title: Outcomes of complex abdominal herniorrhaphy: experience with 106 cases.
abstract: OBJECTIVE
  Reconstruction of abdominal wall defects is a challenging problem. Often, the surgeon is presented with a patient having multiple comorbidities, who has already endured numerous unsuccessful operations, leaving skin and fascia that are attenuated and unreliable. Our study investigated preoperative, intraoperative, and postoperative factors and techniques during abdominal wall reconstruction to determine which variables were associated with poor outcomes.
  
  
  METHODS
  Data were collected on all patients who underwent ventral abdominal hernia repair by 3 senior-level surgeons at our institution during an 8-year period. In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair.
  
  
  RESULTS
  A total of 106 patients were included. Seventy-nine patients (75%) had preoperative comorbid conditions. Sixty-seven patients developed a postoperative complication (63%). Skin necrosis was the most common complication (n = 21, 19.8%). Other complications included seroma (n = 19, 17.9%), cellulitis (n = 19, 17.9%), abscess (n = 14 13.2%), pulmonary embolus/deep vein thrombosis (n = 3, 2.8%), small bowel obstruction (n = 2, 1.9%), and fistula (n = 8, 7.5%). Factors that significantly contributed to postoperative complications (P < 0.05) included obesity, diabetes, hypertension, fistula at the time of the operation, a history of >2 prior hernia repairs, a history of >3 prior abdominal operations, hospital stay for >14 days, defect size > 300 square cm, and the use of human-derived mesh allograft. Factors that significantly increased the likelihood of a hernia recurrence (P < 0.05) included a history of >2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a postoperative complication, particularly infection. Hernia recurrences were significantly reduced (P < 0.05) by using a "sandwich" repair with both a mesh overlay and underlay and by using component separation.
  
  
  CONCLUSIONS
  A history of multiple abdominal operations is a major predictor of complications and recurrences. If needed, component separation should be used to achieve primary tension-free closure, which helps to reduce the likelihood of hernia recurrences. Our data suggest that mesh reinforcement used concomitantly in a "sandwich" repair with component separation release may lead to reduced recurrence rates and may provide the optimal repair in complex hernia defects.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of General Surgery, Stanford University Medical Center, Stanford, CA, USA.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Satterwhite
authors.forename: Sara
authors.initials: S
authors.lastname: Miri
authors.forename: Christina
authors.initials: C
authors.lastname: Chung
authors.forename: David
authors.initials: D
authors.lastname: Spain
authors.forename: Hermann P
authors.initials: HP
authors.lastname: Lorenz
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D034861:Abdominal Wall / Q000503:physiopathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006555:Hernia, Ventral / Q000175:diagnosis / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013526:Surgical Mesh; D013718:Tensile Strength; D016896:Treatment Outcome; D055815:Young Adult