Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience

Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience Jennifer M DiCocco, MD, Louis J Magnotti, MD, FACS, Katrina P Emmett, MD, Ben L Zarzaur, MD, FACS, Martin A Croce, MD, FACS, John P Sharpe, MD, C Patrick Shahan, BS, Haiqiao Jiao, BS, Steven P Goldberg, MD, Timothy C Fabian, MD, FACS Although damage control strategies and the open abdomen have improved survival, they present their own unique set of challenges in caring for the multiply injured trauma patient. We previously reported the technique of staged abdominal wall closure for the management of the open abdomen. The purpose of this study was to evaluate the efficacy of various techniques of abdominal wall reconstruction (final stage of management) on long-term outcomes after planned ventral hernia, and to better define risk factors for recurrence. STUDY DESIGN: Patients undergoing abdominal wall reconstruction over a 15-year period were identified and stratified by gender, age, severity of shock, injury severity, and method of repair: secondary fascial closure ⫾ prosthetic, standard components separation (SCS) ⫾ prosthetic and modified components separation (MCS) ⫾ prosthetic. Long-term outcomes (recurrence) were determined using hospital records, telephone interview, and physical examination. Multivariable logistic regression analysis was performed to determine independent predictors of recurrence. RESULTS: One hundred fifty-two patients were identified. Fourteen (9%) patients underwent secondary fascial closure ⫾ prosthetic, 47 (31%) underwent SCS ⫾ prosthetic, and 91 (60%) underwent MCS ⫾ prosthetic. Long-term follow-up (up to 14.6 years, mean 5.3 years) was obtained in 114 (75%) patients. Sixteen patients (14%) had a recurrence. Prosthetic use increased recurrence 4-fold. There were 2 known recurrences (5%) in patients with MCS without prosthetic. Logistic regression identified both female gender and body mass index as independent predictors of recurrence. CONCLUSIONS: The MCS technique is the procedure of choice for repair of giant abdominal wall defects. This approach can avoid the need for prosthetics. In fact, MCS without prosthetic resulted in an acceptably low hernia recurrence rate (5%). (J Am Coll Surg 2010;210:686–698. © 2010 by the American College of Surgeons) BACKGROUND:

necrosis and/or abdominal compartment syndrome. In 1983, Stone and colleagues2 reported a novel approach for the management of these patients in which the abdominal cavity was left open after initial celiotomy. Recognition of these potential complications led to widespread application of their approach; a decade later it came to be known as “damage control.”3 Although these strategies have led to improved survival, they present their own unique set of challenges. In patients who survive, the resultant abdominal wall defect (planned ventral hernia) can be quite large and present a formidable challenge for reconstruction. In fact, despite a wide variety of techniques for initial management of the resulting acute defect, a paucity of information has been reported concerning definitive management of the planned ventral hernia. Various techniques have been used in the final phase of management, abdominal wall reconstruction. Recurrence

Over the past 30 years, there has been a significant evolution in the management of the multiply injured trauma patient.1 These patients typically sustain massive intraabdominal injuries necessitating large volume resuscitations. Such fluid resuscitation produces significant soft tissue edema. The resultant visceral edema often prevents abdominal wall closure without excessive tension. Attempts at fascial closure under tension often lead to fascial Disclosure Information: Nothing to disclose. Presented at Southern Surgical Association 121st Annual Meeting, Hot Springs, VA, December 2009. Received December 18, 2009; Accepted December 23, 2009. From the Department of Surgery, University of Tennessee Health Science Center, Memphis, TN. Correspondence address: Louis J Magnotti, MD, Department of Surgery, 910 Madison Ave, #217, Memphis, TN 38162.

© 2010 by the American College of Surgeons Published by Elsevier Inc.

