Underlay Versus Retrorectus Mesh Placement in Complex Ventral Hernia Repair Utilizing Endoscopic Component Separation

M Gustafson, MD, R Kimball, MD, B Pellini, MD, I Daoud, MD, FACS. Department of Minimally Invasive Surgery, St. Francis Hospital and Medical Center; Hartford, CT.

Introduction: Abdominal wall reconstruction for complex abdominal wall defects remains a challenge. Although open component separation with medialization of the rectus muscles restores integrity and function of the abdominal wall, it is fraught with wound complications. Multiple studies demonstrate a decreased incidence of wound complications with endoscopic component separation as perforating vessels remain intact. The ideal mesh and its placement, however, remain elusive. We aim to investigate outcomes after endoscopic component separation with open ventral hernia repair and underlay versus retrorectus mesh placement.

Results: Forty-eight patients underwent bilateral endoscopic component separation with open ventral hernia repair and either underlay or retrorectus mesh placement by a single surgeon at our institution between February 2010 and July 2013. Mesh was placed as an underlay in 27 patients and retrorectus in 21. The demographics of the underlay and retrorectus groups were similar in that there was no significant difference in ASA p = 0.53, ethnicity p = 0.50, mean age (59.8 vs 55.1 yrs, p = 0.18), BMI (32.2 vs 35.8 p = 0.48), size of fascial defect (10.8 vs 10.7cm, p = 0.88) and hernia grade p = 0.66. There were more female patients in the retrorectus group, however this was not statistically significant (67% vs 41%, p = 0.067). There were no significant differences in overall incidence of complications (29.6% vs 42.9%, p = 0.15), hospital length of stay (6.8 vs 6.6 days, p = 0.78), surgical site infections (15% vs 14%, p = 0.64), and recurrence (11% vs 0%, p = 0.17). There were more patients with seromas requiring drainage in the retrorectus group (15% vs 0%, p = 0.031).

Discussion: With the exception of increased rates of seroma requiring drainage, retrorectus placement of mesh in our open ventral hernia repairs with endoscopic component separation yields outcomes comparable to underlay mesh placement. The incidence of both procedure-related and nonprocedure-related complications, recurrence and hospital length of stay are equivalent. The majority of seromas requiring drainage have been lateral, in the field of the component separation, thus it is difficult to attribute this to retrorectus mesh placement. Our drain placement has not been consistent throughout this period and this should be investigated for potential association with seroma development. One limitation of this study is a shorter average follow up in the retrorectus group (8.7, range 2-15 months) compared to the underlay group (31.6, range 19-43 months) owing to a later date of service. Although retrorectus mesh placement has not increased perioperative morbidity, at least two years of follow up is sought to better assess recurrence rates. Placing mesh outside of the peritoneal cavity has the potential benefit of utilizing a synthetic mesh above the posterior rectus sheath, thus avoiding the complications feared with intraperitoneal placement of synthetic meshes and significant cost of biologic prostheses.

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