On-lay versus sub-lay placement of proline mesh in patients with mutilated abdomen through abdominoplasty approach

On-lay versus sub-lay placement of proline mesh in patients with mutilated  abdomen through abdominoplasty approach

Shereif  H Farrag, MD; Ashraf  H Abbas, MD; Amr M Moghazy, MD; Osama A Adly, MD

Surgery Department, Suez Canal University, /smalia, Egypt.

Co"esponding author: e.mail: dr_ashrajhussein@yahoo.com, Tel: 00201005051983.

Abstract

Introduction: Abdominoplasty in patients with mutilated abdomen is still a challenging procedure. These patients need anterior wall reconstruction with prosthetic mesh placed either superficial to the primary repair (on-lay), or deep to the musculo-aponeurotic layer (sub-lay). Both techniques have their advantages and disadvantages.

Objective: To compare the on-lay and sub-lay prosthetic mesh application to propose the best   technique  as   standard  in   cases  of   mutilated  abdomen abdominoplasty.

Patients and methods: 140 patients were subjected to this clinical controlled randomized study conducted in Plastic Surgery Unit in Suez Canal University Hospital, Ismailia, Egypt from March 2003 to March 2011. Each group was formed of70 patients.

Results: Seroma,hematoma,wound complications,mesh removal, days before drain removal,

days of post-operative pain, hospital stay, and time before return to work were significantly higher in the on-lay group than in sub-lay group. In addition, the higher rates of DVT, chest complications  and hernia recurrence observed in the on-lay group were not statistically significant.Similarly longer operative time in sub-lay group was without statistical significance.

Conclusion: Sub-lay mesh herniorrhaphy with concomitant abdominoplasty offers significant better functional and cosmetic results. Significant reduction of post operative complications in sublay technique than in the onlay technique was proved.

Introduction:

Abdominoplasty has  become  a popular procedure since its first description in 1899 by Kelly.It is indicated for abdonrinal wall laxity, excess skin, striae, and diastases of the rectus muscles.l-5

Before  1960, most of abdominal defects were repaired by tissue approximation, which was accompanied by a recurrence rate ranging from  30%  to  40%.  This  was  noticed in particular with large defects causing the fascia to be under additional  tension  after closure. The use of a prosthetic mesh for ventral hernia repair started in the early 1960s, when Usher described the  usefulness of a knitted polypropylene mesh  for repair  of complex inguinal and anterior abdominal wall hernias. Although prosthetic mesh  improved the

recurrence rate  (5%  to  20%),  yet  it  was associated with  a higher risk  of  seroma, hematoma, and tissue necrosis from extensive dissection.6-9

Polypropylene mesh  can  be  used  as  a "bridge" or "inlay" attached to the margins of the  aponeurotic defect, or  as  "onlay" reinforcement over  a primary repair. The placement  of prosthetic  material in a pocket beneath the rectus muscles and outside the peritoneum was devised in Europe by J. Rives and Rene Stoppa in the 1970.10,11

The abdominoplasty approach to recurrent hernias is extremely  helpful. It provides the best exposure obtainable. It allows access to all components of the abdominal wall permitting a number of techniques for hernia repair. Other hernias, which otherwise may

not have been detected, can be found. Finally, it may  help  to reduce the incidence of recurrence by enabling removal of a large pannus and the resultant weight on the anterior abdominal wall.I2

The onlay technique requires less dissection because the prosthesis is placed anterior to the abdominal wall fascia; however, in theory the intra abdominal pressure is transferred to the edges of the mesh at the lateral aspect of the defect, and recurrences tend to occur in these regions laterally. The sublay technique is an attractive alternative  because  it offers many theoretical advantages. First, by preserving the hernia sac, a layer of viable autogenous tissue persists to serve  as  a barrier between the prosthesis patching the  defect and  the intraperitoneal contents. Second, intraparietal placement of the prosthesis allows well vascularized anterior soft tissue coverage of all aspects of the prosthesis. Third, fixation of the  prosthesis within  the abdominal wall. Fourth, the intraabdominal pressure tends to hold the mesh in place opposed to the posterior rectus muscle over a wide surface area. Finally, this is a tension-free repair.2,13-15

Patients and methods:

This  study  was  carried  out as a clinical controlled randomized study.It was conducted in Plastic Surgery Unit in Suez Canal University Hospital, Ismailia, Egypt from March 2003 to March2011.

During this period, 140 patients with huge mutilated, deformed abdomen were operated on  for  abdominoplasty with  mesh  repair.

The inclusion criteria were those ofMatarsso III (Moderate skin  laxity, variable fat  and moderate abdominal flaccidity) and IV (Severe skin  laxity, variable fat  and  significant

abdominal flaccidity).16 Patients with mild to moderate redundant abdomen, upper abdominal scars, recent pregnancy, and severe chronic illness were excluded.

