Use of bovine pericardium graft for abdominal wall reconstruction in contaminated fields

Luigi D’Ambra, Stefano Berti, Cosimo Feleppa, Prospero Magistrelli, Pierfrancesco Bonfante, Emilio Falco

Luigi D’Ambra, Stefano Berti, Cosimo Feleppa, Prospero Magistrelli, Pierfrancesco Bonfante, Emilio Falco, Department of Surgery, S. Andrea Hospital, 19100 La Spezia, ItalyAuthor contributions: D’Ambra L and Falco E concept and designed the study; Berti S and Feleppa C collected the data; Magistrelli P and Bonfante P made the data analysis and interpre-tation; D’Ambra L drafted and revised the manuscript. Supported by asl 5 SpezzinoCorrespondence to: Luigi D’Ambra, MD, Department of Sur-gery, S. Andrea Hospital, via Veneto 197, 19100 La Spezia, Italy. luigidambra68@libero.itTelephone: +39-187-533465 Fax: +39-187-533257Received: February 2, 2012 Revised: June 22, 2012Accepted: June 29, 2012Published online: July 27, 2012

AbstractAIM: To employ, in such conditions, a biological graft such as bovine pericardium that offers resistance to in-fection.

METHODS: In our surgical department, from January 2006 to June 2010, 48 patients underwent abdominal wall reconstruction using acellular bovine pericardium; of these 34 patients had a contaminated wound due to diffuse peritonitis (complicated diverticulitis, bowel per-foration, intestinal infarction, strangled hernia, etc. ) and 14 patients had hernia relapse on infected synthetic mesh.

RESULTS: In our series, one patient died of multi-organ failure 3 d after surgery. After placement of the pericardium mesh four cases of hernia relapse oc-curred.

CONCLUSION: Recurrence rate is similar to that of prosthetic mesh repair and the application of acellular bovine pericardium (Tutomesh®, Tutogen Medical Gmbh Germany) is moreover a safe and feasible option that

can be employed to manage complicated abdominal wall defects where prosthetic mesh is unsuitable.

© 2012 Baishideng. All rights reserved.

Key words: Bovine pericardium; Abdominal wall; Con-taminated field; Abdominal hernia; hernia relapse

Peer reviewer: Stefano Scabini, MD, Department of Emato-Oncologic, Aou San Martino, Largo R Benzi 10, Genoa 16132, Italy

D’Ambra L, Berti S, Feleppa C, Magistrelli P, Bonfante P, Falco E. Use of bovine pericardium graft for abdominal wall reconstruction in contaminated fields. World J Gastrointest Surg 2012; 4(7): 171-176 Available from: URL: http://www.wjgnet.com/1948-9366/full/v4/i7/171.htm DOI: http://dx.doi.org/10.4240/wjgs.v4.i7.171

INTRODUCTIONIncisional hernia is one of the most common complica-tions after laparotomy occuring in 10% to 20% of cases[1]. The incidence of this post-surgical ventral defect is largely correlated to wound-healing complications such as infec-tions, rather than the type of wound incision, or the tech-nique and materials used for abdominal wall closure[2].

Incisional hernia repair can be performed by simple primary closure, staged or delayed reconstruction, surgi-cal flaps or by prosthesis repair made by laparoscopic or open methods. The use of prosthetic mesh significantly decreases the hernia recurrence rate, but it cannot be employed in particular conditions such as: septic con-taminated or potentially contaminated surgical fields, pre-irradiated tissue, and in hernia recurrence on infected mesh[3].

The ideal material to use in such conditions is able to: resist infection after its implantation; become completely

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remodelled into host tissue with mechanical and biologi-cal proprieties identical to those of the missing tissue; became rapidly revascularized and to maintain its original physical characteristics. Bioprosthetic meshes have prop-erties that may come close to ideal material. Recent stud-ies have shown the use of acellular dermal allograft and porcine small intestine submucosa as valid solutions for complicated ventral hernia repair[4]. Bovine pericardium is largely employed in paediatric and heart surgery and has replaced dura madre patches as the standard biomaterial for the closure of anterior abdominal wall defects in om-phaloceles and gastroschisis[5,6].

Our study aimed to show the application of acellular bovine pericardium patch (Tutomesh®, Tutogen Medical Gmbh Germany) in ventral hernia repair as a safe, fea-sible option with a minimal complication rate.

MATERIALS AND METHODSIn our surgical department, between January 2006 and June 2010, 48 patients with ventral incisional hernia un-derwent abdominal wall reconstruction using acellular bovine pericardium. Of these, 34 patients were operated as an emergency, having a contaminated wound due to peritonitis as a result of circumstances such as complicat-ed diverticulitis, bowel perforation, intestinal infarction, strangled hernia, etc. The other 14 patients had an hernia relapse on infected synthetic mesh. There were 29 female and 19 male patients, with a median age of 64 years (range 38 to 84 years), and the abdominal wall defects were al-ways localized along the abdominal midline with surface area range of 20 to 600 cm2.

