title: Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Transabdominal Preperitoneal Approaches.
abstract: BACKGROUND
  Abdominal wall reconstruction for complex ventral and incisional hernias is associated with significant complications. Commonly, the peritoneal cavity is opened and adhesiolysis is performed with the potential for enterotomy. A totally extraperitoneal (TE) approach to abdominal wall reconstruction is feasible in many ventral hernia repairs and can reduce visceral injuries without impacting other outcomes. This study compares outcomes after retro-rectus ventral hernia repairs with TE and transabdominal (TA) preperitoneal approaches.
  
  
  METHODS
  An IRB-approved review of a prospective hernia database was performed for all ventral hernia repairs between 2009 and 2013. Preoperative patient characteristics, including demographics and comorbidities; operative variables, including surgical technique, operative duration, type/size/location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and nonwound complications, and readmissions or returns to the operating room were obtained. Groups were compared using t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests as appropriate. Significance was set at p < .05.
  
  
  RESULTS
  One hundred and seventy-five complex abdominal wall reconstructions were performed between 2009 and 2013. Of those, 85 patients underwent hernia repair for CDC grade 1 hernias with retro-rectus mesh placement performed (n = 45 TA, n = 40 TE). Groups did not differ in age, BMI, sex, smoking status, hernia defect size, history of COPD, asthma, hypertension, cancer, or renal failure. More TA patients had diabetes (36% vs. 13%; p = 0.02) and previous hernia repair (73% vs. 45%; p = 0.01) than TE patients. Mesh size was larger in the TE group (625 ± 234 cm(2) vs. 424 ± 214 cm(2); p < .001). There was no difference in enterotomy between TA and TE groups (0% vs. 2%; p = 1.0). However, there was a reduced operative time with TE (170 ± 49 minutes vs. 212 ± 49 minutes; p < .001).
  
  
  CONCLUSIONS
  Abdominal wall reconstruction can be performed safely in a TE fashion. The extraperitoneal approach results in shorter operative duration, but had similar complications when compared with TA preperitoneal approach.
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
authors.forename: Kai C
authors.initials: KC
authors.lastname: Johnson
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Miller
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Plymale
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
authors.forename: Salomon
authors.initials: S
authors.lastname: Levy
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Davenport
authors.affiliation: Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY. Electronic address: s.roth@uky.edu.
authors.forename: J Scott
authors.initials: JS
authors.lastname: Roth
mesh_terms: D034861:Abdominal Wall / Q000601:surgery*; D058107:Abdominal Wound Closure Techniques; D000328:Adult; D000368:Aged; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D013526:Surgical Mesh; D016896:Treatment Outcome