Open preperitoneal abdominal wall reconstruction (AWR) for patients with deep inferior epigastric perforator (DIEP) or transverse rectus abdominis myocutaneous (TRAM) flap hernias.

Abstract

Background: Donor site hernias or eventrations are a known complication of DIEP or TRAM flap breast reconstruction. Surgical management of these complex hernias can be challenging due to missing or atrophic rectus muscle. The purpose of this study was to evaluate outcomes of preperitoneal AWR in patients with a history of DIEP or TRAM flap hernias.

Methods: and procedures. A prospectively-maintained institutional database was queried for patients undergoing open preperitoneal ventral hernia repair (OVHR) with DIEP or TRAM flap hernias. Patient demographics, operative details, and wound complications were analyzed descriptively.

Results: A total of 35 patients met inclusion criteria. All patients were women, and the majority had a TRAM flap hernia (68.6%). The average age was 58.6 ± 10.2 years, and mean BMI was 29.7 ± 4.1 kg/m². One quarter (25.8%) of patients had a history of smoking, 17.1% had diabetes, and 54.3% had history of prior, failed hernia repair. Preoperatively, there were 5.7% who received Botulinum A injections. The majority of the cases were clean (82.6%). The mean defect size was large at 222.8 ± 164.5cm² and mesh size averaged 839.7 ± 361.1cm². Synthetic mesh was used in most cases (80%). Fascial closure rate was 97.1% with 14.3% of cases requiring component separation technique. Postoperatively, 5.7% of patients experienced superficial wound breakdown, 5.7% experienced wound cellulitis, and 14.3% experienced a wound infection, two of which were required OR. There were 20.0% of patients who had a seroma requiring intervention. There was only a single mesh infection (2.9%) requiring mesh removal, accounting for half of the 5.7% who developed a hernia recurrence over a follow-up of 36.8 ± 48.2 months.

Conclusions: DIEP and TRAM flap hernia management is complex due to missing or dysfunctional rectus muscle(s). A preperitoneal OVHR is an effective approach to repair these hernias with limited post-operative complications and low recurrences with long term follow up.