Recalcitrant Abdominal Wall Hernias: Long-Term Superiority of Autologous Tissue RepairJohn A. Girotto, M.D., Michael Chiaramonte, M.D., Nathan G. Menon, M.D., Navin Singh, M.D.,Ron Silverman, M.D., Anthony P. Tufaro, M.D., Maurice Nahabedian, M.D., Nelson H. Goldberg, M.D.,and Paul N. Manson, M.D.Baltimore, Md.

Secondary repair of recurrent ventral hernia is difficult,and success depends on re-establishing the functional in-tegrity of the abdominal wall. Current techniques used forclosure of these defects have documented recurrencerates as high as 54 percent. The authors’ 8-year experienceutilizing variations of the components separation tech-nique for autologous tissue repair of recalcitrant herniasemphasizes that recurrent or recalcitrant hernias benefitfrom the creation of a dynamic abdominal wall. A total of389 patients were retrospectively identified as having ab-dominal wall defects, and 284 of these patients met theselection criteria. Study patients were grouped accordingto the type of surgical repair used. The recurrence rate was20.7 percent over all study groups and was directly relatedto the extent of repair required. Group 1 patients (widetissue undermining) had a recurrence rate of only 15percent, while in group 2 (complete components sepa-ration), the recurrence rate was 22 percent. Group 3 pa-tients (interpositional fascia lata graft) had a 29 percentrecurrence rate. Time to recurrence was also significantlydifferent across treatment groups, with study group 3 ex-periencing earlier hernia recurrence. The most frequentpostoperative complication was wound infection, whichwas directly related to the repair performed. The relativeodds of recurrence versus the risk factors of age, sex,perioperative steroid use, wound infection, defect size,and the presence of enterocutaneous fistula were studiedwith a logistic regression analysis. These factors did notpossess statistical significance for predicting hernia recur-rence. The preoperative presence of mesh was indepen-dently significant for hernia recurrence, increasing therelative odds 2.2 times (p � 0.01). Similarly, when otherrisk factors were controlled for, increasing the complexityof the treatment group, from study group 1 (wide tissueundermining) to study group 3 (interpositional fascia latagraft), also increased the odds of hernia recurrence 1.5-fold per group (p � 0.04). Average inpatient cost was$24,488. The length of inpatient stay ranged from 2 to 172days (average, 12.8 days). The length of inpatient stay andcosts were directly related to the extent of repair required.Using the analysis of variance test for multiple factors, the

presence of an enterocutaneous fistula (p � 0.0014) or apostoperative wound infection (p � 0.008) independentlyincreased the length of inpatient stay and hospital costs.A total of 108 successfully repaired patients were con-tacted by telephone and agreed to participate in a self-reported satisfaction survey. The patients noticed im-provements in the appearance of their abdomen, in theirpostoperative emotional state, and in their ability to liftobjects, arise from a chair or a bed, and exercise. Theseresults suggest that recalcitrant hernia defects should besolved, when possible, by reconstructing a dynamic ab-dominal wall. (Plast. Reconstr. Surg. 112: 106, 2003.)

Ventral hernia complicates nearly 11 per-cent of abdominal surgery procedures. Re-pair of recalcitrant hernias is often difficultand depends on re-establishing the func-tional integrity of the abdominal wall. Cur-rent techniques for closure of these defectshave documented recurrence rates as high as54 percent.1–3 For the past 8 years, we haveutilized variations of the components separa-tion technique for autologous tissue repair ofrecalcitrant hernias. It is our hypothesis thatrecalcitrant hernias— hernias that havefailed at least one prior attempt at repair—benefit from the recreation of a dynamicabdominal wall by muscle approximation.Our long-term outcomes document lower re-currence rates in these difficult patients thando other published techniques. Recalcitranthernia defects represent a difficult surgicalproblem requiring extensive hospital timeand resources.

From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, Department of Surgery, The Johns Hopkins School of Medicine, andthe University of Maryland School of Medicine. Received for publication May 30, 2002; revised October 1, 2002.

Presented in part at the 80th Annual Meeting of the American Association of Plastic Surgeons, in Charleston, South Carolina, May 14, 2001.

DOI: 10.1097/01.PRS.0000066162.18720.C8

106

PATIENTS AND METHODS

A cohort of patients was identified retrospec-tively. The following inclusion criteria were es-tablished: the presence of a ventral wall ab-dominal defect and a history of at least oneprior attempt at repair. These study patientswere defined as possessing recalcitrant abdom-inal wall defects. Patients were specifically ex-cluded from the study if they met one of thethree following criteria: (1) if they requiredemergent closure of their abdominal wall; (2)if they sustained significant abdominal tissueloss, such as from trauma or tumor extirpation;or (3) if their follow-up was less than 6 months.

