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Use of Porcine Small Intestine Submucosa Biologic Material for Repair of Ventral Hernias in Contaminated Fields: Long-Term Outcomes
Amin Madani*1,2, Wanda Marini2, Pepa Kaneva2, Paola Fata1, Kosar a. Khwaja1, Gerald M. Fried1,2, Liane S. Feldman1,2
1General Surgery, McGill University, Montreal, ON, Canada; 2Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University, Montreal, QC, Canada
Current guidelines recommend biologic prosthetic materials for the repair of abdominal wall defects in a contaminated field. However, long-term data are limited. Our objective was to determine the rate of recurrent hernia and other outcomes following the use of porcine small intestine submucosa (SIS) for ventral hernia repair in a contaminated field.
From 2004-2012, consecutive patients undergoing ventral hernia repair in a contaminated field with SIS mesh were identified from a prospectively entered operating room database. Patients with open abdomen were excluded. Paper and electronic charts were reviewed and patients were stratified according to wound classification and compared in terms of demographics, hernia recurrence (based on physical examination and radiological follow-up), surgical site infections (according to CDC criteria), <30 day re-operation rate, and post-operative bowel obstruction, fistula and dehiscence. Data are expressed as N(%) and median (interquartile range). Mann-Whitney-U and Fishers exact test determined significance (p<0.05*). Institutional ethics approval was obtained.
Fifty-five patients (age:59(49-69), male:59%, ASA classification:2(2-3)) were included and stratified: clean-contaminated (20(36%)), contaminated (13(24%)) and dirty (22(40%)). The most common indications for ventral hernia repair using SIS were: removal of a prior infected mesh (22(40%)), enterotomy during repair (20(36%)) and perforated viscus (9(16%)). Median follow-up was 41 months (25-62 months). Post-operative complications included surgical site infection (31(56%)), fistula (6(11%), bowel obstruction (5(9%)), and dehiscence (4(7%)), with 15(27%) requiring re-operation within 30 days, mostly due to a surgical site infection (11(20%)). Of the 47(85%) patients who had >12 months follow-up, hernia recurrence occurred in 26(54%) with a median time to diagnosis of recurrence of 15 months (9-23 months). Patients with dirty wounds were more likely to experience surgical-site infections, and to require early re-operation compared to patients with clean-contaminated wounds*, but the recurrence rate was similar.(Table 1) Recurrence rate was also greater when SIS was used to bridge fascia (16/23(70%)) compared to reinforcing fascia (10/25(40%)).*
Wound infections and hernia recurrences are high with the use of biologic SIS material in contaminated surgical fields. Careful consideration is warranted using this approach, especially when the wound is dirty and the fascia cannot be re-approximated. Table 1: Outcomes of patients following SIS mesh for ventral hernia repair in clean-contaminated (CC), contaminated (C) and dirty (D) fields. Data presented as N(%). * = p<0.05 | CC (N = 20) | C (N = 13) | D (N = 22) | | Surgical Site Infection | 7 (35%) | 6 (46%) | 18 (82%)* | | Fistula | 1 (5%) | 2 (15%) | 3 (14%) | | <30 Day Re-Operation | 2 (10%) | 5 (38%)* | 8 (32%)* | | Hernia Recurrence | 10 (50%) | 7 (64%) | 9 (53%) |
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