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Data collection Abbreviations and Acronyms

BMI MCS SCS STSG

⫽ ⫽ ⫽ ⫽

body mass index modified components separation standard components separation split thickness skin graft

rates vary depending on the method of repair and the length of follow-up and have been reported up to 54%.4 When prosthetic materials are used for definitive abdominal wall reconstruction, the most important complications are prosthetic infection and recurrent hernia. Although grampositive infections occasionally occur in association with the use of permanent prosthetic, many infections result when prosthetic is inserted in conjunction with intestinal contamination from either associated stomal or fistula closure. In 1990, Ramirez and associates5 first described the components separation technique for abdominal wall reconstruction. Since then, others have reported varying results with the subsequent use of this technique.6-8 We found the standard components separation insufficient for most giant defects encountered with the open abdomen technique. As a result, we added a modification (modified components separation) that allows for more extensive mobilization and local advancement of autologous tissue, essentially doubling the mobilization compared with the original description.9 This modified technique uses local myofascial tissue transfer and potentially avoids the need for permanent prosthetic material for abdominal wall reconstruction. We previously reported the results of our staged approach to abdominal wall reconstruction for the management of the open abdomen.9,10 Since that time, we have added to an already sizable experience with definitive reconstruction using the modified components separation reconstruction technique. This study was performed to analyze results of both acute and long-term management, including definitive reconstruction with this staged approach, to evaluate the efficacy of these various techniques of abdominal wall reconstruction on long-term outcomes after planned ventral hernia, and to better define risk factors for recurrence.

METHODS Patients who underwent abdominal wall reconstruction after a planned ventral hernia over a 15-year period (October 1993 to December 2008) were identified from operative logs at The Presley Regional Trauma Center in Memphis, TN. More than 5,000 trauma and 2,500 nontrauma celiotomies were performed during that time period. This study was performed with Institutional Review Board of the University of Tennessee Health Science Center approval and informed consent for follow-up.

Medical records were queried for demographic information, body mass index (BMI), smoking history, alcohol use, hypertension, diabetes, and steroid use. Charts from the patients’ initial hospitalizations were examined for mechanism of injury, injury severity, number of transfusions, indications for open abdomen, types of temporary closure, and size of the defect. Operative reports from the abdominal wall reconstruction were examined for the method of repair used, other procedures done at the time of repair, and the use and type of prosthetic material. Medical records were then reviewed for postoperative complications including wound infection, readmissions, subsequent operations, and postoperative follow-up. Time interval to repair was the time from the last split thickness skin graft (STSG), at which time the patient’s abdomen was completely covered, to the date of abdominal wall reconstruction. The presence of comorbidities and BMI were obtained from records at the time of abdominal wall reconstruction. Early complication was defined as any major complication within the first 30 days after abdominal wall reconstruction, including wound infection, pulmonary embolism, and myocardial infarction. Patient management and surgical technique

Initial management included resuscitation and treatment of the underlying condition and temporary abdominal wall closure. When delayed fascial closure was not possible, STSG was placed over the viscera. The size of the STSG was used to determine the size of the planned ventral hernia. Patients were followed until the graft loosened from underlying bowel. At this time (typically 8 to 12 months), they were deemed ready for reconstruction. There were 6 distinct methods of repair in the study population (Table 1). Patients had no abdominal wall separation if they had simple fascial closure or closure with a prosthetic underlay. Patients with components separation had release of the external oblique fascia just lateral to the rectus abdominus with fascial closure in the midline, or components separation with a prosthetic underlay in the midline defect. Patients with modified components separation (Fig. 1) had anterior release of the external oblique Table 1. Different Methods of Repair for Abdominal Wall Reconstruction Methods of repair No separation No separation with prosthetic Components separation Components separation with prosthetic Modified components separation Modified components separation with prosthetic

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Figure 1. Modified components separation technique for abdominal wall reconstruction. (A) Normal anatomy above the arcuate line. (B) The posterior rectus sheath is mobilized from the rectus muscle, and the external oblique fascia is divided. (C) The internal oblique component of the anterior rectus sheath is divided down to the arcuate line. (D) Completed repair, suturing the medial border of the posterior sheath to the lateral border of the anterior sheath, with approximation of the medial portion of the anterior sheath in the midline. Illustration by Steven P Goldberg.

along with division of the anterior fasical component of the internal oblique (up to but not past the arcuate line, freeing the lateral border of the anterior sheath). Subsequently, the posterior sheath was dissected from the rectus, and the medial border of the posterior sheath was sutured to the

lateral border of the anterior sheath, with fascial closure in the midline. The final group had prosthetic underlay in the midline defect after modified components separation. Some patients had the modified components separation on only 1 side due to anatomic restrictions, such as loss of

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muscle or fascia. These patients were classified as having modified components separation.