The patient presented in Figure 1 is typicalof the study population. Loss of abdominal wallintegrity is seen, and the abdomen is embar-rassed by a skin graft from an earlier attempt atrepair. Intraoperatively, the integrity of the fas-cia and muscle has been re-established with thecomponents separation technique.

RESULTS

Patient Groups

A total of 389 patients were retrospectivelyidentified, and 284 of these patients met theselection criteria. Patient data were prospec-tively studied without matched controls. Theage of our study population ranged from 15 to85 years (mean age, 49.7 years), and 55.4 per-cent were female and 44.6 percent were male.The average follow-up time was 26 months(range, 6 to 96 months). The average defectsize was large, equaling 140 cm2.

Study patients were organized into groupsaccording to the type of surgical repair used.There were significant differences among ourgroups with respect to sex, the presence ofpreoperative synthetic mesh, and the perioper-ative use of immunosuppressive medications.These differences were addressed by our re-gression analysis.

FIG. 1. This patient is typical of the study population. (Left) Loss of abdominal wall integrity is seen, and theabdomen is embarrassed by the presence of a skin graft from an earlier attempt at repair. (Right) Intraoperativeclosure of the abdomen with the “components separation” technique.

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Group 1: Primary muscle repair with mesh overlay(n � 110). Patients with recalcitrant herniadefects were reconstructed by widely separatingthe subcutaneous tissues from the underlyingfascia and muscle. This mobilization permittedprimary repair of muscle and fascia without fas-cial incisions. Synthetic mesh was placed overthe muscle when possible.

Group 2: Component separation and primary mus-cle repair with mesh on lay reinforcement (n �96). Patients were similarly reconstructed bywide separation of the subcutaneous tissuesfrom the underlying muscle and fascia. How-ever, relaxing incisions in the aponeurosis ofthe external oblique muscles and/or elevation

of the rectus muscles from the posterior rectussheath was also performed. Synthetic mesh wassutured over the repair when necessary.

Group 3: Interpositional fascial reconstruction (n� 78). In these patients, the use of syntheticmesh was thought to be contraindicated. Wideseparation of the subcutaneous tissues from theunderlying muscle and fascia was followed by afascia lata graft used as an interposition betweenthe muscles of the abdominal wall. Componentsseparation relaxing incisions were used as nec-essary to minimize tension. Figure 2 demon-strates this technique.

For all repair techniques, the overall recur-rence rate was 20.7 percent. Recurrence was

FIG. 2. This patient is typical of patients in study group 3 (interpositional fascia lata graft). (Above, left and center) Loss ofabdominal wall integrity is seen, and the colostomy represents a relative contraindication to the use of synthetic mesh. (Above,right) The fascia lata interpositional graft is sewn into place. The components separation technique has also been used, with wideseparation of the subcutaneous tissues from the underlying muscle and fascia and relaxing incisions in the aponeurosis of theexternal oblique muscle. (Below) Postoperative appearance after abdominal domain and intestinal continuity have beenre-established.

108 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003

directly related to the extent of repair re-quired. Group 1 patients experienced a recur-rence rate of 15 percent; in group 2, the recur-rence rate was 22 percent. In group 3 patients,it was 29 percent. Time to recurrence was sig-nificantly different across treatment groups,with the earliest recurrence seen in group 3.

Postoperative complications varied but mostfrequently they involved wound infection. Thefrequency of wound infection was directly re-lated to the extent of repair required. Postop-erative infection in group 3 patients was re-lated to either the abdominal repair or thetensor fasciae latae donor site. Infection fre-quency is depicted in Figure 3. Kaplan-Meiercurves were calculated, and interestingly, post-operative wound infection did not affect thefrequency of hernia recurrence.

A logistic regression analysis was undertakento establish the relative risk of recurrence. Riskfactors were age, sex, perioperative steroid use,wound infection, defect size, and the presenceof an enterocutaneous fistula. Interestingly,these risk factors did not significantly increasethe risk of hernia recurrence. A representativeKaplan-Meier curve for perioperative steroiduse is illustrated in Figure 4.