All thirty-four patients admitted with local or diffuse peritonitis underwent a complete cleaning of the perito-neal cavity using hot hydro saline solution with complete evacuation of purulent collections and optimal bowel debridement with removal of contaminated fibrin sites on peritoneal and visceral surfaces. After the surgical manage-ment of the principal acute pathology, a comprehensive preparation of the edge of the abdominal wall defect was carried out. The ideal scenario is to close the peritoneum and the posterior rectus sheath and then place the mesh over it, using the sublay technique, avoiding contact with the visceral loop. This is not always achievable, and in our series we have used the sublay technique in twenty-six cases, with retromuscolar mesh placement, fixing the graft with a non-absorbable interrupted suture according to the Rives procedure (Table 1). The anterior rectus sheath, subcutaneous and cutaneous layer were then close with an interrupted non-absorbable suture (Figures 1 and 2). A subcutaneous over-mesh drain tube, model Pean-Rose, was previously positioned. In the other eight cases we corrected the wall abdominal defect using a bridging inlay technique with a interrupted non-absorbable suture to the edge of abdominal wall defect (Figure 3).

In the fourteen patients affected by hernia relapse on infected synthetic mesh we completely removed the prosthetic material and then positioned a bovine peri-

cardium graft using the sublay technique,fixing it with an interrupted non-absorbable suture and then closed the anterior rectus sheath, subcutaneous and cutaneous layer. Hernia relapse was found in the abdominal mid-line in 12 cases, and in the supra pubic area in 2 cases, always due to infection of the synthetic mesh employed to repair potential contaminated defect.

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Table 1 Reasons for abdominal wall reconstruction and mesh placement

Diagnosis Technique n (%)

Incisional hernia on contaminated wounds

Sublay 26 (54)Inlay 8 (17)

Removal of infected mesh Sublay 14 (29)

Figure 1 Sublay technique. A: Under muscolar plane; B: Mesh fixation.

B

A

Figure 2 Subcutaneous over mesh drain tube.

D'Ambra L et al . Bovine pericardium for abdominal wall reconstruction

RESULTSWe observed all the patients with a mean follow-up of 22 mo, ranging from 1 to 48 mo, as shown in Table 2.

One patient died on the third day after surgery be-cause of multi organ failure. Four cases of hernia relapse occurred after placement of the pericardium mesh. The first case occurred after 4 mo in an obese, diabetic patient who underwent abdominal reconstruction with a bovine pericardium graft during an Hartmann colonic resection for pelvic peritonitis. The peritonitis was caused by a colorectal anastomotic leak which occurred 10 d after a laparoscopic low anterior resection for rectal cancer. The second case of relapse occurred in a 43-year-old patient, 6 mo after the application of a pericardium allograft dur-ing acute peritonitis induced by a venous intestinal infarc-tion due to a thrombosis of superior mesenteric vein. This patient underwent four consecutive interventions, starting with a laparostomy. The third case occurred in

a patient affected by chronic renal failure, diabetes and Alzheimer disease 10 d after an operation for pelvic ab-scess due to sigmoid diverticular perforation.

The fourth case of relapse was in a patient who un-derwent rectal resection with partial cistectomy and distal ureterectomy due to an advanced rectal cancer. Eight days post-operative this patient was affected by severe purulent pelviperitonitis caused by a complete deihscence of the cisto-ileal patch utilized to establish the continuity of urinary tract. He then underwent an ureterocutane-ous anastomosis and Hartmann’s colostomy. During the latter operation the abdominal wall was reconstructed by applying a bovine pericardium graft. However, on the twelfth post-operative day this was completely detached from the fascial edge. In the first two cases mentioned, relapse occurred at 4 and 6 mo, respectively, after initial surgery and the abdominal wall defect was then repaired using synthetic mesh placed under muscular layer accord-ing to the Rives technique (Figures 4 and 5). In the other two cases, we employed vacuum-assisted closure (VAC) therapy to obtain the complete closure of the abdominal wound. The VAC device was maintained on a continuous suction mode with a negative pressure of -75 mmHg to 125 mmHg and the VAC sponge was changed every 3 d (Figures 6 and 7). At the sixth month follow-up the latter two patients demonstrated a complete restitutio ad inte-grum of their wound with a residual and partial diastasis of the rectus abdominis.