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Patients were contacted by telephone, using last known contact information. They were asked to describe their abdominal wall and whether or not they had had any additional abdominal operations. These records were obtained when possible. All patients were invited to return to the outpatient clinic for an abdominal examination. When no valid contact information was available, we reviewed the Social Security death registry, and queried an online locator service (http://www.peoplefinder.com) for the patient and all known associates to obtain additional numbers. All valid telephone numbers were called until follow-up was completed. Patients were deemed lost to follow-up when all contact information was exhausted.

majority were male (83%) and had penetrating injuries (55%). Sixteen patients were identified as having recurrence of their abdominal wall hernias, for a total recurrence rate of 14%. As expected, more recurrent hernias were identified as patients were followed over time. Figure 3 illustrates the percentage of patients who had recurrence over time. Patients were stratified into successful reconstruction and recurrent hernia groups for analysis. Table 2 shows the patient characteristics of each group. Patients in each group were similar in age, presence of comorbid conditions, mechanism of injury, indication for open abdomen, and injury severity. The average base deficit and defect size were both larger in the recurrent hernia group. The interval to repair of the abdominal wall was shorter in the recurrence group by approximately 2 months (329 days vs 389 days). However, none of these differences were statistically significant.

Analysis

Methods of repair

Follow-up

All statistical tests were performed on SAS version 9.1 (SAS Institute Inc). Categorical data were analyzed using chisquared tests; continuous data were analyzed using Student’s t-tests. Univariable analysis was performed on all variables. Multivariable logistic regression analysis with stepwise selection was performed to determine which variables were independent predictors of recurrence. Patients were included in the analysis only if follow-up data were available. A cutoff value of p ⬍ 0.20 was used for model entry, and a cutoff value of p ⬍ 0.05 was used to determine model exit.

RESULTS Over the 15-year period of the study, there were 152 patients who underwent abdominal wall reconstruction for their planned ventral hernias. The majority (140 patients) of these reconstructions followed trauma (92%). The remaining 8% (12 patients) followed nontraumatic events, including gastric bypass leak, necrotizing pancreatitis, and perforated viscus. The most common reason for open abdomen was visceral edema and abdominal compartment syndrome in 71%, followed by dehiscence (17%), abdominal wall loss (7%), and peritonitis (5%). Men accounted for 131 abdominal wall reconstructions (86%) and women for 21 (14%). Follow-up was achieved in 114 patients (75%). Patient characteristics and follow-up

The outcomes and follow-up of study patients are summarized in Figure 2. Of the 152 patients, 114 patients had follow-up after abdominal wall reconstruction, which ranged from 9 months to 14.6 years (mean 5.3 years). The

Patients were stratified according to the method of abdominal wall reconstruction performed (Table 3). There were 13 patients (11%) who had repairs without any separation of abdominal wall components; seven (54%) had fascial closure, and 6 (46%) had prosthetic closure. There were 34 patients (30%) who had components separation; 25 (74%) were performed without prosthetic and 9 (26%) with prosthetic assisted closure. There were 67 patients (59%) who had modified components separations; 37 (55%) were performed without prosthetic and 30 (45%) with prosthetic assisted closure. Recurrence rates were evaluated by method of repair (Fig. 4). The highest recurrence rates occurred in patients with prosthetic-assisted repairs. The recurrence rates for patients with no separation of abdominal wall components were 0% without prosthetic compared with 33% with prosthetic (p ⬍ 0.19); 8% versus 44% for components separation (without vs with prosthetic; p ⫽ 0.03); and 5% versus 20% for modified components separation (without vs with prosthetic; p ⫽ 0.13). Factors associated with recurrence

Table 2 compares the patients with successful abdominal wall reconstruction with those who had hernia recurrence. Univariable analysis identified BMI, female gender, and use of prosthetic material with hernia recurrence. It is not surprising that BMI and prosthetic use were associated with hernia recurrence. However, half of the recurrent hernias occurred in only 17% of the study population (women). Presence of fistula or ostomy was not associated with hernia recurrence. The occurrence of an early complication was also associated with recurrence. The most common complication involved the midline wound, and in-

