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

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.

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.

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.