Purpose: Human acellular dermal matrix (HADM) is favored over synthetic mesh for complex abdominal wall reconstruction in contaminated wounds, direct placement over viscera, potential for cutaneous exposure and wounds at risk for healing complications. We hypothesized that early infectious and wound healing complications would be low but late hernia/bulge rates would increase due to potential laxity with remodeling of the implanted material.
Methods: All consecutive patients who underwent complex abdominal wall reconstruction with HADM over a three-year period were retrospectively analyzed. Patient demographics, defect characteristics, reconstructive techniques, and clinical outcomes were assessed. Indications for repair included oncological resection and/or ventral hernia. Outcomes were assessed with follow-up including serial physical examination and CT scans. All patient, defect and reconstruction characteristics were entered into stepwise regression models. Multivariate logistic regression analysis was used to identify potential protective or predictive factors for postoperative complications.
Results: Fifty patients had abdominal wall reconstruction using HADM. All patients had reconstruction with a dual-circumferential, inlay repair technique. Mean follow-up was 26 months (range: 8 to 51 months). Mean age and body mass index (BMI) was 58 years and 31.7, respectively. Bridged and fascial overclosure repairs (with HADM inlay) were performed in 42% and 58% of patients, respectively. Preoperative abdominal irradiation occurred in 32% of patients and 62% of defects were grossly contaminated. Mean fascial defect size and HADM surface area were significantly greater in the bridged group (511 cm2 and 535 cm2) than fascial overclosure group (276 cm2 and 297 cm2). Eighteen % of patients developed asymptomatic abdominal wall bulges. A higher bulge rate was observed in the bridged (29%) than the fascial overclosure (10%) groups. True hernias identified by physical exam or CT occurred in 14.3% of the bridged group and 3.4% of the fascial reinforcement group. Eighteen % developed minor wound complications; all were successfully treated with local wound care. Modeling for surgical outcomes of bulge, hernia, surgical site infection and wound complication revealed an odds ratio of 5.47 for BMI (p=0.049).
Conclusions: Complex abdominal wall reconstruction with HADM can be performed safely and with low complication rates even when there is bacterial contamination, exposed viscera, compromised soft-tissue vascularity, and prior radiotherapy. When possible, the fascial overclosure technique is preferred over bridging to reduce bulge rate. Initial fascial defect size was not an independent predictor of surgical complications, however, BMI was a predictor of post-operative bulge. Patients should be counseled about potential risks pre-operatively.