Charles P Shahan, MD, Nathaniel Stoikes, MD, David Webb, MD, Guy Voeller, MD. University of Tennessee Health Science Center
Repair of large ventral hernias are a challenging problem. Often the disease process is accompanied by many associated comorbidities that can affect outcomes. Outside of recurrence, other factors such as wound complications and mesh infection create significant morbidity. Chevrel first described onlay ventral hernia repair in 1979. In 1989 he described a modification using fibrin glue in addition to absorbable sutures. The aim of this study is to review the largest case series of sutureless onlay ventral hernia repair whereby mesh is fixated with fibrin glue alone for complex ventral hernias.
All patients who underwent abdominal wall hernia repair with onlay of large-pore, lightweight, polypropylene mesh with fibrin glue fixation from July 2011 through April 2014 performed by the investigating surgeons were identified. Records were then queried for patient demographics, operative details, complications, and follow up. The data was then analyzed and descriptive statistics, Chi-squared, Exact tests, and regression analysis were performed where appropriate.
97 patients underwent hernia repair during the study period. 54.6% were female, with a mean age of 57.3 years. Mean BMI was 32.2. Diabetes was present in 23(23.7%) patients. None of the patients were actively smoking at the time of repair. 90 (92.8%) of the operations were for incisional hernias, 3 (3.1%) primary ventral hernias, 2(2.1%) flank hernias, and 2(2%) were for complex abdominal wall reconstruction. 88(90.7%) of the cases were performed on an elective basis. 85 (85.9%) had bilateral myofascial advancement flaps, while 8 (8.2%) had right-sided only, 3 (3.1%) had left-sided only, and 2 (2.1%) had no advancement flap. 77 (77.3%) cases were classified as clean, 21 (21.6%) clean-contaminated, and 1 (1.0%) contaminated. The mean defect size was 149.5cm2 (median=120cm2). 5 (5.1%) had concurrent underlay. Mean follow up was 119.2 days (median= 76). There were 21 (21.6%) seromas, 4 (4.1%) wound infections, 7 (7.4%) had skin necrosis, and 9 (9.3%) required re-operation due to a complication. Age, gender, diabetes, defect size, contamination, and emergent status were not associated with any of the complications. Increasing BMI was associated with infection and re-operation, but not seroma or skin complications. There were no known hernia recurrences at the time of analysis spanning 3 years.
The complex abdominal wall, especially large, recurrent incisional hernias, is a challenging problem faced by general surgeons. The sutureless onlay ventral hernia repair technique with fibrin glue fixation has proven effective in repairing complex hernias, including a small number of flank hernias. There was a relatively high rate of seroma formation as has been previously reported with the onlay technique. However, there are two notable findings; none of the patients requiring re-operation have required explantation of mesh, and contamination was not associated with any of the observed complications despite the use of permanent synthetic mesh. There have been no recurrences in the cohort. Further study of the biomechanics of onlay ventral hernia repair with fibrin glue fixation as well as long term follow-up are needed.