Schuster Rob, Singh Jaskanwal, Safadi Bassem Y, Wren Sherry M
Department of Surgery, Palo Alto Veterans Health Care System, Palo Alto, CA, USA.
Am J Surg. 2006 Nov;192(5):594-7. doi: 10.1016/j.amjsurg.2006.08.017.
Contaminated abdominal wall fascial defects present a challenging problem. The use of human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, NJ) provides a novel method of primary closure of abdominal wall defects in this setting. The aim of the current study was to determine what factors predicted fascial wall failure as determined by the presence of hernia on follow-up exam after AlloDerm placement.
All patients who underwent surgery for contaminated abdominal wall fascial defects with placement of AlloDerm from June 2003 to September 2005 at a tertiary care Veterans Affairs hospital were included in the analysis. Patients were followed until hernia recurrence or last clinic visit.
Eighteen patients had AlloDerm placed for contaminated fascial defects and all were included in the analysis. Primary wound closure was performed on 12/18 (67%) patients, with 6/18 (33%) patients initially left with open wounds. Patients with open wounds were treated with wound vacuum-assisted closure (VAC) devices (4/6) or saline dressings (2/6). Overall ventral hernia recurrence rate was 50% (9/18) with an average follow up of 9.1 months. Patients who had primary wound closure at the completion of the operation had a 33% (4/12) recurrence rate. Patients who did not have primary wound closure had an 83.3% (5/6) recurrence rate. The significant difference shows (P = .03) that open wound status predicts recurrence. The average size of AlloDerm sheets used was 164.0 cm2 in the closed group and 146.2 cm2 in the primary open wound group (P = .64). Average cost per patient was 4680 dollars for AlloDerm.
These data suggest that an open wound in the postoperative period after AlloDerm placement for treatment of contaminated fascial defects is associated with a high probability of hernia recurrence. Our data do not support the use of this expensive material unless there is a good chance of having a closed wound.
受污染的腹壁筋膜缺损是一个具有挑战性的问题。使用人脱细胞真皮基质（AlloDerm；LifeCell公司，新泽西州布兰奇堡）为在这种情况下一期闭合腹壁缺损提供了一种新方法。本研究的目的是确定在放置AlloDerm后随访检查时，哪些因素可预测因疝的出现而导致的筋膜壁失败。
纳入2003年6月至2005年9月在一家三级医疗退伍军人事务医院接受手术治疗受污染腹壁筋膜缺损并放置AlloDerm的所有患者进行分析。对患者进行随访，直至疝复发或最后一次门诊就诊。
18例患者因受污染的筋膜缺损放置了AlloDerm，所有患者均纳入分析。12/18（67%）例患者进行了一期伤口闭合，6/18（33%）例患者最初伤口开放。伤口开放的患者采用伤口负压封闭引流（VAC）装置治疗（4/6）或生理盐水敷料治疗（2/6）。总体腹疝复发率为50%（9/18），平均随访9.1个月。手术结束时进行一期伤口闭合的患者复发率为33%（4/12）。未进行一期伤口闭合的患者复发率为83.3%（5/6）。显著差异表明（P = 0.03）伤口开放状态可预测复发。闭合组使用的AlloDerm片平均面积为164.0平方厘米，一期伤口开放组为146.2平方厘米（P = 0.64）。AlloDerm每位患者的平均费用为4680美元。
这些数据表明，在放置AlloDerm治疗受污染筋膜缺损后的术后期间，伤口开放与疝复发的高概率相关。我们的数据不支持使用这种昂贵的材料，除非有很大机会实现伤口闭合。