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Figure 2. Schematic representation of long-term outcomes for all patients undergoing abdominal wall reconstruction after planned ventral hernia between 1993 and 2008.

cluded infection, skin necrosis, or hematoma. Mean BMI in this group with wound complications was 32.4 kg/m2. Stepwise multivariable regression analysis was performed to identify variables associated with hernia recurrence. The model was constructed with the following variables: age, gender, BMI, defect size, prosthetic use, smoking history, mechanism of injury, method of repair, sur-

geon volume, presence of early complications, and interval to repair. The 2 variables associated with hernia recurrence were BMI (odds ratio 1.2; 95% CI 1.02 to 1.40) and female gender (odds ratio 17.2; 95% CI 2.6 to 113.3). It is possible that recurrences were under-reported due to the patients that were lost to follow-up. Those patients lost to follow-up were compared with those who were included

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Figure 3. Graphical representation of time to recurrence in months (horizontal axis). The percentage of recurrence is represented on the vertical axis, with the majority occurring within 48 months.

in the study (Table 4). Those lost to follow-up were less likely to be female, had smaller defects, lower BMI, and less likely to have prosthetic material. So it appears that those lost to follow-up had lower risk for recurrence, and would be unlikely to adversely alter the recurrence rates. Salvage repairs

After a recurrence develops, salvage repair of the abdominal wall can be successful. Of the 16 patients with recurrence, 11 underwent subsequent repair. Two of these patients had early technical failures related to the prosthetics on postoperative day 3 and underwent successful repair during the same hospitalization. The other 9 patients had successful salvage operations, and 1 patient had a recurrence. The 5 remaining patients with recurrences have not had repeat attempts at abdominal closure. Of the 114 patients, only 6 had abdominal wall defects at the time of follow-up, for an overall success rate of 95%.

DISCUSSION The idea of intentionally leaving the abdomen of a surgical patient open after celiotomy was considered heresy 30 years ago. In 1983, Stone and colleagues2 noted that trauma patients who sustained massive intra-abdominal injuries frequently died in the perioperative period from complications of hypothermia, coagulopathy, and acidosis resulting from prolonged shock and lengthy operations. In that report, they noted a substantial reduction in mortality in the group of patients treated with damage control surgery. In the intervening years, the understanding of the abdominal compartment syndrome evolved.11-13 Abbreviated celiotomy is performed in this complex and critically ill patient

population and requires at least 1 if not several reoperations to restore intestinal and/or vascular continuity. In those who survive the initial insult, the resultant abdominal wall defect can be quite large and abdominal wall closure may not be possible.14,15 This situation often requires creation of a planned ventral hernia and eventual abdominal wall reconstruction in the ensuing months.1,9 Various techniques have been described for abdominal wall reconstruction after planned ventral hernia. These patients have massive defects and require complex reconstructions. The use of prosthetics has been shown to lead to greater complications and a higher recurrence rate.4 This finding was confirmed by this study. In it, the use of prosthetic, either alone or in combination, resulted in a greater than 4-fold increase in recurrence compared with no prosthetic (26% vs 6%). This is similar to results of our original study, in which 33% of patients undergoing prosthetic reconstruction developed a recurrence.9 In 1990, Ramirez and associates5 introduced the components separation technique for abdominal wall reconstruction. The authors described performance of large relaxing incisions based on division of the external oblique component of the anterior rectus sheath just lateral to the rectus muscle. The incision is carried cephalad to the costal margin and inferiorly to the inguinal region, effectively relaxing the rectus abdominis muscle and fascia, permitting significant medial mobilization. Further separation of the rectus abdominis from the posterior rectus fascia provides increased mobilization. Since then, others have reported varying results with this technique.6-8 In 2003, de Vries Reilingh and coworkers7 evaluated the use of the standard components separation technique for

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Table 2. Characteristics of Patients with Successful Reconstruction Versus Recurrent Hernia Characteristic

Patient characteristics n Age, y Body mass index, kg/m2 Male, % Female, % Smokers, % Diabetes, % Hypertension, % Injury mechanism, % Blunt Penetrating Nontraumatic Injury severity Injury Severity Score 24-h blood transfusion, U Admission base deficit, mEq/L Indication for open abdomen, % Visceral edema (ACS) Loss of abdominal wall Other indication Perioperative factors Size of defect, cm2 Time to repair, d Prosthetic use, % With ostomy, % With fistula, % Complications first 30 d, % Follow-up Months of follow-up Death from any cause, %

