Complex abdominal wall repair with an acellular cross-linked collagen implant – a 7 year experience

Abdominal Wall Reconstruction Presentation

P. Giordano et al.

This is a prospective non-randomised observational study reporting the results of complex abdominal wall reconstructions with Permacol™ porcine collagen mesh performed by a single surgeon (Mr P Giordano).

Background: Complex abdominal wall reconstruction (CAWR), where many previous attempts of repair, large defect’ size, loss of domain or contamination are present, pose a challenging decision to surgeons. Recently, the use of  biological meshes, that helps to complement standard closure techniques, have been an alternative to synthetic due to its overall complications rate of 18-50% which includes bowel adhesions, fistulisation and extrusion and 50-90% risk of infection in contaminated cases1,2. Because of their biocompatible nature and the ability of  being rapidly vascularised, the biological grafts appear to be beneficial in contaminated environments or where the incidence of infections is high, such as when chemo-radiation or immunosuppressive therapy has been used3.

The aim of this non-randomized study is to extend the current literature with our single institution on CAWR with Permacol™ porcine collagen mesh performed by a single surgeon.

Patients and method:  The data of 51(18 females and 33males) consecutive patients were prospectively collected between 2003 and 2015. Fifty-six cases were performed. The indication for surgery was incisional hernia in 41 cases (73%), incisional hernia and enterofistula in 6 cases (11%), parastomal and incisional hernia in 9 (16%) cases. The median defect size was 625cm2 . The mean previous repair was 1.3 and 22 (43%) had a mesh in-situ. Five patientswere re-operated for recurrence with a second pemacol implant.  Among the 56 CAWR procedures, in 23 (41%) fascial closure was achieved and in 22 (39%) patients, bowel resection/anastomosis was performed . Patients had a median of 3 comorbidities (range 0-10) and 33% were wound class II-IV.  With a mean follow-up of 44 months (range, 4-123), the overall recurrence rate was 40%. Post-operative complications were: 20 wound-infections , 2 haematomas and 1 anastomotic leak. Late complications were: 7 seroma, 6 enetero-cutsaneous fistulas, 1 bowel adhesions to mesh, 3 chronic sinus, and 2 chronic abdominal pain. Two patients died; 1 in ITU post-operatively for heparin overdose and one 43 months later for incarcerated recurrent hernia with peritonitis. Two patients were lost at follow-up of whom, 1 died for unrelated cause.  The median post-operative performance status was 0 (range;0-3). Of the 34 patients from whom a satisfaction questionnaire was obtained, 29 (85%) were satisfied with the outcome.

Conclusion: By this observational study, despite the high recurrence rate, in challenging AWR, where the majority of the patients underwent concomitant bowel resection/anastomisis, with a wound Class II or higher and multiple previous attempts of repair, Permacol mesh has demonstrated to be safe and effective. Indeed, after such complex conditions, small incisional relapses which allow the patients to return to their normal daily activities, can be deemed as a success.