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Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

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Abstract

Purpose

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

Methods

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

Results

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

Conclusion

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

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Data availability

Data is available from the corresponding author upon request.

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Acknowledgements

The authors thank John J. McMichael, PhD for running the natural language processing program.

Funding

This project and its related manuscript received no funding.

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Author notes

  1. C. M. McLaughlin and K. C. Montelione are co-first authors.

Authors and Affiliations

  1. Department of General Surgery, Division of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA

    C. M. McLaughlin

  2. Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    K. C. Montelione, A. S. Prabhu, D. M. Krpata, C. C. Petro, S. Rosenblatt & M. J. Rosen

  3. Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA

    C. Tu

  4. Department of Plastic Surgery, University of Pittsburgh Medical Center, Hershey, PA, USA

    X. Candela

  5. Department of General Surgery, Division of Minimally Invasive Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA

    E. Pauli & C. M. Horne

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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Caroline McLaughlin, Katherine Montelione, Chao Tu, and Xavier Candela. The first draft of the manuscript was written by Caroline McLaughlin and Katherine Montelione and all authors commented on previous version of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to C. M. McLaughlin.

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Conflict of interest

Eric Pauli MD: Consultant for Boston Scientific, Acuated Biomedical, Baxter, Wells Fargo, Cook Biotech, CmR Surgical, Neptune Medical, Surgimatix, Boehringer Labs, Allergan, Noah Medical, and ERBE. Royalties from UpToDate and Springer. Financial Interests in IHC Inc., Contamination Source Identification, and Cranial Devices Inc. Ajita S. Prabhu: Grant from Intuitive Surgical Inc.and personal fees from Intuitive Surgical, CMR Surgical, and Verb Surgical David M. Krpata: Grant from W.L Gore Clayton C. Petro: Grant from American Hernia Society Michael J. Rosen: Salary support for leadership position in ACHQC, grants from Intuitive Surgical Inc. and Pacira Pharmaceuticals Inc, and stock options Ariste Medical Charlotte M. Horne: Consultant for Bard and Medtronic. All other authors have no financial disclosures to report.

Ethical approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Cleveland Clinic Foundation (CCF) and Penn State Health (PSH) approved this study.

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Supplementary file1 (DOCX 19 KB)

Supplementary file2 Supplemental Video 1 Preoperative video of patient with right-sided abdominal wall bulge exascerbated by valsalva 10 years following bilateral free TRAM reconstruction. (MP4 1363 KB)

Supplementary file3 Supplemental Video 2 Postoperative video one month status post PCS/TAR reconstruction demonstrating resolution of right-sided bulge at rest and with valsalva. (MP4 8706 KB)

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McLaughlin, C.M., Montelione, K.C., Tu, C. et al. Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias. Hernia 28, 507–516 (2024). https://doi.org/10.1007/s10029-023-02942-5

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