Abstract
With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify “complex” are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.
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References
Nguyen MT, Berger RL, Hicks SC et al (2014) Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA Surg 149:415–421
HCUPnet. Healthcare Cost and Utilization Project (HCUP) (2008–2012) Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/. Accessed July 10, 2015
Higa G, Friese R, O’Keeffe T et al (2010) Damage control laparotomy: a vital tool once overused. J Trauma 69:53–59
Latifi R, Gustafson M (2011) Abdominal wall reconstruction in patients with enterocutaneous fistulas. Eur J Trauma Emerg Surg 37:241–250
Becker HP, Willms A, Schwab R (2007) Small bowel fistuals and the open abdomen. Scand J Surg 96:263–271
Hadeed JG, Walsh MD, Pappas TN et al (2011) Complex abdominal wall hernias: a new classification system and approach to management based on review of 133 consecutive patients. Ann Plast Surg 66:497–503
Connolly PT, Teubner A, Lees NP et al (2008) Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg 247:440–444
Visschers RG, van Gemert WG, Winkens B et al (2012) Guided treatment improves outcome of patients with enterocutaneous fistulas. World J Surg 36:2341–2348. doi:10.1007/s00268-012-1663-4
Visschers RG, Olde Damink SW, van Bekkum M et al (2008) Health-related quality of life in patients treated for enterocutaneous fistula. Br J Surg 95:1280–1286
Latifi R, Peralta R, Al Thani H (2013) Abdominal wall reconstruction in patients with an open abdomen and enterocutaneous fistulas: a nine-step treatment strategy. In: Latifi R (ed) Surgery of complex abdominal wall defects. Springer, New York, pp 133–146
Girard E, Messager M, Sauvanet A et al (2014) Anastomotic leakage after gastrointestinal surgery: diagnosis and management. J Visc Surg 151:441–450
Redden MH, Ramsay P, Humphries T et al (2013) The etiology of enterocutaneous fistula predicts outcome. Ochsner J 13:507–511
Kohler G, Pallwein-Prettner L, Koch OO et al (2015) Magnetic resonance-visible meshes for laparoscopic ventral hernia repair. JSLS 19:e2014.00175
Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228
Dietch ZC, Shah PM, Sawyer RG (2015) Advances in intra-abdominal sepsis: what is new? Curr Infect Dis Rep 17:497
Okita Y, Kobayashi M, Araki T et al (2014) Impact of Surgical Infection Society/Infectious Disease Society of America-recommended antibiotics on postoperative intra-abdominal abscess with image-guided percutaneous abscess drainage following gastrointestinal surgery. Surg Today 45:993–1000
Duszak R Jr, Chatterjee AR, Schneider DA (2010) National fluid shifts: fifteen-year trends in paracentesis and thoracentesis procedures. J Am Coll Radiol 7:859–864
Polk TM, Schwab CW (2012) Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg 36:524–533. doi:10.1007/s00268-011-1315-0
Latifi R (2011) Nutritional therapy in critically ill and injured patients. Surg Clin North Am 91:579–593
Visschers RG, Olde Damink SW, Winkens B et al (2008) Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg 32:445–453. doi:10.1007/s00268-007-9371-1
Lloyd DA, Gabe SM, Windsor AC (2006) Nutrition and management of enterocutaneous fistula. Br J Surg 93:1045–1055
Campos ACL, Andrade DF, Campos GMR et al (1999) A multivariate model to determine prognostic factors in gastrointestinal fistuals. J Am Coll Surg 188:483–490
Li J, Ren J, Zhu W et al (2003) Management of enterocutaneous fistulas 30 year clinical expereince. Chin Med J 116:171–175
Hollington P, Mawdsley J, Lim W et al (2004) An 11-year experience of enterocutaneous fistula. Br J Surg 91:1646–1651
Edmunds LH Jr, Williams GM, Welch CE (1960) External fistulas arising from the gastro-intestinal tract. Ann Surg 152:445–469
Berry SM, Fischer JE (1996) Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am 76:1009–1018
Evenson AR, Fischer JE (2006) Current management of enterocutaneous fistula. J Gastrointest Surg 10:455–464