Successful reconstruction

Recurrent hernia

98 35

16 39

27 (14–40) 89 11 37 8 18

31 (23–48) 50 50 50 6 13

36 57 7

38 44 19

p Value

0.122 0.006 ⬍0.001 0.316 0.793 0.570 0.241 0.128 0.144

26 (9–57)

27 (9–50)

0.731

17 (0–90)

20 (0–79)

0.590

7.38

9.99

0.117

67

63

6 27

19 19

0.123

589 (20–1,800) 831 (420–1,476) 376 329 33 68 22 0 18 13

0.096 0.429 0.009 0.038 0.570 ⬍0.001

14

63

65 (9–175)

60 (11–157)

0.689

5

6

0.407

Values expressed as means (ranges) except as indicated. ACS, abdominal compartment syndrome

reconstruction of giant abdominal wall defects in 43 patients. Both early and late results were examined. Follow-up was attained in 38 patients (mean 15.6 months, range 12 to 30 months). A recurrent hernia was found in 12 of the 38 patients (32%). Despite the relatively high recurrence rate, these authors concluded that this technique was useful for reconstruction of large abdominal wall defects, especially under contaminated conditions.

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Table 3. Characteristics of Patients by Method of Repair

Characteristic

Patient characteristics n Age, y Body mass index Male, % Female, % Smokers, % Diabetes, % Hypertension, % Injury mechanism, % Blunt Penetrating Nontraumatic Injury severity Injury Severity Score 24-h blood transfusion, U Admission base deficit, mEq/L Indication for open abdomen, % Visceral edema (ACS) Loss of abdominal wall Other indication Perioperative factors Time to repair, d Prosthetic use, % With ostomy, % With fistula, % Complications first 30 d, % Follow-up Months of follow up Recurrence, %

No separation

Modified Components components separation separation

13 32 29 (20–36) 85 15 58 17 25

34 33 27 (18–48) 85 15 22 0 13

67 37 27 (14–44) 82 18 46 11 20

31 54 15

35 59 6

37 54 9

23 (9–45)

24 (9–45)

27 (9–57)

16 (0–64)

19 (0–79)

17 (0–90)

11.81

6.75

7.56

54

59

70

8 38

9 32

8 22

571 46 23 23

349 26 21 18

344 45 15 16

8

21

24

80 (23–175) 63 (10–156) 62 (9–175) 15 18 12

Values expressed as means (ranges) except as indicated. ACS, abdominal compartment syndrome.

In a later study, these researchers compared prosthetic repair with the standard components separation technique for reconstruction of giant abdominal wall defects in 39 patients.6 In that study, the authors again noted a high (53%) recurrence rate after standard components separation. The authors also reported a 22% recurrence rate after prosthetic repair and also commented that the prosthetic had to be removed in 39% of the patients. Lowe and colleagues8 reviewed 30 patients who underwent components separation for reconstruction of complex

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Table 4. Characteristics of Patients With and Without Follow-up Characteristic

Figure 4. Graphic representation of repair method (horizontal axis). Vertical axis represents percentage of patients undergoing specific repair method. Percent recurrence for each method is indicated by dark gray bars. No separation, 0%; no separation with prosthetic, 33%; components separation, 8%; components separation with prosthetic, 44%; modified components separation, 5%; modified components separation with prosthetic, 20%.

abdominal wall defects. In that study, mean follow-up was 9.5 months. The authors reported a lower recurrence rate than had previous studies (10%). We previously reported our experience with the standard components separation technique.9 In that study, of the 9 patients who underwent reconstruction with the components separation method, 1 patient (11%) developed a recurrent hernia. In this study, the standard components separation technique was associated with an 8.3% recurrence rate. Table 5 summarizes multiple studies dealing with various methods of ventral hernia repairs. This study has the longest follow-up with a low recurrence rate. Clearly, the standard components separation is insufficient for most giant defects encountered with the open abdomen technique. Consequently, we added a modification (Fig. 1) that allows for more extensive mobilization and local advancement. The modification involves additional division of the internal oblique component of the anterior rectus fascia down to the arcuate line, which essentially doubles the mobilization compared with the original description.9 The medial portion of the posterior rectus fascia is sutured to the lateral border of the anterior rectus sheath. This maneuver provides 3 to 5 cm of further medial mobilization from each side. Anatomic consideration of the blood supply to the rectus muscles demonstrates why this modification is effective. The blood supply to the rectus muscles is from the superior epigastric and deep inferior epigastric arteries, with the inferior epigastric providing the major component.16,17 The inferior epigastric is a branch of the external iliac artery and lies between the internal

