A Single Institutional Comparison of Endoscopic and Open Abdominal Component Separation with Risk Stratification

Said C Azoury, MD, Andrew P Dhanasopon, MD, Xuan Hui, MD, MSc, Carla De La Cruz, BS, Justin M Sacks, MD, Kenzo Hirose, MD, Thomas H Magnuson, MD, Caiyun Laio, MD, Monica Lovins, MS, CRNP, Hien T Nguyen, MD. Department of Surgery, The Johns Hopkins Hospital; The Johns Hopkins University, School of Medicine; Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital; Johns Hopkins Bloomberg School of Public Health.

 
INTRODUCTION
Open component separation (OCS) is associated with complications secondary to loss of blood supply to overlying skin flaps. Endoscopic component separation (ECS) has gained popularity in the last decade. We analyzed surgical factors and outcomes data in the largest single institutional study comparing endoscopic and open component separation.

METHODS AND PROCEDURES
A prospectively maintained database was queried, identifying 76 patients who underwent component separation for ventral hernia repair with mesh from 2010 to 2013: 34 OCS and 42 ECS. Comparisons were made for demographics, surgical factors, ASA class, percent of patients with a history of prior hernia and abdominal surgery, smoking (with and without COPD), diabetes, and the use of chronic anticoagulation. Estimated blood loss (EBL), operative time, and length of stay were analyzed. Group differences by continuous and categorical variables were compared by using simulation ANOVA and Fisher’s exact test respectively. Wound complications and hernia occurrence were reviewed. Univariate and multivariate analyses were used to assess association between technique, surgical factors, and outcomes.

RESULTS
The ECS group had a lower BMI (35 vs 42 kg/m2 ; P = 0.004), older age (58 vs 50; P = 0.0016) and smaller defect size (174 vs 268 cm2 ; P = 0.028), with no other differences in surgical factors. In the ECS group, 25 patients (60%) underwent subsequent laparoscopic hernia repair, and 17 (40%) underwent open repair. Primary fascial closure was achieved in all ECS patients, and all but one OCS patient (97%). Operative time for ECS was significantly longer than OCS (334 vs 239 min; P < 0.001) even when adjusting for BMI (P = 0.021) and defect size (P = 0.023), however there was no difference in length of stay (4 days in both groups, P = 0.64) and estimated blood loss (ECS: 97 vs OCS: 93 cc, P = 0.847). In a sub-analysis of ECS patients, those who underwent laparoscopic hernia repair had a 96 minute shorter operative time (P < 0.001) and lower EBL (63 versus 147 cc, P < 0.001) than open repair. Wound complications were 23% in the ECS (n = 10) and 32% in OCS group (n = 11); 7 required intervention in the ECS versus 10 in the OCS group. There was one midline hernia recurrence in the ECS group (mean follow-up of 8 months, range 0.5 to 34.5 months) and no hernia recurrences in the OCS group (mean follow-up 10 months, range 0.5 to 30 months). Three of the patients in the ECS group developed new lateral abdominal wall hernias post-operatively.

CONCLUSIONS
No significant associations were found between procedure, mesh type, risk factors and outcomes. ECS had a significantly longer operative time than OCS, however in the ECS group, those who underwent subsequent laparoscopic hernia repair had a shorter operative time and blood loss than open repair. Though endoscopic component separation has the potential to decrease morbidity for abdominal wall reconstruction, careful follow-up is essential to determine if hernia outcomes are similar to the open technique.

 

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