DISCUSSIONVentral incisional hernia continues to be a surgical chal-lenge. The incidence of incisional hernia after abdominal surgery ranges from 10% to 20%, with 74% of cases oc-curring within 3 years of laparotomy[1]. There are general and local factors that contribute to the establishment of a ventral incisional hernia. General factors include obesity, diabetes, advanced age, corticosteroid therapy, radio and/or chemotherapy, dyspnoea, coughing, vomiting, post-operative ileus, work, constipation, pulmonary failure, vascular surgery, multiple interventions, enterostomies and collagen diseases. Local factors include wound infec-

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Table 2 Postoperative complications

Complications n (%)

Death 1 (2)Wound dehiscence 2 (4)Seroma 3 (6)Relapse 4 (8)

Figure 3 Inlay technique.

Figure 4 Relapse with diastasis recti after inlay technique.

Figure 5 Synthetic mesh repair after 6 mo from pericardium graft place-ment.

D'Ambra L et al . Bovine pericardium for abdominal wall reconstruction

tion, laparotomy over than 10 cm, surgical technique used (continuous vs interrupted suture), suture material, intol-erance to material and tissue elasticity. Since the introduc-tion of prosthetic mesh in 1958, the repair of incisional hernia has been facilitated because mesh allows a tension free repair of the abdominal wall defect and has a much lower recurrence rate than primary repair[2,7]. However, mesh repair is associated with a complication rate of 5% to 17%, including seroma formation, visceral erosion, en-terocutaneous fistula creation, adhesion formation, bowel obstruction, skin erosion and wound infection[8]. Further-more, it is well known that implantation of mesh material into contaminated or potentially contaminated abdominal wall defects or in patients with high risk of post operative infection, results in a higher risk of mesh complications including infection. Over the years, several surgical pro-cedures have been developed to manage these abdominal wall defects without using mesh, primarily using recon-structive plastic surgery with autologous flap repair or the component separation technique. Even in these cases, postoperative complications and hernia relapse are high, ranging respectively from 20% to 43% and 8% to 32%, respectively[9-11].

For these reasons, in cases of contaminated or poten-tially contaminated abdominal wall defect, abdominal wall defect in pre-irradiated tissues, giant ventral hernia with

loss of domain or recurrent hernia on infected mesh, the use a mesh material able to resist infection after its im-plantation is strongly recommended. Such material can be completely remodelled into host tissue with mechanical and biological proprieties identical to those of the miss-ing tissue, and is able to become rapidly revascularized and maintain its original physical characteristics. Biologic meshes have proprieties that may come close to ideal. At the moment various type of biologic prosthesis are com-mercially available that differ in dimension, cost, and sci-entific-clinical support. Surgisis® (Biodesign™; CBI West Lafayette, IN, USA) is an acellular collagen matrix from porcine small intestinal submucosa; Alloderm® (Lifecell Corporation, Brachburg, NJ, USA) is an acellular human dermal collagen matrix; Permacol® (Tissue Science Labo-ratories plc, Covington, GA, USA) is an acellular porcine dermal collagen matrix.

No long-term studies are not yet available, and most of the current evidence supporting the use biologic mesh in this setting is based on case reports and small case se-ries. The literature does not yet include any clinical trials comparing the advantages and disadvantages of the vari-ous meshes.

A homologous “dura mater” biomaterial was first utilized in 1950 for neonatal abdominal wall defect repair but was abandoned in 1990. Pursuant to the appearance of spongiform encephalopathy (Creutzfeld-Jacobs S), dura mater patches were withdrawn, although no cases of infection were ever found.

The biomaterial used in this study was acellular bo-vine pericardium (Tutomesh®, Tutogen Medical Gmbh Germany). This material has actually replaced dura mater in cardiac and neonatal surgery for treatment of gastros-chisis and omphalocele. It is a cadaveric pure punched collagen membrane, a very soft and flexible heterologous graft of bovine pericardium carved and processed asepti-cally, and is completely antigen-less (bacteria, virus, prion, spore). The graft consists of collagenous connective tis-sue with three-dimensional intertwined fibers, giving it multidirectional mechanical strength, and can be implant-ed regardless of the direction of the graft. Collagenous connective tissue with multidirectional fibers retains the mechanical strength and elasticity of the native tissue, while providing the basic structure to support replace-ment by new endogenous tissue. It is indicated for use in general, gynecological, cardiac and plastic surgery, such as in repair of pericardial structures, soft tissue deficiencies, rectal and vaginal prolapse, and hernias, gastric banding, muscle flap reinforcement, and reconstruction of the pel-vic floor[12].

Bovine pericardium is indicated for abdominal wall defect repair because it is easy to sutureor glue and does not require overlap, resists infection and does not mi-grate. It acts as a valid substrate for tissutal regeneration, causes minimal tissutal irritation with minor creation of seroma and does not cause peritoneal adhesions, demon-strating at the same time an excellent mechanical stability

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Figure 6 Detaching of pericardium graft from the fascial edge on twelfth p.o day.

