title: A dual-stage approach to contaminated, high-risk ventral hernia repairs.
abstract: The Modified Hernia Grading System (MHGS) was developed to risk stratify complex ventral hernia repairs (VHRs). MHGS grade 3 patients have mesh infections, dirty or contaminated fields, and/or violation of the alimentary tract. Reported surgical site infection (SSI) rates are over 40% after single-stage VHR in contaminated fields. In an attempt to decrease the SSI rate in MHGS grade 3 patients, we developed a dual-stage VHR (DSVHR) approach.
  
  
  
  We reviewed adult general surgery patients undergoing DSVHR between January 2010 and June 2014. All patients were MHGS grade 3. Primary end point was 30-d superficial and deep SSI. Secondary end points included other surgical site occurrences, 6-mo recurrence, and mesh excision rates.
  
  
  
  Fifteen patients underwent DSVHR. Mean age was 56 y, and median body mass index was 38.3 kg/m(2). Operative indication included enterocutaneous fistulas (ECF; n = 6), ECF with infected mesh (n = 2), infected mesh (n = 2), and VHR requiring bowel resection (n = 5). Thirty-one operative procedures were performed with median of 2.5 d between procedures. Fascial closure was re-established in 12 patients; five patients had underlay biologic mesh placement; seven underwent component separation with retrorectus mesh placement (synthetic [n = 2], biologic [n = 5]). The remaining patients underwent bridging repair with biologic mesh. One patient developed a recurrence after 6 mo, whereas a single patient had a recurrence of their ECF. Four (27%) patients developed a SSI, with an additional four (27%) experiencing a surgical site occurrence. There were no postoperative mesh infections.
  
  
  
  DSVHR in MHGS grade 3 patients is associated with a lower SSI rate than previously reported for those undergoing single-stage repairs.
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin. Electronic address: nkugler@mcw.edu.
authors.forename: Nathan W
authors.initials: NW
authors.lastname: Kugler
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Melanie
authors.initials: M
authors.lastname: Bobbs
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Travis
authors.initials: T
authors.lastname: Webb
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Carver
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: David
authors.initials: D
authors.lastname: Milia
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Jasmeet S
authors.initials: JS
authors.lastname: Paul
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006555:Hernia, Ventral / Q000382:microbiology / Q000601:surgery*; D059685:Herniorrhaphy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013526:Surgical Mesh; D013530:Surgical Wound Infection / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
keywords: Contaminated; Dirty; Hernia; High-risk; Infected; Surgical site infection; Ventral hernia; Ventral hernia repair