Patient characteristics n Age, y Body mass index Male, % Female, % Smokers, % Diabetes, % Hypertension, % Injury mechanism, % Blunt Penetrating Nontraumatic Injury severity Injury Severity Score 24-h blood transfusion, U Admission base deficit, mEq/L Indication for open abdomen, % Visceral edema (ACS) Loss of abdominal wall Other indication Perioperative factors Size of defect, cm2 Time to repair, d Prosthetic use, % With ostomy, % With fistula, % Complications 1st 30 d, % Follow-up Months of follow-up Death from any cause, %

Follow-up

No follow-up

114 35 27 (14–48) 83 17 40 8 18

38 35 25 (16–41) 95 5 51 6 11

36 55 9

26 68 6

26 (9–57) 18 (0–90)

28 (9–50) 14 (0–62)

7.74

8.52

67 8 25 620 (20–1,800) 369 40 18 18 21 65 (9–175) 5

66 3 31 443 (90–1,800) 372 14 18 21 11 NA 3

Values expressed as means (ranges) except as indicated. ACS, abdominal compartment syndrome.

oblique and transverse abdominis muscles. It enters the rectus sheath around the arcuate line and heads cephalad up the middle of the rectus abdominis and superiorly has anastomotic connections with the superior epigastric artery. Therefore, lateral division of the anterior sheath does not compromise blood supply. Obviously, caution must be taken to avoid injury to the inferior epigastric vessels during mobilization of the posterior rectus fascia and division of the internal oblique fascia. In this study, there remain patients who received prostheses as adjuncts to both the standard and modified components separation. In those reconstructions, there was a higher recurrence rate than in purely autologous repairs. In

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Table 5. Reported Recurrence Rates after Ventral Hernia Repair Using Various Techniques with Variable Lengths of Follow-up First author

n

Follow-up, mo

Recurrence, %

Defect size, cm2

BMI

Methods used

De Vries Lowe8 Jernigan10 De Vries6 Rodriguez19 De Moya20 Diaz18 Ko21 Total This study

43 30 73 37 23 6 165 200 577 114

15.6 9.5 24 36 7 12 10.4 10.3 13.9 63.6

28 10 6 57 9 100 25 22 23 14

234 240 600 400 960 425 201 n/a 437 621

27.3 33.2 n/a 28 27.6 N/A 30.7 31.7 26.4 27.3

CS CS ⫹ P MCS ⫹ P CS vs ePTFE CS ⫹ P Human acellular dermis CS ⫹ P vs P only CS vs. P underlay

7

NS, CS, MCS, P

CS, components separation; ePTFE, expanded polytetrafluoroethylene; MCS, modified components separation; NS, no separation; P, prosthetic.

fact, the use of prosthetic either alone or in combination with the 2 separation techniques resulted in a significant increase (26%) in recurrence—greater than 4-fold over reconstructions without prosthetic. Nevertheless, the etiology of this observation is unclear. It is also not possible to discern the reason for the addition of prosthetic in all cases from the operative reports. There are, however, several potential explanations. First, the addition of prosthetic may have been reserved for defects that could not be completely approximated or approximated without tension after modified components separation. Second, in patients undergoing standard components separation, the modification may not have been possible secondary to an inadequate posterior sheath due to previous resection from destruction or infection, necessitating prosthetic. Third, prosthetic may have been used to reinforce otherwise questionable reconstructions associated with poor quality tissue. Finally, it is possible that these repairs were performed with undue tension. We believe this last consideration is paramount to minimizing hernia recurrences. For example, the recurrence rates for the no release group with prosthetic would be lower if those patients would have been managed using components separation. Similarly, the recurrence rate for patients after components separation and prosthetic repair would be lower had they been managed with the modified components separation technique. Although we cannot prove this, it is consistent with the fundamental surgical principle of avoiding closure under tension. Beyond the realization of recurrences being associated with inappropriate closure under tension, we also wanted to address what other factors contributed to failure of repair. In order to better define potential predictors of recurrence, multivariable logistic regression analysis was performed. Interestingly, after adjusting for age, defect size, use of prosthetic, comorbidities, type of repair, early complications, time interval from skin graft to repair, and indication for abdominal wall reconstruction, use of prosthetics was not inde-

