1. 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

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 Atema JJ, Gans SL, Boermeester MA.
Systemic review
level of evidence IIIA
78 case series with 4,358 patients

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

4. 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)

5. 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

6. 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

7. 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 ( 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

8. Bovine pericardium
in-lay technique

9. 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

10. 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

11. Discussion and Literature Review

12. 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

13. 2009, World Journal of Surgery Systemic review level of evidence IIIA
57 case series with 3,169 patients
median follow-up 48 months
2015, World Journal of Surgery
Systemic review,
level of evidence IIIA
78 case series with 4,358 patients

14. 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???

15. 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.

16. 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⬆

17. 1/9 intentional remove after abdominal wall abscess →Permacol salvage
2006, Current Surgery
level of evidence IV
case report, 9 cases
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

18. 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)

19. 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

20. 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

21. 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

22. 謝謝聆聽！