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Use of Human and Porcine Dermal-derived Bioprostheses in Complex Abdominal Wall Reconstructions: Building on the Cumulative Experience Daniel R. Baillie, MD, S. Peter Stawicki, MD, Nicole Eustance, BA, David Warsaw, DO, Darius Desai, MD, St. Luke’s Hospital & Health Network, Bethlehem, PA
Introduction
The use of bioprosthetic materials is an evolving strategy in reconstructing soft tissue defects. There is limited experience with bioprosthetic use in the setting of complex abdominal wall defects. In addition to a comprehensive literature review of the topic, we present two cases in which bioprosthetic materials were used to reconstruct such large, complex abdominal wall defects. The first case demonstrates the use of Permacol™ (Tissue Science Laboratory, Hampshire, UK), a porcine derived isocyanate cross-linked collagen tissue matrix, while the second case describes the use of AlloDerm™ (Lifecell Corporation, Branchburg, NJ), a decellularized human cadaveric dermis.
Table 1. Summary of literature reports describing the indications and utilization of dermal-derived bioprosthetic materials in tissue reconstruction as well as associated complications Study, Type of report, Number of patients
Prosthesis
Indications
Defect location
Flaps
Complications
Comments
Porcine
Abdominal wall defect secondary to sepsis and abdominal wall dehiscence
Abdomen
C
None
No evidence of incisional hernia 1 year post-operative
Porcine
Large ventral hernia following Hartmann’s procedure for fecal peritonitis and closure by granulation
Abdomen
C
Seroma Superficial wound dehiscence
No recurrence 1 year post-operative
Human
Abdominal wall defect following: tumor resection (11/13), enterocutaneous fistula (1/13), and ventral hernia repair (4/13)
Abdomen (11/13), Pelvis (7/13), Chest (2/13)
MC (3/13) C (2/13) O (1/13) M (3/13) LE (4/13)
Seroma (2/13), Hematoma (1/13), Partial flap necrosis (1/13), Cerebrospinal fluid leak (1/13), Enterocutaneous fistula (1/13), Partial wound dehiscence (1/13)
Bacterial contamination at operative site (7/13), Perioperative radiation (7/13)
Human
Incisional or recurrent abdominal hernias
Abdomen
MF
Seroma (2/16), Wound dehiscence (1/16)
Previous hernia repair procedures (15/16); Two or more previous procedures (6/16); Hernia site infections or prosthetic (PTFE) exposure (9/16)
Human
Open abdomen following: Diverticulitis, Mesh infection, Necrotizing pancreatitis, Perforated colon carcinoma, Septic dehiscence, Strangulated hernia, Blunt and penetrating trauma
Abdomen
C
Superficial wound infection (2/37)
All open abdomen patients treated with wound vacuum and progressive fascial advancement prior to closure with human-derived dermal prosthesis
Human
Abdominal donor site repair following TRAM flap procedures for breast reconstruction
Abdomen
C
Seroma formation (14/54), Bulging at the site of abdominal wall reconstruction (12/54)
Biopsy specimens of AlloDerm 12 and 14 months after donor site repair showed full tissue integration, with cell density, vasculature, and collagen orientation consistent with abdominal fascia tissue
Parker, et al 200614 9 patients Case series
Porcine
Reoperative incisional hernia (3/9), Fascial defect following resection of large abdominal wall tumor (2/9), Abdominal wall infection following previous hernia repair (1/9), Open abdominal wound (1/9), Recurrent hernia repair following previous synthetic mesh repair ± infection (2/9)
Abdomen
C
Recurrent hernia following graft removal secondary to suture erosion into bowel (1/9), Skin separation with exposure of underlying graft, treated with local wound care (1/9)
5/9 (56%) of wounds in this series had contamination present (class II, III, or IV) at the time of Permacol placement
Catena et al, 200612 6 patients Prospective case series
Porcine
Severe wound infection (3/6), Enterovaginal fistula (1/6), Complicated hernia repair (2/6)
Abdomen
C
No recurrences or wound infection over a follow-up period of 3-24 months. No porcine graft-related complications.
Two patients had infection of previously placed polypropylene mesh. One patient with evisceration prior to porcine dermal graft placement.
Porcine (1/2) Human (1/2)
Open abdomen following: Abdominal wall mass resection (1/2), Gastric remnant perforation (1/2)
Abdomen
MC (1/2) C (1/2)
No graft related complications.
Preoperative radiation (1/2), Enteric contamination of the wound (1/2)
Adedeji, et al 2002 8 1 patient Case report Liyanage, et al 20044 1 patient Case report
Butler, et al 20051 13 patients Case series
Kolker, et al 20052 16 patients Case series
Scott, et al 20063 37 patients Large case series
Glasberg, et al 200613 54 patients Large case series
Current cases 2 patients Case reports
Case Reports
Case 1: A 46-year-old woman was admitted for epigastric pain and was found to have free intraperitoneal air on CT imaging, nineteen months after a Roux-en-Y gastric bypass procedure. The patient was septic, with evolving multi-organ failure, and underwent a prompt exploratory laparotomy. A perforation of the gastric remnant was identified with significant enteric leakage. The perforation was repaired without difficulty. However, because of severe soft tissue and bowel edema, it was determined that primary fascial closure would not be possible at that time. The patient was managed with open abdomen utilizing abdominal vacuum assisted closure (VAC) (KCI Inc., San Antonio, Tx) dressing. She underwent a series of planned washouts with VAC dressing changes. After generalized edema improved and multi-system organ failure resolved, the patient was taken for definitive abdominal fascial closure using porcine dermal bioprosthetic material. Large sheets of porcine tissue matrix were used to reconstruct the fascia, with the fascial defect size of approximately 30 cm cephalad to caudad and 20 cm side to side. The sheets were approximated using a combination of running and interrupted non-absorbable sutures (Figure 1). Subcutaneous tissue overlying the porcine tissue material was mobilized and the Figure 1. Repair of large anterior fascial defect with Permacol™. Large sheet of bioprosthetic material skin edges were sutured being implanted. Note sutures being placed between the material and fascia as well as between two pieces together using 2-0 nylon of the bioprosthetic. interrupted mattress sutures. A closed-suction drain was placed underneath the cutaneous flap. Postoperatively the patient showed continuous improvement and was discharged 21 days after her abdominal closure. She was well five months after discharge.
