Discussion Discussion: Evidence-Based Abdominal Wall Reconstruction: The Maxi-Mini Approach Devinder Singh, M.D. Baltimore, Md.
H
ow can we reduce the enormous risk associated with complex ventral hernia repairs? Abdominal wall reconstruction is now widely recognized as a fusion of techniques from general surgery (lysis of adhesions) and plastic surgery (muscle flaps, alloplastic implants, and skin care). The fields overlap so much that it is hard to determine the primary outcome of importance: long-term hernia recurrence rates or surgical-site occurrences such as infection, seroma, necrosis, or dehiscence. Whichever outcome is measured, the repair of ventral hernia, especially complex hernia, remains fraught with high rates of complications. In this issue of Plastic and Reconstructive Surgery, Drs. Jeffrey Janis and Ibrahim Khansa unveil their plan to improve the outcomes of abdominal wall reconstruction.1 The authors conducted a thorough review of the published literature and incorporated the incremental “evidence-based” techniques they identified into their approach, which they call “maxi-mini” for its combination of open and minimally invasive techniques. Despite its peculiar title, the article by Drs. Janis and Khansa is a strong positive step in the right direction. It is an inclusive and compelling review of selected surgical techniques, and the authors conclude with a summary of promising outcomes from a series of 44 consecutive patients managed using their described approach. Unfortunately, the authors fail to acknowledge a nagging central truth: that sometimes experience-based medicine overrules the attempt toward evidence-based medicine. A close reading of their article and its cited evidence base illustrates the limitations of the available evidence describing ventral hernia repair. Of the high-quality studies cited by the authors, the majority pertain not to hernia repair, per se, but to important aspects From the Division of Plastic Surgery, University of Maryland School of Medicine. Received for publication May 23, 2015; accepted May 29, 2015. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001801
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of patient optimization and medical management. The cited evidence describing techniques and outcomes in hernia repair is limited to three randomized trials; a few nonrandomized prospective studies; and the large mass of retrospective studies, case series, systematic reviews, and expert opinion that typify the current hernia literature. This dearth of high-quality evidence requires that surgeons lean heavily on their own experience to guide their approach to hernia repair. Some important questions have been answered by the literature. For example, reinforcement of most repairs with prosthetic mesh reduces recurrence compared to primary repair, as demonstrated in the seminal (and nearly solitary) randomized trial by Luijendijk and colleagues.2 Other approaches have achieved broad consensus, such as limiting tension across the repair and the superiority of reinforced primary closure to bridged repairs. However, many key questions remain keenly debated. For example, although there is growing favor among experts for posterior reinforcement of the hernia defect, I will be the first to disagree and would gladly extol the virtues of anterior onlay positioning of mesh, which I reported in the literature in a retrospective study.3 Indeed, the truth and enduring challenge with the so-called evidence-based approach to complex ventral hernia repair is that each surgeon uses slightly different techniques, nomenclature, and materials, and these variations in approach contribute to wide disparity in reported outcomes of ventral herniorrhaphy. Even well-worn terms such as “recurrence” or “bulge” take on different meanings in different studies. We almost never compare apples to apples in a controlled, prospective, randomized fashion, and even when such courageous studies are performed, we rarely if ever seek to confirm their findings through independent study to determine whether the results are reproducible in someone else’s hands. Disclosure: The author is a paid consultant to Acelity (KCI, LifeCell) and Novadaq.
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 6 • Discussion The result is confusion among hernia surgeons, who continue to bicker over basic questions such as which technique (laparoscopic or open), which mesh (synthetic, resorbable, or biological), what mesh placement (underlay or overlay), and which suture (permanent, absorbable, continuous, or interrupted) contribute to optimal outcomes. The answers to these questions are bedeviling precisely because the proposed surgical solutions depend on many thorny issues that have proved nearly impossible to control simultaneously. Outcomes of ventral hernia repair depend on all manner of variables, including hernia size, intrinsic patient comorbidities, extrinsic risks of the procedure (such as previous scarring, raising skin flaps, and/or sparing perforators), and of course each surgeon’s individual preferences and techniques, among many others. Standardization of nomenclature, techniques, and outcomes reporting in the hernia literature is sorely needed. Here, Drs. Janis and Khansa carefully and critically describe the techniques used to achieve
their impressive abdominal wall reconstruction results. Ironically, it is more experience-based than it is evidence-based. In the absence of highlevel evidence, I am reluctant to abandon my way, yet I would gladly yield to anyone who can demonstrate the truly scientific way. Devinder Singh, M.D. Anne Arundel Medical Center 2001 Medical Parkway Annapolis, Md. 21401 [email protected]
REFERENCES 1. Janis JE, Khansa I. Evidence-based abdominal wall reconstruction: The maxi-mini approach. Plast Reconstr Surg. 2015;136:1312–1323. 2. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–398. 3. Singh DP, Zahiri HR, Gastman B, et al. A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia. Surg Innov. 2014;21:137–146.