pendently predictive of recurrence. In fact, only female gender and BMI were identified as independent predictors of recurrence after abdominal wall reconstruction for planned ventral hernia. Not surprisingly, increasing BMI has been shown previously to be associated with increased recurrence after hernia repair.7,8,18 In these patients, the defect size is often larger and may require addition of prosthetic for closure, increasing the amount of tension placed on the repair. These patients also seem to have a more substantial loss of abdominal domain than patients with a smaller body habitus. These factors combine to place obese patients at greater risk for recurrence. Female gender is also associated with recurrence. The reasons for this are unclear. This could be due to pregnancy weakening the abdominal wall musculature. The childbearing status of the patients in this study is unknown. Additionally, anatomic muscular differences in men and women might contribute to the high recurrence rate in women. This study is retrospective and as such has several inherent limitations. First, it is difficult to control for patient variables among the different reconstruction methods. Second, it is not possible to determine from the operative reports the reason (quality of fascia, tension, etc.) for the method of reconstruction used in all cases. Finally, despite exhaustive efforts, not all of the patients could be contacted for follow-up. The reported recurrence rate could potentially underestimate the actual rate. Despite these limitations, there are 2 key factors that strengthen the data presented: study size and length of follow-up. This study represents one of the largest single institutional series reported in the literature of abdominal wall reconstruction after planned ventral hernia. In addition, long-term follow-up (up to 14.6 years) was obtained in the majority (75%) of patients, with an average follow-up of 5.3 years. It is also important to stress that patients lost to follow-up were not included in the analysis in order to prevent any potential under-reporting of recur-

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rence; were less likely to be female; were more likely to have lower BMIs and smaller defects; and were less likely to have needed prosthetics. So, all factors associated with recurrence were less in patients lost to follow-up. In addition, patients with a recurrence are more likely to follow up. In summary, we believe this staged management scheme provides a consistent and effective approach for management of the open abdomen. Long-term follow-up of abdominal wall reconstruction after planned ventral hernia demonstrated a recurrence rate of 14% for all methods. The low recurrent hernia rate (5%) after modified components separation without prosthetics, with an excellent follow-up interval, provides good results for repair of major abdominal wall defects. For definitive reconstruction, the modified components separation technique is the procedure of choice for repair of giant abdominal wall defects. This approach can avoid the need for prosthetic material. The modified components separation without prosthetic resulted in an acceptably low hernia recurrence rate. The modified components separation technique should be used rather than prosthetic material. In the largest defects, adjunctive prosthetics may be necessary to avoid undue tension when all available autologous tissue has been maximally used. Author Contributions Study conception and design: DiCocco, Magnotti, Emmett, Zarzaur, Croce, Fabian Acquisition of data: DiCocco, Magnotti, Emmett, Croce, Sharpe, Shahan, Jiao, Goldberg, Fabian Analysis and interpretation of data: DiCocco, Magnotti, Emmett, Zarzaur, Croce, Fabian Drafting of manuscript: DiCocco, Magnotti, Emmett, Croce, Fabian Critical revision: Magnotti, Croce, Fabian

REFERENCES 1. Fabian TC. Damage control in trauma celiotomy wound management acute to chronic. Surg Clini North Am 2007; 87:73–93. 2. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during celiotomy. Ann Surg 1983;197: 532–535. 3. Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375– 383. 4. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008;16:CD006438. 5. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–526.

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Discussion DR LD BRITT (Norfolk, VA): I want to thank Dr DiCocco and colleagues for asking me to be the invited discussant. I certainly hope after this discussion there will be no regrets. In my presidential ad-