Methods
Study Design
Approval for this retrospective audit was granted by the techniques and devices committee at Royal Liverpool Hospital where waiver of informed consent was granted. Patient consent was obtained to publish the surgery images contained in this manuscript. All review procedures were conducted according to the principles outlined in the Declaration of Helsinki. Medical records of 23 patients undergoing abdominal wall reconstruction at Royal Liverpool Hospital between 2009 and 2012 were retrospectively analysed. Patient co-morbidities, hernia classification, and previous surgeries were identified. Operative notes were studied and the surgical reconstruction technique was recorded. Length of stay, complications and recurrence were also noted.
Pre-surgical Work-up
Preoperatively, all patients were assessed clinically. Their hernia was graded using the Ventral Hernia Working Group system, taking into account co-morbidities, presence of stoma, fistula or infection. For patients presenting with fistulas, contrast studies were performed to confirm the fistula anatomy and a CT scan was obtained to assess the size of the hernia, extent of loss of domain, and to identify occult hernia defects so that the surgical technique could be planned (Figure 1).
(Enlarge Image)
Figure 1.
CT scan demonstrating a patient with a stoma and a large incisional hernia with loss of domain.
Surgical Technique
Laparotomy, adhesiolysis and restoration of intestinal continuity, if achievable, was performed. The abdominal midline was then reconstructed; the Rectus sheath was mobilised and the Ramirez technique of components separation was used to close the midline depending on the individual patient and defect. Finally, the repair was reinforced with mesh with wide overlap, with the intent to situate it in a sublay position. In most cases, only one mesh was placed in the position noted (Table 1). When mesh was placed as both a sublay and onlay, a large piece of mesh was placed diagonally as a sublay, the corners were cut, and the cut pieces were used as an onlay over the lateral release of the component separation. Collatamp®G sponges were placed in some patients prior to closure as a means to reduce the risk of surgical site infection.
Post-operative Care
Patients remained in the hospital following their surgery until they were ambulatory and their bladder and bowel functions were normal. Drains were left in for an average of 14 days and removed after discharge. Patients were followed up regularly for the first 3 months and then were followed up on an as-needed basis.