The best reconstructive approach for large fascial defects precipitated from a previous open abdomen has not been elucidated to date. We use a posterior component separation with transversus abdominis muscle release (TAR) in this scenario.
Patients with a history of an open abdomen who ultimately underwent complex hernia repair with TAR from 2010 to 2013 at Case Medical Center were identified in our prospective database and analyzed.
Of 34 patients (mean [SD] age, 54 [11.3] years; mean [SD] body mass index, 32.5 [7.2]) with a history of an open abdomen, the fascia was closed primarily in 11 and skin alone closed primarily in 4 patients after a mean (SD) of 5.9 (6.7) days. Those unable to achieve primary closure either received a skin graft (n = 16) or healed by secondary intention (n = 3). Patients presented to our institution a mean (SD) of 25.1 (26.5) months after their initial operation, eight having already undergone at least one hernia repair, including four anterior component separations. Operations consisted of 21 (61.8%) contaminated cases, including 7 enterocutaneous fistula takedowns, 2 stoma revisions, 2 stoma reversals, and 3 excisions of infected mesh. Wound morbidity consisted of 12 (35%) surgical site occurrences: 1 wound dehiscence, 2 hematomas, 1 seroma, 8 surgical site infections (23.5%; 3 superficial, 3 deep, and 2 organ space), and no enterocutaneous fistulas or chronic mesh infections. One reoperation was necessary for debridement of a hematoma and deep surgical site infection. With a mean follow-up of 18 months (range, 3–42 months), two (5.9%) new parastomal hernias and three (8.8%) midline recurrences have been documented.
To our knowledge, this is the first report describing the use of TAR in patients with a history of an open abdomen for definitive abdominal wall reconstruction. We have demonstrated that this approach is associated with low significant perioperative morbidity and recurrence.
Therapeutic study, level V.
From the Case Comprehensive Hernia Center (C.C.P., S.Y., A.S.P., Y.W.N., M.J.R.), University Hospitals Case Medical Center; and Division of Trauma Critical Care, Burns, and Acute Care Surgery (C.C.P., J.J.C., S.Y.), MetroHealth Medical Center, Cleveland, Ohio.
Submitted: July 14, 2014, Revised: September 11, 2014, Accepted: October 3, 2014.
This work was presented at the 73rd annual meeting of the American Association for the Surgery of Trauma, September 10–13, 2014, in Philadelphia, Pennsylvania.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).
Address for reprints: Clayton C. Petro, MD, University Hospitals Case Medical Center, 11100 Euclid Ave, 7th Floor Lakeside, Cleveland, OH 44106; email: Clayton.Petro@UHhospitals.org.