Soeters PB, Ebeid AM, Fischer JE (1979) Review of 404 patients with gastrointestinal fistulas: impact of parenteral nutrition. Ann Surg 190:189–202
Wu Y, Ren J, Wang G et al (2014) Fistuloclysis improves liver function and nutritional status in patients with high-output upper enteric fistula. Gastroenterol Res Pract. doi:10.1155/2014/941514
Lévy E, Palmer DL, Frileux P et al (1983) Inhibition of upper gastrointestinal secretions by reinfusion of succus entericus into the distal small bowel. A clinical study of 30 patients with peritonitis and temporary enterostomy. Ann Surg 198:596
Teubner A, Morrison K, Ravishankar H et al (2004) Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg 91:625–631
Soares KC, Baltodano PA, Hicks CW et al (2015) Novel wound management system reduction of surgical site morbidity after ventral hernia repairs: a critical analysis. Am J Surg 209:324–332
Heineman JT, Garcia LJ, Obst MA et al (2015) Collapsible enteroatmospheric fistula isolation device: a novel, simple solution to a complex problem. J Am Coll Surg 221:e7–e14
Dumville JC, Owens GL, Crosbie EJ et al (2015) Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Libr 1–37 (review)
Horch RE (2015) Incisional negative pressure wound therapy for high-risk wounds. J Wound Care 24:21–28
Mutafchiyski VM, Popivanov GI, Kjossev KT et al (2015) Open abdomen and vac® in severe diffuse peritonitis. J R Army Med Corps. doi:10.1136/jramc-2014-000386
Willms A, Gusgen C, Schaaf S et al (2015) Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbecks Arch Surg 400:91–99
Slade DA, Carlson GL (2013) Takedown of enterocutaneous fistula and complex abdominal wall reconstruction. Surg Clin North Am 93:1163–1183
Majercik S, Kinikini M, White T (2012) Enteroatmospheric fistula from soup to nuts. Nutr Clin Pract 27:507–512
Schecter WP, Hirshberg A, Chang DS et al (2009) Enteric fistulas: principles of management. J Am Coll Surg 209:484–491
Rohrich RJ, Lowe JB, Hackney FL et al (2000) An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 105:202–216
Sukkar SM, Dumanian GA, Szczerba SM et al (2001) Challenging abdominal wall defects. Am J Surg 181:115–121
Lowe JB (2006) Updated algorithm for abdominal wall reconstruction. Clin Plast Surg 33:225–240
Lynch AC, Delaney CP, Senagore AJ et al (2004) Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg 240:825–831
Owen RM, Love TP, Perez SD et al (2013) Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg 148:118–126
Brenner M, Clayton JL, Tillou A et al (2009) Risk factors for recurrence after repair of enterocutaneous fistula. Arch Surg 144:500–505
Higa G, Latifi R (2013) A difficult abdomen: clinical course-based management. In: Latifi R (ed) Surgery of complex abdominal wall defects. Springer, New York, pp 47–58
Rodriguez ED, Bluebond-Langner R, Silverman RP et al (2007) Abdominal wall reconstruction following severe loss of domain: the R Adams Cowley Shock Trauma Center algorithm. Plast Reconstr Surg 120:669–680
Lord JW, Howes EL, Jolliffe N (1949) The surgical management of chronic recurrent intestinal obstruction due to adhesions. Ann Surg 129:315–322
Joyce MR, Dietz DW (2009) Management of complex gastrointestinal fistula. Curr Probl Surg 46:384–430
Martinez JL, Luque-de-Leon E, Mier J et al (2008) Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg 32:436–443. doi:10.1007/s00268-007-9304-z (discussion 444)
Leppaniemi A, Tukiainen E (2013) Reconstruction of complex abdominal wall defects. Scand J Surg 102:14–19
Albanese A (1951) Eventracion mediana xifoumbilical gigante: metodo para su tratamiento. Rev Asoc Med Argent 65:376–378
Ramirez OM, Ruas E, Dellon AL (1990) “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 86:519–526
Lisiecki J, Kozlow JH, Agarwal S et al (2015) Abdominal wall dynamics after component separation hernia repair. J Surg Res 193:497–503
