Does Perfusion Matter?
Brittany O. Aicher, MD, Jhade Woodall, MD, Richa Kalsi, MD, Thomas Monahan, MD, Shahab Toursavadkohi, MD.
University of Maryland Medical Center, Baltimore, MD, USA.
Objective(s): Incisional hernias are common among patients undergoing aortic surgery, with rates of 10-17% for occlusive disease and 17-32% for aneurysmal disease. This is much higher than the 12-15% occurrence in the general population. Incisional hernias develop due to failure of fascial tissues to heal and are thought to arise from technical failure, infection, or intrinsic tissue defects that also predispose to aneurysmal development. Incisional hernias are frequently repaired due to progressive enlargement, discomfort, unpleasant aesthetics, and risk of bowel incarceration or strangulation. We propose that the underlying perfusion of the abdominal wall impacts hernia development. A greater understanding of which patients are at increased risk of developing incisional hernias may enhance our ability to confidently predict which patients would benefit from prophylactic fascial closure with mesh.
Methods: Fifty-three consecutive patients [age, 62ą12 years, (meanąSD)] who underwent laparotomy between 1/1/2012 and 12/31/2013 through either a midline or left thoracoabdominal approach at the University of Maryland Medical Center were included in the study. All patients had at least 24-months of documented follow-up, of these thirty-three had pre-operative imaging available. We reviewed preoperative imaging to assess vessel patency and clinic notes to evaluate patients for ventral hernia development. The vessels evaluated included bilateral internal mammary, inferior epigastric, circumflex, common iliac, internal iliac, common femoral, and lumbar arteries.
Results: Ventral hernias occurred in 20% (2 of 10) of patients undergoing surgery for aortoiliac occlusive disease and 36% (8 of 22) of those undergoing surgery for aneurysmal disease. There was no significant difference in the type of incision used between the two groups (p=0.21). Occlusion of at least one internal mammary or inferior epigastric artery was not associated with ventral hernia development (7/10 vs 10/22, P=0.20), however a lack of perfusion on either side of midline from both the cranial and caudal direction was associated with hernia development (3/10 vs. 1/22, P=0.04). There was no correlation with the number of patent lumbar arteries (P > 0.3). Conclusions: Patency of the inferior epigastric and inferior mammary arteries are a major factor in ventral hernia development after aortic surgery. Preoperative assessment of these vessels may be useful in conveying risk of postoperative hernia development.
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