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A number of papers have examined the use of AlloDerm as a tissue graft for contaminated abdominal wall defects and hernia repair. Wound infection and infection of the mesh can be grave complications of hernia repair, often necessitating removal of the mesh and application of a tissue graft. In breast reconstruction, AlloDerm has been used in conjunction with a subpectoral (major) placement of breast implants to achieve more complete implant coverage without the use of other muscles. Although these indications are promising, evidence is limited to small retrospective case series with limited follow-up.

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In another comparative study, Espinosa-de-los-Monteros et al (2007) retrospectively reviewed 39 abdominal wall reconstructions with AlloDerm in 37 patients and compared them with 39 randomly selected abdominal wall reconstructions without AlloDerm. The investigators reported a significant decrease in recurrence rates when AlloDerm was added as an overlay to primary closure plus rectus muscle advancement and imbrication in patients with medium-sized hernias. On the other hand, no differences were observed when adding AlloDerm as an overlay to patients with large-size hernias treated with underlay mesh.

Jin et al (2007) compared 2 techniques of fascial bridging versus fascial re-inforcement repair with regard to their long-term recurrence rates using Alloderm in patients with abdominal wall defects, and concluded that, because of high recurrence rates with fascial bridging, Alloderm should be used only as a re-inforcement after primary fascial re-appoximation. The investigators retrospectively studied the outcomes of 37 patients with abdominal defects repaired with Alloderm. Eleven patients underwent bridged fascial repair, and 26 patients had reinforced fascial repair. Mean follow-up was 21.4 months (range of 15 to 36 months). In the bridged group, 1 patient died on post-operative day 20. Of the remaining 10 patients, 8 patients (80 %) developed recurrences; 7 patients required re-operation, but 1 patient refused repair. In the re-inforced group, 4 patients were lost to follow-up and 2 patients died. Four of the remaining 20 patients (20 %) developed recurrences that required repair; this was significantly different from the recurrence rate in the bridged group (p = 0.009).

Bluebond-Lagner et al (2008) reported on recurrent laxity requiring secondary intervention in a series of patients who were repaired with interpositional Alloderm. The investigators reviewed all patients who underwent repair of massive ventral hernias and identified 7 patients who presented with abdominal wall laxity following component separation with interpositional Alloderm alone. The investigators reported that all patients developed laxity within 12 months and required a secondary procedure. At the time of re-exploration, severe attenuation in the Alloderm was noted. The segment was excised, the edges closed primarily, and prolene mesh was placed as an onlay.

Vetrees et al (2008) reported on a retrospective review of outcomes of surgical repair of 83 patients with open abdomen that were treated at Walter Reed Army Medical Center. Surgical management included early definitive abdominal closure (EDAC) (serial abdominal closure with prosthetic Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh or Alloderm in 56 patients, primary fascial closure in 15 patients, planned ventral hernia (PVH) in 9 patients, and vacuum-assisted closure with Alloderm in 3 patients). Complications included removal of infected prosthetic mesh in 4 EDAC closure patients; the investigators noted that mesh-related complications had decreased over time. The investigators reported that rates of infection, abdominal wall hematoma, deep venous thrombosis, and pulmonary embolism did not differ between groups. In the EDAC group, infections complicated final polypropylene mesh closure in 3 of 28 patients closed with prosthetic mesh; 1 of 14 patients closed with biologic mesh (Alloderm) noted increased laxity at the repair site. Of 56 patients treated with EDAC, 2 patients had recurrent ventral hernia. Of the 3 patients closed with Alloderm and vacuum assisted closure, 1 patient had recurrent ventral hernia. The investigators reported that no final Alloderm closures required removal after placement, but "long-term results have been disappointing ... The excessive cost of biologic material requires better results than those documented in previous studies." Limitations of this study include its lack of randomization, variation in the described closure methods, its retrospective nature, and limitations of some data points. The investigators concluded that "polypropylene mesh final EDAC closure risks infection and subsequent fistula formation, and long-term follow-up are needed. Use of biologic mesh as either final EDAC closure or with vacuum-assisted closure also requires long-term follow-up to justify its increased cost and increased risk of abdominal wall laxity."

Booth et al (2013) stated that many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. These investigators hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation. They retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent mid-line AWR between 2000 and 2011 at a single center. These researchers compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence; multi-variate logistic regression analysis was used to identify factors predictive of or protective for complications. This study included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56 % versus 8 %; hazard ratio [HR] 9.5; p

Sbitany et al (2015) stated that repair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the co-morbid nature of the patient population. These investigators evaluated their institutional outcomes when performing single-stage repair of these hernias, with biologic mesh for abdominal wall reinforcement. A prospectively maintained database was reviewed for all patients undergoing repair of grade 3 (potentially contaminated) or grade 4 (infected) hernias, as classified by the Ventral Hernia Working Group. All those patients undergoing repair with component separation techniques and biologic mesh reinforcement were included. Patient demographics, co-morbidities, and post-operative complications were analyzed. Uni-variate analysis was performed to define factors predictive of hernia recurrence and wound complications. A total of 41 patients underwent single-stage repair of grade 3 and grade 4 hernias during a 4-year period. The overall post-operative wound infection rate was 15 %, and hernia recurrence rate was 12 %. Almost all recurrences were seen in grade 4 hernia repairs, and in those patients undergoing bridging repair of the hernia; 1 patient required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (p = 0.023), increasing body mass index (p = 0.012), increasing defect size (p = 0.010), and bridging repair (p = 0.042). No mesh was removed due to peri-operative infection. Mean follow-up time for this patient population was 25 months. The authors concluded that single-stage repair of grade 3 hernias performed with component separation and biologic mesh reinforcement was effective and offered a low recurrence rate. Furthermore, the use of biologic mesh allows for avoidance of mesh explantation in instances of wound breakdown or infection. Bridging repairs were associated with a high recurrence rate, as is single-stage repair of grade 4 hernias.

Romain et al (2016) noted that different types of biologic mesh have been introduced as an alternative to synthetic mesh for use in repairing contaminated ventral hernias because of their biocompatible nature. These researchers compared the clinical outcomes of patients who underwent complex ventral hernia repairs with either non cross-linked or cross-linked porcine dermal meshes. This was retrospective analysis from a prospectively maintained database from January 2010 to May 2013. Patients undergoing open incisional hernia repair with a biologic mesh in the presence of a clean-contaminated, contaminated or dirty wound were reviewed. There were 39 patients who underwent single-staged abdominal wall reconstruction for a contaminated ventral hernia with a biologic mesh. In 15 cases, non-crosslinked mesh was used (Strattice, n = 8; Protexa, n = 1; XenMatrix, n = 6); a cross-linked mesh was used in the remaining 24 cases (Permacol n = 21; CollaMend n = 3). The median follow-up was 11.9 10.6 months. The overall morbidity was 71.8 % (n = 28), with 15.4 % (n = 6) for grade I, 23.1 % (n = 9) for grade II, 23.1 % (n = 9) for grade III (n = 3 grade IIIA, n = 6 grade IIIB), 7.7 % (n = 3) for grade IV and 2.6 % (n = 1) for grade V. In the cross-linked group, there were 6 complications directly linked to the biologic mesh, compared with 3 in the non-cross-linked group. Overall wound morbidity was 41.0 % (n = 16). There were 13 hernia recurrences (33.3 %), and recurrence rate was not significantly different for both groups. The authors concluded that despite the high rate of wound morbidity associated with the single-staged reconstruction of contaminated fields, it could be safely performed with biologic mesh reinforcement. Recurrence rate was not significantly different between cross-linked and non-crosslinked porcine meshes. 2ff7e9595c