Mericli AF, Bell D, DeGeorge BR Jr et al (2013) The single fascial incision modification of the “open-book” component separation repair: a 15-year experience. Ann Plast Surg 71:203–208
O’Halloran EB, Barwegen CJ, Dombrowski JM et al (2014) Can’t have one without the other: component separation plus mesh for repairing difficult incisional hernias. Surgery 156:894–899
Slater NJ, Bokkerink WJ, Konijn V et al (2015) Safety and durability of one-stage repair of abdominal wall defects with enteric fistulas. Ann Surg 261:553–557
Slater NJ, van Goor H, Bleichrodt RP (2015) Large and complex ventral hernia repair using “components separation technique” without mesh results in a high recurrence rate. Am J Surg 209:170–179
Fischer JP, Basta MN, Mirzabeigi MN et al (2014) A comparison of outcomes and cost in VHWG grade II hernias between Rives-Stoppa synthetic mesh hernia repair versus underlay biologic mesh repair. Hernia 18:781–789
Cobb WS, Warren JA, Ewing JA et al (2015) Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence. J Am Coll Surg 220:606–613
Petro CC, Posielski NM, Raigani S et al (2015) Risk factors for wound morbidity after open retromuscular (sublay) hernia repair. Surgery. doi:10.1016/j.surg.2015.1005.1003
Richmond B, Harrah T, Dyer B et al (2014) Component separation with porcine acellular dermal reinforcement is superior to traditional bridged mesh repairs in the open repair of significant midline ventral hernia defects. Am Surg 80:725–731
Harth KC, Broome AM, Jacobs MR et al (2011) Bacterial clearance of biologic grafts used in hernia repair: an experimental study. Surg Endosc 25:2224–2229
Latifi R, Joseph B, Kulvatunyou N et al (2012) Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches. World J Surg 36:516–523. doi:10.1007/s00268-011-1306-1
Ventral Hernia Working G, Breuing K, Butler CE et al (2010) Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558
Kohler G, Weitzendorfer M, Kalcher V et al (2015) Synthetic mesh repair for incisional hernia treatment in high-risk patients for surgical site occurrences. Am Surg 81:387–394
Pinell-White XA, Gruszynski M, Losken A (2014) Ventral hernia repair after bowel surgery: does gastrointestinal contamination matter in the era of biologic mesh? Ann Plast Surg 72:S150–S152
Rosen MJ, Krpata DM, Ermlich B et al (2013) A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 257:991–996
Bluebond-Langner R, Keifa ES, Mithani S et al (2008) Recurrent abdominal laxity following interpositional human acellular dermal matrix. Ann Plast Surg 60:76–80
Peralta R, Latifi R (2012) Long-term outcomes of abdominal wall reconstruction. What are the real numbers? World J Surg 36:534–538. doi:10.1007/s00268-012-1454-y
Slater NJ, van der Kolk M, Hendriks T et al (2013) Biologic grafts for ventral hernia repair: a systematic review. Am J Surg 205:220–230
Fabian TC, Croce MA, Pritchard FE et al (1994) Planned ventral hernia: staged management for acute abdominal wall defects. Ann Surg 219:643–653
Krpata DM, Stein SL, Eston M et al (2013) Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. Am J Surg 205:354–358 (discussion 358-359)
Satterwhite TS, Miri S, Chung C et al (2012) Outcomes of complex abdominal herniorrhaphy: experience with 106 cases. Ann Plast Surg 68:382–388
Darehzereshki A, Goldfarb M, Zehetner J et al (2014) Biologic versus nonbiologic mesh in ventral hernia repair: a systematic review and meta-analysis. World J Surg 38:40–50. doi:10.1007/s00268-013-2232-1
Broyles JM, Abt NB, Sacks JM et al (2013) Bioprosthetic tissue matrices in complex abdominal wall reconstruction. Plast Reconstr Surg Glob Open 1:1–7
Burger JWA, Luijendijk RW, Hop WCJ et al (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–585
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Latifi, R. Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects. World J Surg 40, 836–848 (2016). https://doi.org/10.1007/s00268-015-3294-z
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DOI: https://doi.org/10.1007/s00268-015-3294-z