J. S. Roth1, M. T. Miller1, K. Johnson1, M. Plymale1, S. Levy1, D. Davenport1, J. Roth1 1University Of Kentucky,General Surgery/Surgery/College Of Medicine,Lexington, KENTUCKY, USA
Introduction: Abdominal wall reconstruction for complex hernia repairs are challenging with significant complications. The retro-rectus approach typically involves creation of submuscular flaps from an intraperitoneal approach following adhesiolysis, potentially resulting in visceral injuries. A totally extraperitoneal approach to abdominal wall reconstruction is feasible in most hernia repairs and may minimize visceral injuries without impacting outcomes. This study compares outcomes following abdominal wall reconstructions by means of an extraperitoneal and intraperitoneal approach.
Methods: An IRB approved review of a prospective hernia database was performed for all abdominal wall reconstructions between 2009 and 2013. Pre-operative patient characteristics including demographics and comorbidities; operative variables including surgical technique (intraperitoneal vs. extraperitoneal), operative duration, type, size and location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and non-wound complications, readmissions and return to the operating room were obtained. Cases were evaluated based surgical approach. Groups were compared using t-tests, Mann-Whitney U tests, chi-square and Fisher’s Exact tests as appropriate. Significance was set at p < .05.
Results: Patient groups were compared based upon surgical approach; intraperitoneal (n=121) vs. extraperitoneal (n=54). Pre-operative patient characteristics were similar between the two groups including age, BMI, gender, comorbidities, smoking status, and prior hernia repairs. Hernia defect sizes were similar; mesh size was larger in the extraperitoneal group (675 ±317 vs. 440 ± 185 cm2; p<.001); Operative time was less in the extraperitoneal group (172 ±46 vs. 217 ±52 minutes; p<.001). An extraperitoneal approach resulted in fewer inadvertent bowel injuries ( 0 vs 9.1%, p = .02). Readmissions, reoperations, recurrences and other patient outcomes were similar between the two groups. Among patients undergoing mesh placement in the retrorectus space (extraperitoneal n=47; transabdominal preperitoneal n=74) operative time was less in the extraperitoneal group while other outcomes were similar.
Conclusion: Abdominal wall reconstruction may be performed in a totally extraperitoneal fashion. The extraperitoneal approach results in fewer enterotomies, shorter operative duration and similar readmissions, reoperations and recurrences when compared to an intraperitoneal approach.