All patients were operated on by the same surgical  team  and  technique. All  included patients  completed  at least 6 months follow up period.

Patients were randomly assigned to one of the two groups:

- Group 1: Abdominoplasty  with on-lay mesh repair (70 patients).

- Group 2: Abdominoplasty with sub-lay mesh

repair (70 patients.

Preoperative preparations:

Patients were subjected to detailed history taking and  clinical examination. Routine preoperative investigations were done. Prophylactic antibiotics (cephalosporin 3rd generation) and anticoagulants were introduced.

Surgical techniques:

Lower  abdominal skin  crease  incision, extended laterally  to both anterior  superior iliac  spines, was  done.  The  incision was deepened  to reach the anterior rectus sheath medially and external oblique muscles laterally. Dissection was then completed cephalically to reach the xiphestemum in the mid-line and the costal margins laterally. During this dissection any old meshes were removed. Hernial  sacs were opened and adhesolysis was done when indicated. Any anterior wall defect was located.

In group 1, primary repair of the defects in

two layers was done then the polypropylene mesh was placed aver the repair (on-lay). The edges of the  mesh  were sutured to the abdominal wall under tension with polypropylene 0 Figure(l).

Figure(l)

In group 2t bilateral anterior fasciotomy through the anterior rectus sheath was donet thus exposing the medial edge of the rectus muscle, and developing the space laterally was done bluntly to the midclavicular line (lateral edge of the rectus muscle). The mesh was placed between the rectus muscles superiorly

and  posterior rectus sheath and fascia transversalis or peritoneum inferiorly. If the peritoneum was deficient, the omentum was mobilized to cover the defect. Multiple polypropylene 0 sutures were taken to secure the position of the mesh without tension Figare(l).

Figure(2)

Two closed suction drains were left in the subcutaneous  space. Drains were removed

Results:

The mean age of the study population was

36.34±9.04 years, ranging from 20-57 years, with group (1) patients had having slightly higher  age, but no statistically significant

when the accumulation of fluid in the container was less than 50 ml/day.

difference was found between both groups (p

< 0.05) Table(l). Moreover, 70.7% of the patients were females with slightly higher

percentage among  group  (1),  (p > 0.05) Table(l).

Table (1): Distribution of both groups according to age & Body Moss Index "BMI".

-&iVHI!AifP*WtM#fliM'

Regarding the preoperative risk factors, diabetes mellitus was slightly higher among group (2) patients (27.1% compared to 24.3% in group (2); p > 0.05), while body mass index, hypertension, smoking and chest diseases were slightly higher among group (1) patients (p >

0.05) Table(l&2). The majority of patients in

both groups was of grade 3 Mattarsso (58.6% of group 1 compared  to 51.4%  in group 2); however, no statistically significant difference was found between them (p > 0.05). On the other hand, 64.3% of patients in both groups had   previous  hernia  repair  Table(2).

Table (2): Comparison of common pre-operative risk factors between both groups.

*Statistically significant at p< 0.05 and 95% confidence level

On-lay repair  operation took  a slightly shorter time than sub-lay repair operation (p­ value > 0.05). However, drains were removed earlier,  and postoperative pain disappeared faster in patients who underwent sub-lay repair (p-value < 0.05) Table(4).

Complications were more common in the on-lay  repair  group  (1) when  compared to patients with sub-lay repair group (2). Seroma developed early in 15.7% of patients in group

1 compared to 1.4% in group 2. No patient in group 2 developed  late seroma while it was detected  in 27.1% of patients in group 1 (p­ value < 0.05). Similarly,  hematoma,  wound complications and  mesh removal were significantly higher among  group 1 patients when compared to group 2. Although deep venous thrombosis (DVT), chest complications and hernia recurrence were higher in group 1 than  in group 2, the difference was  not statistically significant (p-value > 0.05) Table(3) & Figure(2). On the other hand, sub­ lay   repair  operation  was   found to  be

significantly associated with less hospital stay and earlier return to work compared to on-lay repair (p-value < 0.05) Table(4).

Logistic regression analysis of independent predictors of  common postoperative complications in  both  groups was  done. Covariates in the model were  surgical technique, sex, age, body mass index, Mattarsso grade, diabetes mellitus, hypertension, previous hernia  repair, chest  diseases and smoking. Surgical technique (On-lay  versus  sub-lay repair) was found to be a predictor for seroma, hematoma, wound complications and recurrence; on-lay repair was associated with those complications more than sub-lay repair Table(5).Mattarsso grade was also a predictor for   hematoma, wound complications, recurrence and deep venous thrombosis with more  representation among on-lay repair patients Table(5&3). However,previous hernia repair was a predictor for seroma and hematoma only Table(5&3).

Table (3): Comparison of post-operative complieations between both groups.