Membership in the American Society of Plastic Surgeons For information regarding membership in the American Society of Plastic Surgeons, contact: American Society of Plastic Surgeons 444 E. Algonquin Road Arlington Heights, Ill. 60005 Tel: 847-228-9900 Fax: 847-228-9131
1325 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
H
ow can we reduce the enormous risk associated with complex ventral hernia repairs? Abdominal wall reconstruction is now widely recognized as a fusion of techniques from general surgery (lysis of adhesions) and plastic surgery (muscle flaps, alloplastic implants, and skin care). The fields overlap so much that it is hard to determine the primary outcome of importance: long-term hernia recurrence rates or surgical-site occurrences such as infection, seroma, necrosis, or dehiscence. Whichever outcome is measured, the repair of ventral hernia, especially complex hernia, remains fraught with high rates of complications. In this issue of Plastic and Reconstructive Surgery, Drs. Jeffrey Janis and Ibrahim Khansa unveil their plan to improve the outcomes of abdominal wall reconstruction.1 The authors conducted a thorough review of the published literature and incorporated the incremental “evidence-based” techniques they identified into their approach, which they call “maxi-mini” for its combination of open and minimally invasive techniques. Despite its peculiar title, the article by Drs. Janis and Khansa is a strong positive step in the right direction. It is an inclusive and compelling review of selected surgical techniques, and the authors conclude with a summary of promising outcomes from a series of 44 consecutive patients managed using their described approach. Unfortunately, the authors fail to acknowledge a nagging central truth: that sometimes experience-based medicine overrules the attempt toward evidence-based medicine. A close reading of their article and its cited evidence base illustrates the limitations of the available evidence describing ventral hernia repair. Of the high-quality studies cited by the authors, the majority pertain not to hernia repair, per se, but to important aspects From the Division of Plastic Surgery, University of Maryland School of Medicine. Received for publication May 23, 2015; accepted May 29, 2015. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001801
1324
of patient optimization and medical management. The cited evidence describing techniques and outcomes in hernia repair is limited to three randomized trials; a few nonrandomized prospective studies; and the large mass of retrospective studies, case series, systematic reviews, and expert opinion that typify the current hernia literature. This dearth of high-quality evidence requires that surgeons lean heavily on their own experience to guide their approach to hernia repair. Some important questions have been answered by the literature. For example, reinforcement of most repairs with prosthetic mesh reduces recurrence compared to primary repair, as demonstrated in the seminal (and nearly solitary) randomized trial by Luijendijk and colleagues.2 Other approaches have achieved broad consensus, such as limiting tension across the repair and the superiority of reinforced primary closure to bridged repairs. However, many key questions remain keenly debated. For example, although there is growing favor among experts for posterior reinforcement of the hernia defect, I will be the first to disagree and would gladly extol the virtues of anterior onlay positioning of mesh, which I reported in the literature in a retrospective study.3 Indeed, the truth and enduring challenge with the so-called evidence-based approach to complex ventral hernia repair is that each surgeon uses slightly different techniques, nomenclature, and materials, and these variations in approach contribute to wide disparity in reported outcomes of ventral herniorrhaphy. Even well-worn terms such as “recurrence” or “bulge” take on different meanings in different studies. We almost never compare apples to apples in a controlled, prospective, randomized fashion, and even when such courageous studies are performed, we rarely if ever seek to confirm their findings through independent study to determine whether the results are reproducible in someone else’s hands. Disclosure: The author is a paid consultant to Acelity (KCI, LifeCell) and Novadaq.
www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 6 • Discussion The result is confusion among hernia surgeons, who continue to bicker over basic questions such as which technique (laparoscopic or open), which mesh (synthetic, resorbable, or biological), what mesh placement (underlay or overlay), and which suture (permanent, absorbable, continuous, or interrupted) contribute to optimal outcomes. The answers to these questions are bedeviling precisely because the proposed surgical solutions depend on many thorny issues that have proved nearly impossible to control simultaneously. Outcomes of ventral hernia repair depend on all manner of variables, including hernia size, intrinsic patient comorbidities, extrinsic risks of the procedure (such as previous scarring, raising skin flaps, and/or sparing perforators), and of course each surgeon’s individual preferences and techniques, among many others. Standardization of nomenclature, techniques, and outcomes reporting in the hernia literature is sorely needed. Here, Drs. Janis and Khansa carefully and critically describe the techniques used to achieve
their impressive abdominal wall reconstruction results. Ironically, it is more experience-based than it is evidence-based. In the absence of highlevel evidence, I am reluctant to abandon my way, yet I would gladly yield to anyone who can demonstrate the truly scientific way. Devinder Singh, M.D. Anne Arundel Medical Center 2001 Medical Parkway Annapolis, Md. 21401 [email protected]
REFERENCES 1. Janis JE, Khansa I. Evidence-based abdominal wall reconstruction: The maxi-mini approach. Plast Reconstr Surg. 2015;136:1312–1323. 2. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–398. 3. Singh DP, Zahiri HR, Gastman B, et al. A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia. Surg Innov. 2014;21:137–146.
Membership in the American Society of Plastic Surgeons For information regarding membership in the American Society of Plastic Surgeons, contact: American Society of Plastic Surgeons 444 E. Algonquin Road Arlington Heights, Ill. 60005 Tel: 847-228-9900 Fax: 847-228-9131
1325 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
