Complex abdominal wall reconstruction, harnessing the power of a specialized multidisciplinary team to improve pain and quality of life

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Abdominal wall reconstruction with the free functional L-shaped latissimus dorsi flap: A case report

Extensive tridimensional defects of the abdominal wall are usually addressed with soft tissue flaps combined with meshes. In this scenario, the additional value of dynamic abdominal wall reconstruction with functional flaps has yet to be demonstrated. In this paper the authors describe for the first time a unique case of total abdominal wall reconstruction with the free functional L-shaped latissimus dorsi (LD) flap, designed to increase the surface area of skin flap coverage while minimizing donor site morbidity, highlighting technical tips and long-term outcomes. A 65-year-old patient underwent abdominal wall resection for a dermatofibrosarcoma protuberans, leaving her with a 23 × 15 cm full-thickness defect. After placing a mesh, a myo-cutaneous free LD Flap with an L-shaped configuration was planned. The flap was composed of Paddle A, designed vertically along the anterior margin of the muscle and Paddle B, designed over the inferior aspect of the LD muscle, extending obliquely from the midline and intersecting Paddle A laterally with a 60° angle. End-to-end anastomoses to the deep inferior epigastric artery and vein and thoracodorsal nerve coaptation to a sizeable intercostal nerve were performed. The LD muscle was sutured according to its native tension while the two skin islands allowed an almost complete resurfacing of the abdominal wall defect. Donor site was closed primarily. Post-operative course was uneventful. One year postoperatively, good abdominal contour was observed, with adequate abdominal tone at rest in laying and standing position. Muscle neurotization was confirmed with clinical examination showing voluntary contraction of the transplanted muscle and the patient reported very high functional outcomes at the hernia-related quality-of-life (HerQles) questionnaire. The free L-shaped LD flap represents an innovative solution to reconstruct extensive full-thickness defects of the abdominal wall while reducing donor site morbidity. Flap neurotization should be attempted whenever possible to improve functional outcomes of the procedure.

The external oblique muscle flap technique for the reconstruction of abdominal wall defects

PURPOSE

Several modifications to the anterior component separation technique (ACST) have been reported to facilitate the closure of abdominal wall defects. In this study, the external oblique (EO) muscle flap for modified ACST during major abdominal wall defect reconstructions has been described.

METHODS

A retrospective review of consecutive patients undergoing modified ACST was conducted. The clinical data were collected and retrospectively analyzed.

RESULTS

Among the 36 patients admitted to our hospital from December 2014 to December 2020, 9 cases had rectus abdominis tumors, 1 case had rectus abdominis trauma, and 26 cases had incisional hernias. The average age was 61.17 ± 13.76 years, and the mean BMI was 24.25 ± 3.18 kg/m². The average width of the defect was 14.33 ± 2.90 cm. Unilateral EO muscle flap technique was used to reconstruct the abdominal wall. 3 cases of surgical site infection (8.3%), 4 cases of grade III or IV seroma (11.1%) and 2 cases of intestinal obstruction (5.5%)were reported postoperatively. Ischemic necrosis of the abdominal EO muscle flap, incision dehiscence, intestinal fistula, or other complications were not observed. 1 case of incisional hernia recurrence (2.8%) was reported. Recurrence of tumors or abdominal wall bulging were not noted during the follow-up period of 32.53 ± 14.21 months.

CONCLUTIONS

The EO muscle flap technique is associated with low postoperative morbidity and recurrence rate, which approves it a reliable technique for selected groups of patients. Further research are needed to confirm the effectiveness of this technique.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair

INTRODUCTION

The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes.

METHODS

A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement.

RESULTS

Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness.

CONCLUSIONS

CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey

BACKGROUND

Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated.

METHODS

Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients.

RESULTS

In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02).

CONCLUSIONS

VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Reconstrucción de la pared abdominal en pacientes con inmunosupresión: experiencia en una institución de alta complejidad

Introducción. Los pacientes con inmunosupresión llevados a cirugía abdominal convencional tienen un mayor riesgo de desarrollar hernias incisionales en el posoperatorio, y cuando ellas ocurren, es necesario individualizar el procedimiento quirúrgico de elección, según las características anatómicas, fisiológicas y clínicas de cada paciente. Este estudio describe las características demográficas y clínicas de los pacientes con inmunosupresión, llevados a reconstrucción de la pared abdominal, y sus desenlaces después de 30 días del procedimiento quirúrgico. Métodos. Serie de casos de pacientes con inmunosupresión llevados a reconstrucción de la pared abdominal, en un centro especializado de cuarto nivel de complejidad. Se incluyeron pacientes mayores de 18 años, operados en el período de enero de 2016 a diciembre de 2019. Resultados. Se presenta una serie de 18 pacientes, cinco (27,7 %) con algún tipo de inmunosupresión primaria y 13 (72,2 %) con algún tipo de inmunosupresión secundaria. La edad promedio fue de 56 años, 11 (61 %) fueron mujeres, el peso promedio de los participantes fue de 73,3 kg. Se encontraron complicaciones en ocho pacientes (44,4 %). Dos pacientes requirieron manejo en la Unidad de Cuidados Intensivos, por un máximo de tres días. Ninguno de los pacientes presentó recidiva de la hernia ni mortalidad. Discusión. La reconstrucción de la pared abdominal en pacientes inmunosuprimidos representa un reto para cualquier equipo quirúrgico debido a las condiciones especiales de los pacientes y a las variables asociadas al procedimiento. Las tasas de recidiva y de complicaciones de este estudio, se asemejan a las descritas en la literatura.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AIM

To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.

METHODS

All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.

RESULTS

During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m². ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004).

CONCLUSION

CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction

BACKGROUND

Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch.

METHODS

Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin.

RESULTS

Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps.

CONCLUSIONS

This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Measuring quality of life in patients with abdominal wall hernias: a systematic review of available tools

INTRODUCTION

Abdominal wall herniation (AWH) is an increasing problem for patients, surgeons, and healthcare providers. Surgical-site specific outcomes, such as infection, recurrence, and mesh explantation, are improving; however, successful repair still exposes the patient to what is often a complex major operation aimed at improving quality of life. Quality-of-life (QOL) outcomes, such as aesthetics, pain, and physical and emotional functioning, are less often and less well reported. We reviewed QOL tools currently available to evaluate their suitability.

METHODS

A systematic review of the literature in compliance with PRISMA guidelines was performed between 1st January 1990 and 1st May 2019. English language studies using validated quality-of-life assessment tool, whereby outcomes using this tool could be assessed were included.

RESULTS

Heterogeneity in the QOL tool used for reporting outcome was evident throughout the articles reviewed. AWH disease-specific tools, hernia-specific tools, and generic tools were used throughout the literature with no obviously preferred or dominant method identified.

CONCLUSION

Despite increasing acknowledgement of the need to evaluate QOL in patients with AWH, no tool has become dominant in this field. Assessment, therefore, of the impact of certain interventions or techniques on quality of life remains difficult and will continue to do so until an adequate standardised outcome measurement tool is available.