented in this manuscript.