An Umbrella Approach to Large Or Massive Incisional Hernias with Open Components Separation and Biologic Mesh Reinforcement

Gordon Lee, BS, Audriene Sanchez, MS, Heidi Ryan, MD, Shawn Tsuda, MD, FACS. University of Nevada School of Medicine.

Background: Large (> 10 cm diameter) or massive (> 20 cm diameter) or complex hernias remain a challenge with frequent complications. Ideal patient selection for techniques including open or endoscopic components separation, reinforcement with porous prosthetics or biologic tissue matrixes, or a combination of these remain subject to investigation. This study reviews an umbrella approach to large or massive ventral hernias, regardless of patient characteristics, with open components separation and wide biologic mesh reinforcement.

Methods: Thirty-four patients underwent open ventral (including incisional) hernia repair between September 2009 and August 2013 and were retrospectively reviewed for primary outcomes of recurrence and infection. Secondary analyses assessed associations with patient characteristics, risk factors, and operative variables with a student’s t-test for continuous variables and two-tailed Fischer’s exact test for categorical variables.

Results: Follow-up ranged from 1 to 25 months. Mean hernia size was 356 + 280 cm2. Recurrences and wound infections occurred in 9% and 38% of patients. Postoperative soft tissue infections were associated with age > 55 years (p=<0.01), prior history of wound infection (p = 0.02), and presence of infected prosthetic mesh at operation (p=0.03). No biologic mesh explants were required for infection.

Conclusion: An umbrella approach to large or massive ventral hernias with open components separation to achieve primary closure without tension and biologic mesh reinforcement to reduce need to explant in the face of infection, regardless of patient factors, may be a reasonable technique in the absence of ideal patient selection criteria for components separation and reinforcement materials. Soft tissue infections remain consistent with published series, but need for major secondary operations were absent and short- to medium-term recurrences are low.

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