Long-term outcomes (>5 year follow-up) with porcine

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treated with primary suture of the midline and retromus- cular PADM reinforcement (Rives–Stoppa technique). When ventral rectus sheaths could not be ...

Comment to “Long-term outcomes (>5 year follow-up) with porcine acellular dermal matrix (Permacol™) in incisional hernias at risk for infection” by Abdelfatah MM, Rostambeigi N, Podgaetz E, Sarr MG (DOI 10.1007/s10029-013-1165-9) P. Negro, L. D’Amore, F. Ceci & F. Gossetti Hernia The World Journal of Hernia and Abdominal Wall Surgery ISSN 1265-4906 Hernia DOI 10.1007/s10029-015-1406-1

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Author's personal copy Hernia DOI 10.1007/s10029-015-1406-1


Comment to ‘‘Long-term outcomes (>5 year follow-up) with porcine acellular dermal matrix (PermacolTM) in incisional hernias at risk for infection’’ by Abdelfatah MM, Rostambeigi N, Podgaetz E, Sarr MG (DOI 10.1007/s10029-013-1165-9) P. Negro1 • L. D’Amore1 • F. Ceci1 • F. Gossetti1

Received: 16 March 2015 / Accepted: 28 June 2015 Ó Springer-Verlag France 2015

We read with great interest the article by Abdelfatah et al. titled ‘‘Long-term outcomes ([5 year follow-up) with porcine acellular dermal matrix (PermacolTM) in incisional hernia at risk for infection’’ [1]. This retrospective study included 65 consecutive patients, who underwent abdominal wall reconstruction (AWR) with porcine acellular dermal matrix (PADM) for repair of incisional hernias at high risk for surgical site infection (SSI). The surgical wound was clean in 49 %, clean-contaminated or contaminated in 45 % and infected in 6 % of cases. At the end of the study, authors concluded the use of PermacolTM PADM is far from ideal to unsatisfactory in the overall picture. Only in selected patients its use might prove to be useful. In fact, results from Abdelfatah et al. are discouraging and PADM as bioprosthesis for ventral hernia appears unreliable as definitive repair at this time. In Abdelfatah series, SSI occurred in 20 % within 30 postoperative days and in 37 % after this period (with 25 % of PADM infection). Infection required subtotal or total removal of PADM in 15 cases. Fifty-nine patients with a follow-up C5 years displayed overall recurrence in 66 %, documented at physical examination or objective findings (CT scan or reoperation). Why these bad results? authors have full knowledge of some limitations of their study, including the heterogeneous differing types of repair, onlay, inlays and sublays

This comment refers to the article available at doi:10.1007/s10029013-1165-9. & P. Negro [email protected] 1

Sapienza University of Rome, Rome, Italy

with bridging (patches) or reinforcement by the PADM. We absolutely agree with them and we believe that the explanation of such discouraging results actually must be sought in the surgical technique. Abdelfatah et al. report that a bridging patch repair was performed in 31/65 patients, an onlay or intraperitoneal reinforcement of an autogenous suture repair in 28/65 and an inlay repair in 6/65. PADM was never placed as a sublay in the retromuscular space, as described by Rives and Stoppa [2, 3]. Results from our experience are different. Between July 2005 and December 2013, 45 consecutive patients underwent abdominal wall reconstruction (AWR) with PADM (32 with PermacolTM, Covidien and 13 with CollaMendTM, Bard, Davol) for incisional hernias. Four patients needed more than one implant, due to concomitant hernias in other sites (parastomal or perineal), for a total number of 50 implants. All patients were at risk of infection, 87 % of them displaying grade III, according to mod.WVHG (Table 1) [4]. In 86 % of implants, PADM was used as augmentation repair while in 14 % of them sublay bridging repair was performed (Table 2). Sixty-eight percent of defects were treated with primary suture of the midline and retromuscular PADM reinforcement (Rives–Stoppa technique). When ventral rectus sheaths could not be reapproximated, techniques of posterior components separation were performed [5, 6]. All patients were collected in a database and examined every year. The presence or absence of recurrent hernias was documented by cross-sectional imaging (CT scan or MRI) with Valsalva manoeuvre. Our short-term SSI rate was quite similar to Abdelfatah et al. (26 vs. 20 %), despite the higher risk of infection in our patients (87 vs. 50 %). In our series, one patient died due to sepsis on 30th postoperative day. Long-term SSI was demonstrated in 2 cases (4 %), both belonging to the


Author's personal copy Hernia Table 1 Patients demographics and co-morbidities Age

59.8 (28–80)


28.6 (19–52)

Risk factors for SSI (%) Surgical wound Cleana


Clean-contaminated or contaminatedb


Associated GI surgery


Infected mesh


Parastomal hernia


Prior hernia procedure (%) None


One procedure


C2 procedure


BMI body mass index a

Grade I


Grade III mod.WVHG

Table 2 Type of PADM repair

PADM location (%) Reinforcement














CollaMendTM group and one requiring partial removal of the implant, compared to 15 cases (25 %)in Abdelfatah’s study. During the outcome of our study, 3 patients deceased without signs of hernia recurrence, at 12, 30 and 70 months of follow-up. At January 2015, the database analysis showed an overall recurrence rate of 8.8 %, with a medium follow-up of 59.3 months (ranging from 15 to 114 months). Recurrence occurred in 4 patients (at 15, 71, 72 and 79 months, respectively) and it was missed at physical examination but documented at CT scan in 2 cases. If we consider patients with follow-up C5 years only


(22 cases), our recurrence rate stands at 13.6 % (3 recurrences), lower than in Abdelfatah’s series (66 %). One more patient showed abdominal bulging at CT scan during the Valsalva manoeuvre. PermacolTM bridging repair was been performed in one out of four recurrences and in the patient with bulging. In conclusion, the outcomes of our patients differ from those by Abdelfatah et al. PermacolTM PADM has proven the putative advantages of biologics are true. In our opinion, the key role of successful AWR with biologics depends on correct indications and, overall, on a proper surgical technique. PADM should be never used on dirty fields; retromuscular is the better position for biologics as reinforcement between posterior and anterior rectus sheaths. This approach, generally considered the gold standard of open AWR, is the most effective for PADM remodelling. Bridging repair must be avoided.

Conflict of interest PN declares no conflict of interests, LDA declares no conflict of interests, FC declares no conflict of interests, and FG declares no conflict of interests.

References 1. Abdelfatah MM, Rostambeigi N, Podgaetz E, Sarr MG (2015) Long-term outcomes ([5 year follow-up) with porcine acellular dermal matrix (PermacolTM) in incisional hernias at risk for infection. Hernia 19:135–140 2. Rives J, Pire JC, Flament JB, Palot JP, Body C (1985) Treatment of large eventrations. New therapeutic indications apropos of 322 cases. Chirurgie 111:215–225 3. Stoppa RE (1989) The treatment of complicated groin and incisional hernia. World J Surg 13:545–554 4. Kanters AE, Krpata DM, Blatnik JA, Novitsky YM, Rosen MJ (2012) Modified hernia grading scale to stratify surgical site occurrence after open ventral repairs. J Am Coll Surg 215:787–793 5. Carbonell AM, Cobb WS, Chen SM (2008) Posterior components separation during retromuscular hernia repair. Hernia 12:359–362 6. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 204:709–716

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