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Published Online 14 May 2015

Abdominal wall reconstruction with biological mesh: novel reinforcement with mesh ‘off-cuts’

Publication: The Annals of The Royal College of Surgeons of England
Volume 96, Number 8

Background

Abdominal wall repair for complex defects is challenging, especially when restorative intestinal surgery is also undertaken (eg enterocutaneous fistula surgery). Under these circumstances, using a biological mesh enables single stage repair with a lower risk of infection than conventional meshes.1,2 Controversy remains over the optimal reconstruction technique and the most suitable position for mesh placement in the abdominal wall. In our opinion, components separation (CS) is the ideal approach. This enables advancement of the rectus muscles and anterior rectus sheath towards the midline3 (Fig 1) with intraperitoneal underlay fixation of biological mesh as a ‘bridge’, with 3–5cm overlap (Fig 2). However, subsequent defects created laterally by CS are potential sites of weakness, particularly below the arcuate line where there is no posterior rectus sheath.
Figure 1 The result of components separation with medial advancement of the sheath (in this case also preserving perforator vessels)
Figure 2 Abdominal wall following fixation of Strattice™ biological mesh in an intraperitoneal bridging inlay position with internal overlap

Technique

We use Strattice™ (LifeCell, Branchburg, NJ, US) porcine collagen mesh, which is produced as a rectangular sheet. As the abdominal wall defect requiring bridging is oval, the redundant mesh corners can be removed prior to fixation. Following completion of the midline repair, these ‘off-cuts’ are more usefully sutured separately in an onlay position to reinforce the CS lateral defects (Fig 3). The subcutaneous tissues and skin are closed in layers over suction drains.
Figure 3 Appearance following onlay reinforcement of the lateral components separation defects with Strattice™ ‘off-cuts’ below the level of the arcuate line

Discussion

Complex abdominal wall reconstruction is time consuming and demanding. The described technique combines the advantages of underlay mesh placement for the full-thickness midline defect and onlay reinforcement where it is most needed, aiming to reduce the risk of further abdominal wall failure and repeat surgery.

References

1.
Itani KM, Rosen M, Vargo D, et al. Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH study. Surgery 2012; 152: 498–505.
2.
Datta V, Engledow A, Chan S, et al. The management of enterocutaneous fistula in a regional unit in the United Kingdom: a prospective study. Dis Colon Rectum 2010; 53: 192–199.
3.
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.

Information & Authors

Information

Published In

cover image The Annals of The Royal College of Surgeons of England
The Annals of The Royal College of Surgeons of England
Volume 96Number 8November 2014
Pages: 623 - 624
PubMed: 25350190

History

Published in print: November 2014
Published online: 14 May 2015

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Authors

Affiliations

S Warraich
Oxford University Hospitals NHS Trust, UK
R Lovegrove
Oxford University Hospitals NHS Trust, UK
Oxford University Hospitals NHS Trust, UK

Notes

CORRESPONDENCE TO Richard Guy, E: [email protected]

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