title: Evolution of abdominal wall reconstruction: development of a unified algorithm with improved outcomes.
abstract: BACKGROUND
  Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair.
  
  
  METHODS
  One hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence.
  
  
  RESULTS
  Seventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001).
  
  
  CONCLUSIONS
  Simplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.
authors.affiliation: From the Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Koltz
authors.forename: Jordan D
authors.initials: JD
authors.lastname: Frey
authors.forename: Derek E
authors.initials: DE
authors.lastname: Bell
authors.forename: John A
authors.initials: JA
authors.lastname: Girotto
authors.forename: Jose G
authors.initials: JG
authors.lastname: Christiano
authors.forename: Howard N
authors.initials: HN
authors.lastname: Langstein
mesh_terms: D000009:Abdominal Muscles / Q000601:surgery; D034861:Abdominal Wall / Q000601:surgery*; D000328:Adult; D000465:Algorithms; D005260:Female; D005500:Follow-Up Studies; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control; D012307:Risk Factors; D055502:Secondary Prevention; D013526:Surgical Mesh; D016896:Treatment Outcome