approved study included consecutive patients who underwent ventral hernia repair with components separation with padm reinforcement performed by the author at the university of pittsburgh medical center ( pittsburgh , pennsylvania ) and butler memorial hospital ( butler , pennsylvania ) .
surgeries were performed between august 2008 and january 2012 , with follow - up data available through february 2013 .
information on patient demographics , comorbidities , relevant medical and surgical history , presence of previously placed mesh , and length of surgical incision were recorded .
prior to surgery , smokers were advised regarding smoking cessation , and all patients received prophylactic antibiotics .
ventral hernia repair , including components separation with bilateral dissection of the external oblique to the inferior portion of the pectoralis major muscle ( fig .
1 ) , removal ( if possible ) of any previously placed mesh , and placement of padm was performed in all patients according to the author 's usual technique . for midline closure ,
1 prolene monofilament nonabsorbable ( ethicon , inc , somerville , new jersey ) , or no . 1 surgipro monofilament nonabsorbable ( covidien , mansfield , massachusetts ) sutures were used .
padm was overlaid in a medial position across the anterior side of the rectus abdominis and sutured into place with interrupted maxon no .
two size-19 french blake drains ( ethicon ) were placed in all patients and remained in place until drainage was < 30 ml for 2 consecutive days .
midline closure showing overlay of non  cross - linked porcine - derived acellular dermal matrix in place .
postoperative outcomes assessed included seroma , evidenced by localized accumulation of fluid in the perioperative area , confirmed via computed tomography ( ct ) evaluation ; wound infection , based on presence of erythema , exudate , tenderness , pain , and/or fever , as well as positive blood or tissue culture results ; deep - vein thrombosis , identified by clinical signs and symptoms including swelling , pain , and color changes in the affected area , and confirmed based on ultrasound imaging ; and bleeding .
hernia recurrence was diagnosed based on clinical or ct evaluation ; any patient with a palpable mass , pain , swelling , or bulge extending beyond the reestablished abdominal wall boundary was identified as a possible hernia recurrence and confirmed based on ultrasound examination .
follow - up visits occurred at 1 , 3 , 6 , 9 , and 12 months after surgery and yearly thereafter .
the majority of patients were female ( 68% ) and obese [ body mass index ( bmi ) > 30 kg / m , 60% ] , and most ( 64% ) were classified as having vhwg grade 2 or grade 3 risk for postoperative complications at the surgical site .
other comorbidities that were present in 5% of the study population included diabetes ( n = 14 , 30% ) , history of cancer ( n = 6 , 13% ) , chronic obstructive pulmonary disease ( n = 4 , 9% ) , and history of deep - vein thrombosis ( n = 3 , 6% ) .
patient demographics and characteristics twenty - three patients ( 49% ) had undergone previous ventral herniorrhaphy . the number of previous herniorrhaphies in the total study sample ranged from 0 to 11 ( median , 0 ) ; the majority of patients ( 79% ) had 1 previous repair .
the mean ( sd ) length of surgical incision was 26 ( 9 ) cm .
primary fascial closure was achieved , and padm was successfully placed in all 47 patients .
herniorrhaphy was performed in the setting of infected previously placed mesh in 5 patients ( 11% ) , and the infected mesh was removed during surgery in all of these patients .
the mean ( sd ) length of hospital stay was 8 ( 6 ) days ( median , 6 days ; range , 229 days ) .
patients were followed for a mean ( sd ) duration 31 ( 12 ) months ( median , 34 months ; range , 1354 months ) .
overall , 12 patients experienced a total of 14 postoperative complications ( 3 hernia recurrences and 11 other complications ; table 2 ) .
of the 3 patients ( 6% ) who experienced hernia recurrence during the follow - up period , 2 had recurrences at 18 months postsurgery and 1 had recurrence at 7 months postsurgery .
the patient with recurrence at 7 months was an 85-year - old , nonobese ( bmi , 25 kg / m ) man who had 2 previous herniorrhaphies .
he had no other relevant comorbidities and was classified as having vhwg grade 1 risk at the time of the most recent surgery .
one patient who had a hernia recurrence at 18 months postsurgery was a 50-year - old , morbidly obese ( bmi , 46
he had vhwg grade 2 risk for postsurgical complications and no other relevant comorbidities at the time of surgery .
the other patient who experienced hernia recurrence at 18 months after surgery was a 75-year - old obese ( bmi , 36 kg / m ) woman who had a history of 11 previous ventral hernia repair procedures .
she had a previously placed infected mesh removed during her most recent surgery ( vhwg grade 4 risk ) .
