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The relationship of abdominal wall reconstruction to intra-abdominal pressure in a pathophysiologic porcine model
Vol. 211, No. 3S, September 2010
Fascial repair was fortified using acellular dermal allograft/ xenograft as an underlay beneath the fascia and the second layer as an overlay. Pedicled flap was used as an adjunct in 1 patient. RESULTS: Using the “Extended component separation technique,” direct fascial approximation was achieved in all patients. There were no hernia recurrences. Marginal skin necrosis occurred in 4, wound infection in 2 patients and seroma in 1 patient. CONCLUSIONS: The “Extended component separation technique” is helpful in the management of complex abdominal hernia having demonstrated no hernia recurrence and a low complication rate in our study group. Extension should be incremental based on hernia size. If abdominal wall muscles are partially destructed other techniques like pedicled or free flaps may be used as an adjunct.
The relationship of abdominal wall reconstruction to intra-abdominal pressure in a pathophysiologic porcine model Helen G Hui-Chou MD, Leigh Ann Price MD, Arthur J Nam MD, Michael Magarakis MD, Gerhard S Mundinger MD, Luke S Jones BS, Eduardo D Rodriguez MD, DDS, FACS Johns Hopkins University School of Medicine, Baltimore, MD INTRODUCTION: The impact of complex abdominal ventral hernia repair on intra-abdominal pressure (IAP) has not been comprehensively investigated. We sought to correlate changes in IAP following primary hernia repair and components separation in a porcine model. METHODS: Primary ventral hernia repair was simulated by fascial imbrication in sixty swine. A 10x15 cm ellipse was outlined on the abdominal fascia where full thickness sutures were placed on the lateral edge of the outlined marks and then approximated in the midline. IAP was measured by veress needle. Parameters including bladder pressure (BLP) and femoral central venous pressure (CVP) were measured before and after imbrication and components separation (CS). Animals were desufflated, recovered, and survived to 12 week endpoint. RESULTS: There were significant changes in IAP, BLP, and CVP with primary hernia repair and components separation. During imbrication, these pressures increased by an average of 13, 15, and 15mmHg, respectively (p⬍0.01). After CS, pressures decreased by an average of 9, 8, and 9mmHg, respectively (p⬍0.01). Pressure increases from baseline more than 10-15mmHg had adverse effects on airway pressures, venous return, cardiac output, and urine output. CONCLUSIONS: We have demonstrated the impact of reconstructing major abdominal wall defects on several hemodynamic and physiologic parameters, which revealed that BLP is an accurate correlate to IAP. Components separation reduces IAP following primary hernia repair, but it may be inadequate to prevent the detrimental effects of intra-abdominal hypertension and may lead to abdominal compartment syndrome.
Surgical Forum Abstracts
S89
Subcutaneous talc and thrombin decrease seroma rates and drain duration after open ventral hernia repair with massive skin and subcutaneous reconstruction Rita A Brintzenhoff MD, Ajita Prabhu MD, Stanley Getz MD, H James Norton PhD, Amy Lincourt PhD, B Todd Heniford MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Wound complications after open ventral hernia repair with massive skin and subcutaneous reconstruction (OVHR/ MSSR) range from seroma to wound breakdown. Following OVHR, these occur in 12-20% and increase to 17-34% when combined with MSSR. This study evaluates a novel technique of applying talc and thrombin to subcutaneous flaps to prevent seroma formation. METHODS: A prospectively collected surgical outcomes database was accessed identifying all patients undergoing OVHR/MSSR from 1999-2010. Patients were divided into two groups based on receiving talc and thrombin therapy: PRE group did not receive therapy and POST group did. Demographics, peri-operative data, and outcomes were analyzed. RESULTS: PRE group consisted of 106 patients and POST group consisted of 44 patients. Demographic and peri-operative data was similar between groups. Complication rates for PRE/ POST were: cellulitis or oral antibiotics 26.4%/15.9%, intravenous antibiotics 10%/4.5%, operative/radiologic intervention for wound infection 17%/15.9%, seroma intervention 21%/4.5%, wound breakdown 14.2%/6.8%, and hernia recurrence 10.4%/0%. Of these, seroma intervention and hernia recurrence were significantly decreased in the POST group (p⫽0.014, p⫽0.034). Mean drain duration was 28.4 days for PRE and 17 days for POST (p⫽0.004). Mean follow-up was 5.6 months for PRE and 2.5 months for POST (p⫽0.032). CONCLUSIONS: To improve outcomes after massive OVHR/ MSSR, we treat the subcutaneous flaps created for MSSR with talc and thrombin. We found a decreased percentage of wound complications, with a significant reduction in seroma formation, recurrence, and drain duration. This suggests talc and thrombin will provide a means to decrease wound complications in massive ventral hernias.
Hematoma rate with and without tumescent solution in patients undergoing mastectomy with immediate tissue expander reconstruction Akhil K Seth MD, Elliot M Hirsch MD, John Y S Kim MD, Gregory A Dumanian MD, Thomas A Mustoe MD, FACS, Neil A Fine MD, FACS Northwestern University Feinberg School of Medicine, Chicago, IL INTRODUCTION: It has been postulated that using tumescent solution during mastectomy may lead to an increased hematoma rate. This study evaluates hematoma formation in patients undergoing mastectomy and immediate tissue expander reconstruction with and without tumescent solution.
