Abdominal Wall Reconstruction and Patient Comorbidities.

I n a recently published study of abdominal wall reconstruction and patient comorbidities, Naran et al cited an article originating from my practice. The context of the citation identifies our study as one that associates patient comorbidities with failures of abdominal wall reconstruction. Actually, our series specifically did not find any associations between comorbidities and hernia recurrence. In our patients, obesity, hypertension, diabetes, and previous repairs were not associated with hernia recurrence. This study anticipated the findings of Naran et al, as well as such investigation as that of Giordano et al. who have analyzed large series of abdominal wall reconstruction cases without establishing a relationship between comorbidities and increased failure rates of abdominal wall reconstruction. There is a larger issue here than a point of precedence. There exists a school of “herniologents,” who maintain that obesity is specifically related to increased failure of abdominal wall reconstruction. These surgeons advocate weight loss as a relative precondition to ventral hernia repair. This position, however, is largely based on extrapolation of outcomes from other procedures and from series of repair cases with poorly defined procedures and unstandardized use of adjuncts. Studies such as the one by Naran et al serve to uncouple the surgical problem of abdominal wall reconstruction from the comorbidities of patients with abdominal wall breakdown. Comorbidities must of course be factored into the overall management strategy developed for any specific patient. Realizing, however, that abdominal wall reconstruction is primarily a challenge of surgical technique allows the surgeon to concentrate on anatomy, performance, and adjuncts. In my own practice, ongoing assessment of the reconstructive procedure led to specific technical developments. Use of an onlay reinforcement of thick bovine fetal collagen significantly improved my success rate. In an animal model, component repairs with onlay bovine fetal collagen reinforcement decreased repair breakdowns and increased tensile strength at the repair site, findings that support this specific clinical practice. In an effort to decrease skin breakdown, I adopted the “fleur-de-lis” resection pattern, which removed vertical and horizontal scars aswell as the hernia sac and its overlying skin and subcutaneous tissue. This technique removes bulk and compromised tissue, creates optimum exposures, avoids tedious dissection to preserve perforators, and allows closure with 2 superior-lateral skin flaps whose blood supplies are outside the scarring and distortions of the ventral hernia. This approach has decreased skin infarctions in my cases, but unsolved problems of seroma formation and fat necrosis have maintainedmy overall complication rates at high levels. Specific maneuvers to address these problems remain to be analyzed. The work of Naran et al, as well as other groups who are thoroughly analyzing large groups of patients with abdominalwall reconstruction procedures, is providing valuable definition of the applicability of abdominalwall reconstruction. Increasingly, this applicability can be seen as appropriate to the symptoms and complications of the abdominal wall disruption itself.