Holland Alexis M, Lorenz William R, Mylarapu Namratha, Kerr Samantha W, Mead Brittany S, Ayuso Sullivan A, Scarola Gregory T, Augenstein Vedra A, Kercher Kent W, Heniford B Todd
Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. Electronic address: https://www.twitter.com/AlexisHollandMD.
Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. Electronic address: https://www.twitter.com/WLorenzjr.
Surgery. 2025 Mar;179:108894. doi: 10.1016/j.surg.2024.06.084. Epub 2024 Oct 29.
Conflicting literature suggests that larger defects in abdominal wall reconstruction both increase the risk of recurrence and have no impact on recurrence. In our prior work, hernias with defect areas ≥100 cm were associated with increased discomfort, operative time, and length of stay but not recurrence or reoperation. Our goal was to determine if defect size, even in giant hernias, would impact recurrence after mesh repair with complete fascial closure.
A prospectively maintained hernia database was reviewed for clean, abdominal wall reconstruction with fascial closure and synthetic mesh. Patients were grouped and compared by defect area: moderate hernias <200 cm (LT200) and giant hernias ≥200 cm (GT200).
Of 984 patients, 607 LT200 (average area: 92.8 ± 60.8 cm) were compared with 377 GT200 (average area: 363.2 ± 196.7 cm). LT200 and GT200 had similar mean age, body mass index, and smoking rate, but GT200 had higher rates of diabetes (22.1% vs 27.9%; P = .040), recurrent hernias (52.7% vs 63.4%; P = .001), preoperative Botox (0.7% vs 8.8%; P < .001), component separation (23.4% vs 59.9%; P < .001), panniculectomy (8.7% vs 15.4%; P = .001), and negative-pressure incisional vacuum placement (5.9% vs 13.5%; P < .001). GT200 had increased mesh size (753.5 ± 367.1 vs 1168.2 ± 412.0 cm; P < .001), operative time (147.8 ± 55.7 vs 205.3 ± 59.9 minutes; P < .001), and length of stay (5.1 ± 3.2 vs 6.9 ± 4.4 days; P < .001). GT200 had more wound complications (24.7% vs 36.1%; P < .001) and readmissions (9.1% vs 15.1%; P = .004) but similar recurrence rates (3.0% vs 3.7%; P = .520) over the mean follow-up of 30.1 ± 38.9 and 23.0 ± 33.6 months for LT200 and GT200, respectively. On multivariable regression, previous abdominal wall reconstruction, lightweight mesh, and wound complications independently predicted recurrence; component separation was protective, but defect size was not predictive of recurrence.
GT200 required more complex measures to achieve fascial closure and resulted in increased length of stay, wound complications, and readmissions; however, GT200 had the same recurrence rate as smaller defects when fascial closure was achieved.
相互矛盾的文献表明，腹壁重建中的较大缺损既会增加复发风险，也对复发没有影响。在我们之前的研究中，缺损面积≥100平方厘米的疝与不适、手术时间和住院时间增加相关，但与复发或再次手术无关。我们的目标是确定缺损大小，即使是巨大疝，在采用完全筋膜闭合的补片修补术后是否会影响复发。
回顾前瞻性维护的疝数据库中采用筋膜闭合和合成补片进行的清洁腹壁重建病例。根据缺损面积对患者进行分组并比较：中度疝＜200平方厘米（LT200）和巨大疝≥200平方厘米（GT200）。
在984例患者中，607例LT200（平均面积：92.8±60.8平方厘米）与377例GT200（平均面积：363.2±196.7平方厘米）进行比较。LT200和GT200的平均年龄、体重指数和吸烟率相似，但GT200的糖尿病发生率更高（22.1%对27.9%；P = 0.040）、复发疝发生率更高（52.7%对63.4%；P = 0.001）、术前使用肉毒杆菌毒素率更高（0.7%对8.8%；P ＜0.001）、采用成分分离术的比例更高（23.4%对59.9%；P ＜0.001）、行腹壁成形术的比例更高（8.7%对15.4%；P = 0.001）以及负压切口引流的比例更高（5.9%对13.5%；P ＜0.001）。GT200的补片尺寸更大（753.5±367.1对1168.2±412.0平方厘米；P ＜0.001）、手术时间更长（147.8±55.7对205.3±59.9分钟；P ＜0.001）、住院时间更长（5.1±3.2对6.9±4.4天；P ＜0.001）。GT200的伤口并发症更多（24.7%对36.1%；P ＜0.001）、再入院率更高（9.1%对15.1%；P = 0.004），但在LT200和GT200分别平均随访30.1±38.9个月和23.0±33.6个月时复发率相似（3.0%对3.7%；P = 0.520）。多变量回归分析显示，既往腹壁重建、轻质补片和伤口并发症可独立预测复发；成分分离术具有保护作用，但缺损大小不能预测复发。
GT200需要更复杂的措施来实现筋膜闭合，导致住院时间延长、伤口并发症增加和再入院率升高；然而，当实现筋膜闭合时，GT200的复发率与较小缺损相同。
