鄭存翔1 黃耀廣2 林唯農1 嘉義長庚紀念醫院外科部整形外科1 心臟血管外科2 Successful reconstruction of huge abdominal defect with Bovine pericardium and negative pressure wound therapy – a case report 鄭存翔1 黃耀廣2 林唯農1 嘉義長庚紀念醫院外科部整形外科1 心臟血管外科2

78 case series with 4,358 patients Introduction Open abdomen Systematic Review and Meta-analysis of the Open Abdomen and Temporary Abdominal Closure Techniques in Non-trauma Patients World J Surg. 2015 Atema JJ, Gans SL, Boermeester MA. Systemic review level of evidence IIIA 78 case series with 4,358 patients 1983-2013

Case report: A 63 y/o male Underlying: HTN Chief Complaint: abdominal pain for 1 day CT of abdomen: abdominal aortic aneurysm, suspect ruptured

Transfer from LMD with AAA Day 1 Transfer from LMD with AAA 1st OP: EVAR Day 2 2nd OP: Explor-Lapa Sudden onset tearing abdominal pain Doppler: R L Popliteal: + + Post. tibia + - Dorsalis - - pedis CT: AAA, ruptured ACS after EVAR Open abdomen IV bag: change under GA every 3 days (Day 2-15)

Transfer from LMD with AAA Day 1 Transfer from LMD with AAA 1st OP: EVAR Day 2 2nd OP: Explor-Lapa Sudden onset tearing abdominal pain Doppler: R L Popliteal: + + Post. tibia + - Dorsalis - - pedis CT: AAA, ruptured ACS after EVAR Open abdomen IV bag: change under GA every 3 days (Day 2-15) ACS: abdominal compartment syndrome EVAR: endovascular aneurysm repair

Transfer from LMD with AAA Day 1 Transfer from LMD with AAA 1st OP: EVAR Day 2 2nd OP: Explor-Lapa Sudden onset tearing abdominal pain Doppler: R L Popliteal: + + Post. tibia + - Dorsalis - - pedis CT: AAA, ruptured ACS after EVAR Open abdomen IV bag: change under GA every 3 days (Day 2-15) ASA classification: V

Bovine pericardium Sponge-based VAC Day 15-55 Bovine pericardium Sponge-based VAC Day 55 OP: Cholecystectomy & primary closure 2 month later: Local flap Fascia defect: 25x15 cm 1st-layer: Dura-Guard & Bovine pericardial patch 2nd-layer: Bard Mesh Sponge-based VAC (75-125 mmHg) Fever and RUQ pain CT: cholecystitis Cholecystectomy: reattach Bovine pericardium Primary closure: still high tension Discharge on Day 80 Fascia defect: 4x4 cm Rotation fasiciocutaneous flap from left abdomen

Bovine pericardium in-lay technique

OP: Cholecystectomy & primary closure Day 15-55 Bovine pericardium Sponge-based VAC Day 55 OP: Cholecystectomy & primary closure 2 month later: Local flap Fascia defect: 25x15 cm 1st-layer: Dura-Guard & Bovine pericardial patch 2nd-layer: Bard Mesh Sponge-based VAC for 40 days Fever and RUQ pain CT: cholecystitis Cholecystectomy: reattach Bovine pericardium Primary closure: still high tension Discharge on Day 80 Fascia defect: 4x4 cm Rotation fasiciocutaneous flap from left abdomen

f/u 16 months Day 15-55 Bovine pericardium Sponge-based VAC Day 55 OP: Cholecystectomy & primary closure 2 month later: Local flap Fascia defect: 25x15 cm 1st-layer: Dura-Guard & Bovine pericardial patch 2nd-layer: Bard Mesh Sponge-based VAC for 40 days Fever and RUQ pain CT: cholecystitis Cholecystectomy: reattach Bovine pericardium Primary closure: still high tension Discharge on Day 80 Fascia defect: 4x4 cm Rotation fasiciocutaneous flap from left abdomen f/u 16 months

Discussion and Literature Review

Temporary Abdominal Closure(TAC) techniques and its fascial closure, complication and mortality rate Negative pressure wound therapy (NPWT) Mesh (synthetic) Wittmann patch (artificial burr) Silo techniques (Bogota bag) Dynamic retention suture Zipper

2009, World Journal of Surgery Systemic review level of evidence IIIA 57 case series with 3,169 patients 1981-2007 median follow-up 48 months 2015, World Journal of Surgery Systemic review, level of evidence IIIA 78 case series with 4,358 patients 1983-2013

Wittmann patch: closure rate 90% NPWT: closure rate 51-73% Wittmann patch: closure rate 90% 2009, 2015, World J Surg Systemic review, level of evidence IIIA Biological Mesh???

The data available in the literature on biological graft implants for ventral incisional hernia repair or abdominal wall defect repair are scarce and frequently in the form of case series.

case control, level of evidence IIIB 2015, Hernia case control, level of evidence IIIB 40 patients follow-up 3 years Sutured Mesh on-lay Bovine pericardium free from Incisional hernia⬆

1/9 intentional remove after abdominal wall abscess →Permacol salvage 2006, Current Surgery level of evidence IV case report, 9 cases 2003-2005 median follow-up 18.2 months Contamination (wound classification II, III, or IV) in 5/9 patients (56%), no infectious complications occurred 1/9 intentional remove after abdominal wall abscess →Permacol salvage

2010, World journal of Gastroenterology level of evidence IV case report, 2 cases Case 1 62 y/o female Right hemicolectomy for carcinoma through a midline incision →abdominal wall abscess and incisional hernia(6 months) repair with prolene mesh →fistulae formation(4 months) replace with bovine pericardium →no recurrence(5 years follow-up) Case 2 69 y/o male Left hemicolectomy for diverticular disease →incisional hernia repair with PTFE mesh →infection seroma (8 months) debridement and replace with bovine pericardium mesh →no recurrence(4 years follow-up)

Luigi et al. 2012, World Journal of Gastrointestinal Surgery case series, level of evidence IV 14/48 patients mean follow-up 22 months hernia relapse on infected synthetic mesh →Bovine pericardium reconstruction: relapse again 4/14 fistulae formation 0/14 1st: peritonitis, colorectal anastomotic leak 2nd: venous intestinal infarction, thrombosis of superior mesenteric vein 3rd: pelvic abscess, sigmoid diverticular perforation 4th: severe purulent pelviperitonitis, deihscence cisto-ileal patch

No hernia recurrence, No infection after 6 months follow-up 2014, Case Report Medicine level of evidence IV case report, 1 cases multiple laparotomies for a sigmoid-rectal adenocarcinoma that infiltrated into the abdominal wall → abdominal wall defect 16 x 10 cm Procine dermal collagen + NPWT(43 days) → STSG No hernia recurrence, No infection after 6 months follow-up

Vacuum-assisted closure Conclusion reduce hernia recurrence as a guard to protect bowel from both adhesion and fistulae formation easy for salvage if prosthetic mesh infection Bovine pericardium Prosthetic mesh for better fascial traction and as second insurance Vacuum-assisted closure Vacuum-assisted closure avoid frequently change IV bag under general anesthesia

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