*Statistically significant at p< 0.05 and 95% confidence level

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H"o\at·oml                Wound               Me.h Removal

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Table (4): Comparison ofpostoperlllive prognostic factors for on-illy & sub-illy repair operations.

*Statistically significant at p< 0.05 and 95% confidence level

-&iVHI!AifP*WtM#fliM'

Variable(s) entered on the Jst step of logistic regression: Surgical technique, sex, age, BML Mattarsso  classification, DM, HTN, previous hernia repair, chest diseases and smoking.

Discussion:

All  mesh  repair techniques have  high complication rates with classical abdominoplasty. Modifications in surgical procedures and techniques for incisional hernia repair and the availability of newer prosthetic materials have allowed improvement of surgical results  with  reduced complication rates.17

In our study,  wound  complications were

21.4% in onlay repair while it was only 4.3% in the sublay group. Also; 30 patients of 70 of onlay group developed seroma (early and late) while only one patient of 70 of the sublay group developed early seroma.

Infections of the implanted mesh prosthetics

can be especially difficult to treat and can lead to mesh resection and hernia recurrence. The use of mesh  is not necessarily related  to a higher  incidence of wound infection (5.5% with  mesh  versus  6%  without mesh).18  A similar study had an infection rate of9.6%.19

The few observed minor wound complications of small cutaneous dehiscence without infection are  consistent with  previous reports of abdominoplasty combined with hernia repair.2o Postoperative wound infections occurred in 0-

18%  of the patients of many  previous studies.11,21-23

Postoperative seromas are a common finding after ventral hernia  repairs.  Some surgeons

have  categorized these  as  postoperative findingsrather than as true complicationsdue to the fact that they represent a nearly universal finding.  Seroma is  the   most   common complication of these proceduresoccurring in 1-23% ofcases.24 Bauer and his colleagues' rate ofseroma formation (12.3%) was similar to those in previous series of incisional hernia repairs using prostheses.I6

Our data revealed significant correlations between  smoking  history  and   any   of postoperative chest complications.Krueger et alfound that  the complication rates  for abdominoplasty  are significantly  higher in smokers.25

Regarding co-morbidities in our patients; we found that diabetes mellitus, chest diseases and previous hernia repair were significant predictors for post-operative complications . Hensel et al. and van Uchelen et al. found the same observation that patients suffering from co-morbid conditions like diabetes mellitus and hypertension had significantly higher complication rates after abdominoplasty.26,27

Obesity is a major contributing factor in the initial  development  of a hernia. When the morbidly obese patients are consideredboth the recurrence rates and the complication rates tend to increase regardless of the technique.28-31

Mean body mass index of our patients was

31.95 in onlay group and 31.3 in the sublay group. There was no significant difference between the two groups regarding BMI. We could not find that BMI was a predictor of post operative complications in our work. We can explain these findings by that our patients were not having a high BMI.

The development of tension-free incisional hernia  repairs employing prosthesis has decreased recurrence rates markedly, to about

6-10%.21 Bauer et al. series had no recurrences (except in one patient whose prosthesis was removed) and an infection rate of3.5%. These results are superior to those generally achieved with onlay repairsfor  which the recurrence rate  is about  4-6%  and the infection  rate approximately 7-10%_16 Recurrence rates in previous studies of Stoppa repairs range from zero   to  approximately 4%_11,21,22,32,33

Recurrence in our patients was 8.6% in onlay group and 1.4% in sublay group.

Since its introduction in 1989the Rives­ Stoppa technique has been popularized by many surgeons and recently was proclaimed to be the gold standard for open mesh hernia repairs by the American Hernia Society. The advantages of a large mesh with significant overlap placed under the muscular abdominal wall can possibly be explained by Pascal's Principles ofHydrostatics. The intraabdominal cavity functions as a cylinder, so pressures are distributed uniformly to all aspects of the system. The same forces that are attempting to push the mesh through hernia defects are also holding it in place against the adjacent intact abdominal waU_lO,lS

Inour series DVT was 5.7% in onlay group and 2.9% in sublay group. In Mark F. Berry, and his colleagues series; the most common postoperative complications were thromboembolic events (13%).33

Avoidance of onlay methods has been recommended because  of minimal tissue incorporation of the prosthesis,34 excessive tension on the repair,35 and a possible increase in the risk of seroma and infection_ll,24,36,37

Conclusion:

For patients with complex recurrent hernias

and deformed abdomen, sub-lay mesh herniorrhaphy with concomitant abdominoplasty offers significant functional and esthetic results. Sub-lay placement of prosthetic mesh in the repair of abdominal wall is effective and superior  to other methods. Approaching the recurrent abdominal wall hernia and certain primary hernias through an abdominoplasty incision; provides access to all components  of the abdominal  wall and identifies previously undetected hernias. Significant complications are low and patient satisfaction is high.

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