summary of postoperative complications nine of the 47 ( 19% ) patients experienced 11 other postoperative complications , including deep - vein thrombosis ( n = 4 ) , seroma ( n = 3 ) , wound infection ( n = 2 ) , and bleeding ( n = 2 ) .
in this cohort of patients , ventral hernia repair with use of components separation and non  cross - linked padm resulted in low rates of postsurgical complications .
overall , 75% of patients did not experience any postsurgical complications , and only 3 experienced a recurrent hernia during a mean follow - up of approximately 2.5 years .
these observations are particularly encouraging given that about half of the patients included in the study had undergone one or more previous ventral hernia repairs .
prior abdominal surgery is a known risk factor for hernia recurrence , and this risk increases with each subsequent repair .
the risk of postsurgical complications after awr with prosthetic mesh placement can be impacted by numerous factors , including patient comorbidities , the complexity of the patient 's condition at the time of surgery , the surgeon 's techniques for prosthetic mesh placement , the specific physical and/or chemical properties of the individual matrix or mesh , and the time elapsing since hernia repair .
reported rates of recurrence across studies of synthetic mesh in awr range from 4% to 32% , with a mean of approximately 19% across studies . reported recurrence rates following placement of biologic tissue matrix range between 0% and 44% , with a mean of approximately 12% across studies , compared with the recurrence rate of 6% observed in the current study .
there have been several previous reports of results from prospective and retrospective studies of padm use in complex awr .
it is not surprising that incidences of postsurgical complications observed in the current study were lower than complication rates in previous studies involving populations that largely comprised patients with potentially contaminated ( vhwg grade 3 ) or infected ( vhwg grade 4 ) surgical sites .
one previous study included a population largely comprising patients with vhwg grade 2 risk for postsurgical complications , as in the current study .
patel and colleagues retrospectively assessed postsurgical outcomes following awr with components separation and padm in a cohort of 41 patients ; of whom , 33 ( 81% ) were classified as having vhwg grade 2 risk for postsurgical complications .
the authors observed incidences of seroma , wound infection , and hernia recurrence of 7% , 2% , and 0% , respectively , at a mean follow - up of 16 months . in the current study ,
the incidences of seroma , wound infection , and hernia recurrence were 6% , 4% , and 6% , respectively , in a population that had 62% of patients classified as vhwg grade 2 risk followed for a mean of 31 months .
the high incidence of postoperative deep - vein thrombosis ( 9% ) in the current study may be explained by patient histories .
of the 4 patients who experienced deep - vein thrombosis , 1 was a cancer patient who was also a smoker with chronic obstructive pulmonary disease , and he had a previously placed infected mesh removed during the current surgery ( i.e. , classified as vhwg grade 4 risk ) .
the other 3 patients with deep - vein thrombosis were classified as having grade 2 risk , though all 3 were smokers and 2 were obese .
interpretation of the results of this study is limited by its retrospective design ; the fact that the study included a heterogeneous group of patients undergoing surgery at one health system by a single surgeon ; the lack of a control group or comparator ; and its limited duration of follow - up . it will be important to continue follow - up on these patients to evaluate long - term outcomes .
the use of non  cross - linked padm for reinforcement following components separation in complex ventral hernia repair resulted in low rates of postoperative complications and hernia recurrence in this patient cohort .
continued follow - up of these patients will be key for evaluating the long - term success of this approach for ventral hernia repair .
 repair of complex ventral hernias frequently results in postoperative complications . 
 this study assessed postoperative outcomes in a consecutive cohort of patients with ventral hernias who underwent herniorrhaphy using components separation techniques and reinforcement with non  cross - linked intact porcine - derived acellular dermal matrix ( padm ) performed by a single surgeon between 2008 and 2012 . 
 postoperative outcomes of interest included incidence of seroma , wound infection , deep - vein thrombosis , bleeding , and hernia recurrence determined via clinical examination . 
 of the 47 patients included in the study , 25% were classified as having ventral hernia working group grade 1 risk , 62% as grade 2 , 2% as grade 3 , and 11% as grade 4 ; 49% had undergone previous ventral hernia repair . during a mean follow - up of 31 months , 
 3 patients experienced hernia recurrence , and 9 experienced other postoperative complications : 4 ( 9% ) experienced deep - vein thrombosis ; 3 ( 6% ) , seroma ; 2 ( 4% ) , wound infection ; and 2 ( 4% ) , bleeding . 
 the use of padm reinforcement following components separation resulted in low rates of postoperative complications and hernia recurrence in this cohort of patients undergoing ventral hernia repair . 
Patients and Methodology
Postoperative Assessments
Results
Discussion
Conclusion