Case 2: A 54-year-old woman was seen in surgical clinic for a left abdominal wall mass for which she was previously treated abroad approximately nine months earlier for a presumed soft tissue sarcoma. At that time she underwent excisional biopsy and a subsequent course of external beam radiation. An ultrasoundguided biopsy demonstrated spindle cell neoplasm. CT scan of the abdomen and pelvis showed enhancing soft tissue masses in the left abdominal wall. The largest mass measured 7.7 x 4.9 cm (Figure 2A) with two satellite nodules (Figure 2B). Figure 2. Computed tomography (CT) of abdomen and pelvis was performed and showed enhancing soft tissue masses present within The patient the left abdominal wall. (A) The largest mass measured 7.7 X 4.9 centimeters. (B) Two satellite nodules. underwent enbloc resection of the abdominal wall masses and adjacent tissue, including excision of four ribs and a portion of the diaphragm to obtain oncologically Figure 3. Abdominal defect resulting from excision of soft tissue (A). Excised specimen with old biopsy scar (B). Fascial defect negative margins. mass closure with AlloDerm™ (C). Complete wound closure using rotation flap over closed suction drains (D).z Following excision, the left abdominal wall defect measured approximately 20 x 15 cm (Figure 3A and 3B). To reconstruct the large abdominal wall defect, three sheets of human acellular dermis were sutured in place using running 2-0 Prolene sutures (Figure 3C). A curvilinear incision was made medially and a large myocutaneous rotational flap was created to fill the defect. The skin and subcutaneous tissue were closed over two closed suction drains (Figure 3D). The patient was discharged on post-operative day six without complications. Final pathology identified the mass as a leiomyosarcoma of moderate grade. All margins were free of tumor. Twenty weeks after discharge the patient showed no evidence of recurrence or hernia.
Discussion
Traditional methods available for soft tissue reconstruction include primary closure, closure with synthetic mesh, and closure with myocutaneous flaps 2,4. Dermal-derived bioprosthetic materials, including a decellularized human cadaveric dermis, and a porcine-derived isocyanate cross-linked collagen tissue matrix, have been developed to further expand reconstructive options available to surgeons 1,4. The two cases presented here use these new methods with promising results and no apparent complications associated with the use of bioprosthetic materials. Dermal-derived bioprosthetic materials can be manipulated intraoperatively according to the various shape and size specifications required in abdominal wall defect repairs. The goal of abdominal wall reconstruction is to restore and maintain abdominal domain 9. Difficulty arises when the fascial defects are large and the underlying viscera are exposed. The use of synthetic mesh in previously irradiated or contaminated tissues increases complication rates, and there may be benefit of utilizing bioprosthetic material in such settings in order to minimize infectious risk and/or adhesions 1,12. Case 1 shows the use of bioprosthetic material in the setting of enteric spillage and subsequent placement of the porcine tissue matrix material directly over the exposed bowel. Case 2 involved tissue that had been subjected to external beam radiation prior to radical resection, resulting in a defect that was suitable for closure with the human dermal-derived material. The use of bioprosthetic material allowed both of these wounds to be closed successfully without the need for multiple procedures, and no complications noted in the follow-up period.
Given the overall versatility and characteristics of both human and porcine dermal-derived grafts, clinical indications for their use are largely interchangeable. We determined which material to use based on the size of the defect relative to the size and thickness of available prosthetic pieces. Given the very large size of the largest available porcine dermal prosthesis (20x30 cm), it may be better suited for the larger defects. In addition, the phenomenon of bioprosthetic material ‘bulging’ following implantation may be related to expansile properties and thickness of the implanted graft, and both size and thickness of the material should be considered in the context of each individual wound. Butler, et al proposed techniques which include the use of thicker or extra-thick bioprosthetic material, the use of appropriate technique for joining of multiple sheets, use of inlay technique with maximal fascia overlap for abdominal wall defects and onlay technique for chest wall defects, and seroma prevention strategies utilizing suction-drainage catheters, quilting sutures, and compression garments 1. Although there is a growing body of literature pointing to safety and efficacy of human- and porcinederived prosthesis use in the setting of complex tissue reconstructions, there are no prospective, randomized trials comparing this methodology to existing reconstruction techniques. While a significant number of case series and reports indicate that the use of bioprosthetic dermal-derived materials may results in low recurrence rates and very few postoperative infectious complications, this contention has to be validated in the setting of large prospective clinical trials.
Bioprosthetic materials are changing the paradigm of abdominal wall reconstruction. In the presence of irradiated and/or contaminated tissues, these materials provide new options for definitive abdominal wall repair. Based on the two cases presented and the review of current literature, it appears that bioprosthetic
materials are safe and effective when used for repair of complex abdominal wall defects, and the indications for their use are likely to expand. The need remains for prospective, randomized comparison studies to better determine the applicability, indications, risks, and benefits of dermal-derived bioprostheses.
Conclusion