The preoperative presence of mesh was in-dependently significant for hernia recurrenceand increased the relative risk of recurrence bya factor of 2.2 (p � 0.01). Graphic depiction ofthis risk is seen in Figure 5. Similarly, whenother risk factors were controlled for, increas-ing the complexity of the treatment group also

increased the risk of hernia recurrence by afactor of 1.5 per group (p � 0.04).

Comprehensive billing data were availablefor 79.3 percent of our study patients from1995. Average inpatient costs were $24,488,and the length of inpatient stay ranged from 2to 172 days (average, 12.8 days). The length ofinpatient stay and costs were directly related tothe study group. Specifically, group 3 patientsrequired nearly 3 weeks in the hospital at a costof more than $40,000, whereas groups 1 and 2stayed only 10 days in the hospital at a cost ofapproximately $20,000. Using the analysis ofvariance test for the significance of multiplefactors, the presence of an enterocutaneousfistula (p � 0.0014) or a postoperative woundinfection (p � 0.008) independently increasedboth the length of inpatient stay and hospitalcosts (Fig. 6).

A total of 108 successfully repaired patientswere contacted by telephone and agreed toparticipate in a self-reported satisfaction sur-vey. They were asked a series of questions re-garding their emotional health and well being,the appearance of their abdomen, and theirability to perform daily activities. Patients wereasked to score their postoperative satisfactionin these areas on a 50-point scale, with 30representing no improvement and 50 indicat-ing “much better.” The patients noticed im-provements in the appearance of their abdo-men, in their emotional state postoperatively,in abdominal strain, and in their ability to liftobjects, arise from a chair and a bed, andexercise. Interestingly, they reported nochange in their bowel function or in their backpain. Patient satisfaction results are graphicallydepicted in Figure 7.

DISCUSSION

Incisional hernias frequently complicate ab-dominal surgery procedures.4–6 Incisional her-nias may cause serious morbidity from a varietyof symptoms, including bowel or omental in-carceration and strangulation. The abdominalwall is a uniquely dynamic structure. Its three-dimensional motion is essential to both respi-ratory and gastrointestinal function. Unlike themobile thoracic cage, the abdominal wall isonly supported at its periphery by bony an-chors. The ideal abdominal wall reconstruc-tion should fulfill the criteria of DiBello andMoore7: (1) prevent visceral eventration; (2)incorporate with the remaining abdominalwall; (3) provide dynamic muscle support; (4)

FIG. 3. Frequency of postoperative wound infection bystudy group: group 1, wide tissue undermining; group 2,complete components separation; group 3, interpositionalfascia lata graft.

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provide a tension-free repair, and (5) endureover time.

Many techniques for hernia repair havebeen described. Recurrence frequently followsprimary repair, and rates have been quoted ashigh as 54 percent.1–3 It is this group of patientswith recalcitrant defects who frequently re-

quire special closure techniques. For all pa-tients studied here, at least one prior attemptat repair had failed. Our patients comprised aunique and challenging cohort that has re-ceived only peripheral attention in the litera-ture. For the past 8 years, we have utilizedvariations of the components separation tech-

FIG. 4. Kaplan-Meier curves indicating that perioperative steroid administration does notsignificantly predict hernia recurrence.

FIG. 5. Kaplan-Meier curves indicating that the preoperative presence of mesh was indepen-dently significant for hernia recurrence. The presence of preoperative mesh increased therelative odds of recurrence 2.2-fold (p � 0.01).

110 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003

nique for autologous tissue repair of recalci-trant hernias. It is our hypothesis that recur-ring or recalcitrant hernias benefit from thecreation of a dynamic abdominal wall and thatwide exposure of the entire anterior abdomi-nal wall permits identification of additional ar-eas of weakness and simultaneous hernias. Fiftypercent of patients had more than one herniaat the time of exploration.

The practice of direct suture repair of herniadefects by limited exposure is inadequate fortwo reasons. First, there is no relief of abdom-inal wall tension. Second, there is no opportu-nity to inspect the entire anterior abdominal

wall. Luijendijk et al.8 reported on a cohort ofpatients prospectively randomized to either di-rect repair or repair with interpositional mesh.The long-term recurrence rate was significantlydifferent between these two groups, with thesuture repair failing 43 percent of the time andthe mesh failing only 24 percent of the time.Among the patients in Luijendijk et al.’s study,only 27 could be classified as having recalci-trant hernias. Recurrences in patients with re-calcitrant defects ranged from 20 to 58 per-cent.8 The authors conclude that even for smalldefects, the use of interpositional mesh is su-perior to direct closure.