Figure 7 Vacuum-assisted therapy.

D'Ambra L et al . Bovine pericardium for abdominal wall reconstruction

of 16 to 42 N/cm (maximum abdominal wall tension measured).

In our series we placed pericardium graft in a retro-muscolar sublay manner except in eight cases, in which the mesh was fixed, according to the inlay technique, at the edges of the fascial defect. Four cases of hernia relapse occurred after inlay technique placement. For this reason we suggest the securing of the mesh, using a tension-free procedure, behind the abdominal rectus muscle over the posterior rectus sheath to chive closure of the peritoneum. This retromuscolar mesh implanta-tion assures better outcomes in terms of relapse rate and of diastasis recti abdominis. When the ideal placement of the biological graft is not possible, it is recommended that the contaminated wall defect is managed in a bridg-ing manner, placing the mesh according to the inlay tech-nique and providing a temporary restoration of abdomi-nal wall integrity. In alater operation, implantation of a composite synthetic mesh will be able to re-establish the abdominal wall integrity.

The data available in the literature on biological graft implants for ventral incisional hernia repair are scarce and frequently in the form of case series. Post et al[13] in their series of 13 incisional hernias treated with sublay bovine pericardium graft, found no occurrence of relapse, pain and infection. Lindermann et al[14] reporting their experi-ences from employing bovine pericardium mesh in 37 incisional and 2 parastomal hernias, described 4 cases of recurrence in the group treated with the inlay technique.

From analysis of the literature data it appears clear that the correction of contaminated abdominal wall defects with a biological mesh using the technique inlay significantly increases the recurrence rate in comparison to corrections performed using the sublay technique. For this reason, the use of biological mesh in a bridging man-ner (inlay) provides a solution which is temporary but absolutely not definitive, requiring a future mesh implan-tation to definitively correct the defect[4]. On the other hand, when the biological mesh is fixed retromuscularly employing a sublay technique the recurrence rate seems comparable to other synthetic prosthesis[9,15].

In conclusion, the acellular bovine pericardium graft seems to be a valid tool to use to meet the complex sur-gical challenge of repairing contaminated or potentially contaminated wall abdominal defect or the replacement an infected synthetic prosthesis. This biological mesh is relatively inexpensive compared with other available biomaterials used in abdominal wall reconstruction[16], and when fixed using the sublay technique provides a recurrence rate similar to that achieved with conventional synthetic prostheses used in less complicated areas of surgery.

COMMENTSBackground Complex abdominal wall defects are difficult to manage because the recon-struction of the wall integrity can not be achieved using synthetic mesh because

of the high infection rate. In recent years biological materials have obtained consensus for their employment in contaminated fields due to their optimal tis-sutal tolerance and their unique ability to provide a safety scaffold in the repair of complicated wall defects.Research frontiersHomologous “dura mater” biomaterial was first utilized in clinical practice in 1950 for neonatal abdominal wall defect repair but was abandoned in 1990. Acellular bovine pericardium has actually replaced dura mater in cardiac and neonatal surgery for treatment of gastroschisis and omphalocele. It is a cadav-eric pure punched collagen membrane, a very soft and flexible heterologous graft of bovine pericardium carved and processed aseptically, and is completely antigen-less (bacteria, virus, prion, spore). The graft consists of collagenous connective tissue with three-dimensional intertwined fibers. Collagenous con-nective tissue with multidirectional fibers retains the mechanical strength and elasticity of the native tissue, while providing the basic structure to support replacement by new endogenous tissue. It is indicated for use in general, gyne-cological, cardiac and plastic surgery, such as repair of pericardial structures, soft tissue deficiencies, rectal and vaginal prolapse, hernias, gastric banding, muscle flap reinforcement, and reconstruction of the pelvic floor. Innovations and breakthroughsAcellular bovine pericardium allows management of complex defects which cannot be otherwise resolved.ApplicationsBovine pericardium is indicated for abdominal wall defect repair because it is easy to suture or glue and does not require overlap, is infection resistant and does not migrate. It acts as valid substrate for tissutal regeneration, causes minimal tissutal irritation with only minor creation of seroma and it does not cause peritoneal adhesions, demonstrating at the same time an excellent me-chanical stability.Peer reviewThis is a good study in which authors analyze the effective safety and utility of acellular bovine pericardium in managing of complicated abdominal wall defect.

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COMMENTS

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S- Editor Wang JL L- Editor Hughes D E- Editor Zheng XM

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D'Ambra L et al . Bovine pericardium for abdominal wall reconstruction