Component Separation versus Bridged Repair for Large Ventral Hernias: A Multi-Institutional Risk Adjusted Comparison

Julie Holihan, University of Texas Health Science Center at Houston; Ioana Bondre, University of Texas Health Science Center at Houston; Erik Askenasy, Baylor College of Medicine; Jacob Greenberg, University of Wisconsin; Jerrod Keith, University of Iowa; Robert Martindale, Oregon Health & Science University; John Roth, University of Kentucky; Curtis Wray, University of Texas Health Science Center at Houston; Lillian Kao, University of Texas Health Science Center at Houston; Mike Liang, University of Texas Health Science Center at Houston

Ventral hernia repair (VHR) of large defects (width ≥8 cm) is associated with high rates of surgical site infection (SSI) and recurrence. Two operative strategies exist: component separation with primary fascial closure and mesh reinforcement (CS) and bridged repair (mesh spanning the hernia defect). CS creates a functional abdomen and protects the mesh with a vascularized, functional barrier. Bridged repairs avoid high-risk skin flaps and require less operative time. Few studies have compared outcomes between these options.

VHR of large defects with CS is associated with more SSIs but fewer recurrences than bridged repair.

A multi-center database of patients with VHR from 2010-2011 was queried for patients with at least 1 month of follow up and a defect ≥ 8 cm. CS repairs were compared to bridged. Univariate and multivariate stepwise regression were performed to identify factors associated with SSI and recurrence. Subgroup analysis was performed of patients undergoing elective repair.

129 VHR were followed for a median of 17(1-48) months: 84 underwent CS and 45 had bridged repair. Between the two cohorts, there were differences in patient and hernia characteristics (table). Unadjusted results demonstrated a clinically significant but statistically non-significant difference in SSI and recurrence. There were fewer deep/organ space SSIs with CS. On multivariate analysis, there was a trend toward fewer SSIs (OR2.2, 95%CI 0.7-6.8) and recurrences (OR2.1, 95%CI 0.9-5.1) with CS. On subgroup analysis of elective VHR only (n=114), multivariate analysis showed fewer SSI with CS (OR2.7, 95%CI 1.1-6.8).  The multivariate model for recurrence in elective repairs did not converge.

In this multi-center study, CS had fewer SSIs—particularly deep and organ space SSI—and recurrences compared to bridged repair of large ventral hernias. While these differences were not statistically significant, CS may be a more suitable option for large VHR. Future studies should compare the risks and benefits of these repairs in similar patient populations to determine in which settings CS and bridged repair are best utilized.