Luijendijk et al.8 reported few mesh-relatedcomplications. Traditionally, synthetic mesh incontact with the bowel carries the risk of ero-sion, infection, and fistula formation. Voyles etal.9 reported long-term mesh extrusion or fis-tula formation to be 78 percent and 22 per-cent, respectively. Karakousis et al.10 confirmedthese data, documenting a fistula occurrencerate following abdominal wall repair with un-protected mesh of 23 percent.

Although new Marlex, Prolene, and Gore-Tex products are available for implantation, itremains desirable to interpose omentumand/or peritoneum between the mesh and thebowel. Such an interposition dramatically low-ers the incidence of gastrointestinal complica-tions.8,11 Omentum, however, is often at a pre-mium in the patient with a recalcitrantabdominal wall hernia. For that reason, wehave advocated the use of vascularized, inner-vated tissue obtained with wide underminingand variations of the components separation

FIG. 6. (Left) Average length of inpatient stay (LOS, in days) by study group.(Right) Average hospital costs (in thousands of dollars) by study group. Group1 (wide tissue undermining), �; group 2 (complete components separation), f;group 3 (interpositional fascia lata graft), o.

FIG. 7. Successfully repaired patients scored their post-operative satisfaction on a 50-point scale, with 30 represent-ing no improvement and 50 indicating “much better.” Im-provements were noted in abdominal appearance (Looks),emotional state (Emotions), subjective abdominal strength(Strength), and ability to lift objects (Lift), arise from a chairand a bed (Stand), and exercise (Ex).

Vol. 112, No. 1 / RECALCITRANT ABDOMINAL WALL HERNIAS 111

technique to release tension and re-establishthe integrity of the abdominal wall. Wide un-dermining, as performed in group 1 study pa-tients, accomplishes two important goals: (1)inspection of the entire abdominal wall toidentify secondary hernia defects or weak-nesses missed by physical examination and (2)release of the tension imposed by scar and skincontracture.

In our series of recalcitrant abdominal wallrepairs, the recurrence rate was 20.7 percent.Recurrence was directly related to the extent ofrepair. When vascularized, innervated tissue isavailable and utilized via variations of the com-ponents separation technique, recurrence islower. Specifically, group 1 patients had a re-currence rate of only 15 percent, whereas ingroup 2, the recurrence rate equaled 22 per-cent. Group 3 patients, repaired with the fascialata graft, had a recurrence rate of 29 percent.The patients in study group 3 are a unique anddifficult cohort. The degree of preoperativewound contamination in this group, eitherfrom fistulas or ostomy, theoretically prohibitsthe use of synthetic mesh. Clearly, the tensilestrength of autologous fascia is less than that ofsynthetic mesh,12 and this may ultimately con-tribute to the increased rate of recurrenceobserved.

Using the components separation techniquein a limited group of patients (n � 35) withrecalcitrant hernias, DiBello and Moore7 re-ported an overall recurrence rate of only 8.5percent. Similarly, we have previously reporteda group of recalcitrant hernia patients (n � 37)with a recurrence rate of 5 percent overall.13

Our average follow-up is now greater than 26months (range, 6 to 96 months), comparedwith studies in which average follow-up timeswere less than 2 years. Time has proven to be asterner judge of clinical outcomes.

The risks of recurrence were also evaluatedby multivariate logistical regression. Most stan-dard risk factors did not affect recurrence. Spe-cifically, age, sex, perioperative immunosup-pressive medications, size of defect, infection,and prior surgical treatment did not alter therelative risk of hernia recurrence. These resultsare different from the findings of Luijendijk etal.,18 who reported a statistically significant linkbetween infection and recurrence and be-tween prior abdominal aneurysm surgery pro-cedures and hernia recurrence. They also notethat others have reported a similar increasedfrequency of inguinal and incisional hernias in

patients who have undergone prior abdominalaneurysm surgical treatment.14 No clear mech-anism of association is apparent.

The size of the defect has frequently beencited as a risk for hernia recurrence.15 Exces-sive tension at the edges of the abdominal walldefect produces local tissue ischemia and hasbeen widely implicated in the failure rates ofsome repair techniques,1 especially primary re-pairs. Luijendijk et al.8 have advocated the useof interpositional mesh to decrease wound clo-sure tension. When mesh is contraindicated, asin the contaminated wound, the use of inter-positional fascia lata grafting similarly reduceswound tension.