Fascial repair was fortified using acellular dermal allograft/ xenograft as an underlay beneath the fascia and the second layer as an overlay. Pedicled flap was used as an adjunct in 1 patient. RESULTS: Using the “Extended component separation technique,” direct fascial approximation was achieved in all patients. There were no hernia recurrences. Marginal skin necrosis occurred in 4, wound infection in 2 patients and seroma in 1 patient. CONCLUSIONS: The “Extended component separation technique” is helpful in the management of complex abdominal hernia having demonstrated no hernia recurrence and a low complication rate in our study group. Extension should be incremental based on hernia size. If abdominal wall muscles are partially destructed other techniques like pedicled or free flaps may be used as an adjunct.
The relationship of abdominal wall reconstruction to intra-abdominal pressure in a pathophysiologic porcine model Helen G Hui-Chou MD, Leigh Ann Price MD, Arthur J Nam MD, Michael Magarakis MD, Gerhard S Mundinger MD, Luke S Jones BS, Eduardo D Rodriguez MD, DDS, FACS Johns Hopkins University School of Medicine, Baltimore, MD INTRODUCTION: The impact of complex abdominal ventral hernia repair on intra-abdominal pressure (IAP) has not been comprehensively investigated. We sought to correlate changes in IAP following primary hernia repair and components separation in a porcine model. METHODS: Primary ventral hernia repair was simulated by fascial imbrication in sixty swine. A 10x15 cm ellipse was outlined on the abdominal fascia where full thickness sutures were placed on the lateral edge of the outlined marks and then approximated in the midline. IAP was measured by veress needle. Parameters including bladder pressure (BLP) and femoral central venous pressure (CVP) were measured before and after imbrication and components separation (CS). Animals were desufflated, recovered, and survived to 12 week endpoint. RESULTS: There were significant changes in IAP, BLP, and CVP with primary hernia repair and components separation. During imbrication, these pressures increased by an average of 13, 15, and 15mmHg, respectively (p⬍0.01). After CS, pressures decreased by an average of 9, 8, and 9mmHg, respectively (p⬍0.01). Pressure increases from baseline more than 10-15mmHg had adverse effects on airway pressures, venous return, cardiac output, and urine output. CONCLUSIONS: We have demonstrated the impact of reconstructing major abdominal wall defects on several hemodynamic and physiologic parameters, which revealed that BLP is an accurate correlate to IAP. Components separation reduces IAP following primary hernia repair, but it may be inadequate to prevent the detrimental effects of intra-abdominal hypertension and may lead to abdominal compartment syndrome.
Surgical Forum Abstracts
S89
Subcutaneous talc and thrombin decrease seroma rates and drain duration after open ventral hernia repair with massive skin and subcutaneous reconstruction Rita A Brintzenhoff MD, Ajita Prabhu MD, Stanley Getz MD, H James Norton PhD, Amy Lincourt PhD, B Todd Heniford MD, FACS Carolinas Medical Center, Charlotte, NC INTRODUCTION: Wound complications after open ventral hernia repair with massive skin and subcutaneous reconstruction (OVHR/ MSSR) range from seroma to wound breakdown. Following OVHR, these occur in 12-20% and increase to 17-34% when combined with MSSR. This study evaluates a novel technique of applying talc and thrombin to subcutaneous flaps to prevent seroma formation. METHODS: A prospectively collected surgical outcomes database was accessed identifying all patients undergoing OVHR/MSSR from 1999-2010. Patients were divided into two groups based on receiving talc and thrombin therapy: PRE group did not receive therapy and POST group did. Demographics, peri-operative data, and outcomes were analyzed. RESULTS: PRE group consisted of 106 patients and POST group consisted of 44 patients. Demographic and peri-operative data was similar between groups. Complication rates for PRE/ POST were: cellulitis or oral antibiotics 26.4%/15.9%, intravenous antibiotics 10%/4.5%, operative/radiologic intervention for wound infection 17%/15.9%, seroma intervention 21%/4.5%, wound breakdown 14.2%/6.8%, and hernia recurrence 10.4%/0%. Of these, seroma intervention and hernia recurrence were significantly decreased in the POST group (p⫽0.014, p⫽0.034). Mean drain duration was 28.4 days for PRE and 17 days for POST (p⫽0.004). Mean follow-up was 5.6 months for PRE and 2.5 months for POST (p⫽0.032). CONCLUSIONS: To improve outcomes after massive OVHR/ MSSR, we treat the subcutaneous flaps created for MSSR with talc and thrombin. We found a decreased percentage of wound complications, with a significant reduction in seroma formation, recurrence, and drain duration. This suggests talc and thrombin will provide a means to decrease wound complications in massive ventral hernias.
Hematoma rate with and without tumescent solution in patients undergoing mastectomy with immediate tissue expander reconstruction Akhil K Seth MD, Elliot M Hirsch MD, John Y S Kim MD, Gregory A Dumanian MD, Thomas A Mustoe MD, FACS, Neil A Fine MD, FACS Northwestern University Feinberg School of Medicine, Chicago, IL INTRODUCTION: It has been postulated that using tumescent solution during mastectomy may lead to an increased hematoma rate. This study evaluates hematoma formation in patients undergoing mastectomy and immediate tissue expander reconstruction with and without tumescent solution.