Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial

Abstract

Background: Reconstruction of giant midline abdominal wall hernias is difficult, and no data are available to decide which technique should be used. It was the aim of this study to compare the "components separation technique" (CST) versus prosthetic repair with e-PTFE patch (PR).

Method: Patients with giant midline abdominal wall hernias were randomized for CST or PR. Patients underwent operation following standard procedures. Postoperative morbidity was scored on a standard form, and patients were followed for 36 months after operation for recurrent hernia.

Results: Between November 1999 and June 2001, 39 patients were randomized for the study, 19 for CST and 18 for PR. Two patients were excluded perioperatively because of gross contamination of the operative field. No differences were found between the groups at baseline with respect to demographic details, co-morbidity, and size of the defect. There was no in-hospital mortality. Wound complications were found in 10 of 19 patients after CST and 13 of 18 patients after PR. Seroma was found more frequently after PR. In 7 of 18 patients after PR, the prosthesis had to be removed as a consequence of early or late infection. Reherniation occurred in 10 patients after CST and in 4 patients after PR.

Conclusions: Repair of abdominal wall hernias with the component separation technique compares favorably with prosthetic repair. Although the reherniation rate after CST is relatively high, the consequences of wound healing disturbances in the presence of e-PTFE patch are far-reaching, often resulting in loss of the prosthesis.

Figure 1.

Operative technique of the “components separation technique.” 1 = rectus abdominis muscle; 2 = external oblique muscle; 3 = internal oblique muscle; 4 = transversus abdominis muscle; 5 = posterior rectal sheath. A. Dissection of skin and subcutaneous fat. B. Transaction of aponeurosis of external oblique muscle and separation of internal oblique muscle. C. Mobilization of posterior rectal sheath and closure in the midline. Adapted from Bleichrodt et al., with permission of Elsevier.

Figure 2.

A. Preoperative view of a giant abdominal wall hernia covered with a split skin. B. Postoperative view of the same abdominal wall after reconstruction using the components separation technique.

Figure 3.

Kaplan-Meier for recurrent hernia after prosthetic repair (n = 18) and components separation technique (n = 19). Seven of 18 prostheses were removed during the first 7 months after implantation. Reherniation rates after 36 months are similar in both groups.

Figure 4.

The operation wound after performing a components separation technique for abdominal wall reconstruction, showing the large wound surface and the extensive skin dissection needed.