Advancing the individual components of theabdominal wall with the components separa-tion technique, where fascia is incised, clearlyreduces the tension of the closure, but it alsoweakens the abdominal wall in the areas ofrelease. Nahas et al.16 have presented cadaverdata to document this statement. Document-ing tension measurements from various posi-tions along the rectus sheath during the stagesof the components separation dissection, theydemonstrated a statistically significant reduc-tion in the traction index with increaseddissection.

The risk of recurrence is also directly relatedto the presence of preoperative mesh. Fre-quently, this mesh was exposed and contami-nated. The recalcitrant abdominal wall defectthat has already failed a mesh repair is a testa-ment to the severity of that defect.

In today’s environment of managed care,outcomes must also be examined within theframework of patient satisfaction and hospitalcosts. These interrelated measurements reflectthe increase in the power of patient advocacygroups and of financial managers in medicalcare, including the government.

Comprehensive financial data were availablefor nearly 80 percent of our patients. The costsof recalcitrant hernia repair were striking, av-eraging more than $24,000. Hospital costs weredirectly related to the extent of repair re-quired. Patients in groups 1 and 2 spent fewerdays in the hospital and had lower overall coststhan patients in group 3. Analysis of variancetesting for multiple factors revealed that onlythe presence of an enterocutaneous fistula (p� 0.0014) or a postoperative wound infection(p � 0.008) independently increased thelength of inpatient stay and hospital costs. Itshould be noted that both of these risk factors

112 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003

were found more frequently in group 3patients.

Numerous studies have addressed the costsassociated with inguinal hernia repair. Authorshave attempted to justify open versus laparo-scopic repair in terms of hospital costs, totalcosts, and time off work.17,18 The results do notdemonstrate a superior technique and bridgemany different health care delivery systems.Few studies in the literature have examined thecosts associated with ventral hernia repairs. Is-raelsson and Wimo19 studied the operativecosts as they related to different suture closuretechniques. They found that the average costof one hernia repair was $42,643 Swedish Kro-nors ($4028.48 in 2000 U.S. dollars). This costis dramatically lower than the cost of the recal-citrant hernia defect. Patient selection, opera-tive techniques, varying exchange rates, anddiffering national health care standards are, ofcourse, difficult to equate.

Holzman et al.20 compared the hospital costsand lengths of inpatient stay of patients withventral hernias repaired laparoscopically andof patients repaired with a traditional openapproach. Those patients repaired with a tra-ditional open technique required a longer in-patient hospital stay (5 days versus 1.6 days) ata greater overall cost ($7300 versus $4400, p �0.05) compared with patients treated laparo-scopically. Overall recurrence rates were simi-lar (12 percent), with an average follow-uptime of less than 2 years. Similarly, DeMaria etal.21 studied laparoscopic ventral hernia repairsin comparison to traditional open techniques.This group documented a less painful recoveryin the patients treated laparoscopically. Therewere also statistically significant differences be-tween the groups with respect to length ofinpatient stay and total cost. For our compari-son, patients who required open repair expe-rienced an average length of inpatient stay of4.4 days at a total cost of $12,500.

Most data are gathered on patients whopresent for their initial ventral hernia defectrepair. For the 284 patients in this study, atleast one prior attempt at repair had failed,and they had, by definition, recalcitrant de-fects. It is not surprising that this is a uniqueand challenging cohort of patients who expe-rience longer hospital stays and incur greateroverall costs than their counterparts; they alsohave more recurrences.

However, the satisfaction data suggest addi-tional social and psychological benefits follow-

ing autologous tissue reconstruction. Thereare no similar data in the literature addressingabdominal wall repair.

CONCLUSIONS

The incisional hernia frequently complicatesabdominal surgery procedures. For the past 8years, we have utilized variations of the compo-nents separation technique for autologous tis-sue repair of recalcitrant hernias. It is our hy-pothesis that recurring or recalcitrant herniasbenefit from the recreation of a dynamic ab-dominal wall by components separation tech-niques. When surveyed, patients with success-ful autologous tissue repairs noticedimprovements in the appearance of their ab-domen, in their postoperative emotional state,in abdominal strength, and in their ability tolift objects, arise from a chair or a bed, andexercise. Our long-term outcomes documentlower recurrence rates in these difficult pa-tients than do other published surgical tech-niques. Recalcitrant hernia defects remain achallenging surgical problem, requiring exten-sive hospital stays and resources for successfulrepair.

Paul N. Manson, M.D.The Johns Hopkins Hospital601 North Caroline StreetBaltimore, Md. 21286pmanson@jhmi.edu

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