Journal of Visceral Surgery (2014) 151, 9—16

Available online at

ScienceDirect www.sciencedirect.com

ORIGINAL ARTICLE

Practice patterns in complex ventral hernia repair and place of biological grafts: A national survey among French digestive academic surgeons C. Mariette a,∗, P. Wind b, R. Micelli Lupinacci c, C. Tresallet c, M. Adham d, C. Arvieux e, S. Benoist f, S. Berdah g, A. Berger h, N. Briez a, C. Brigand i, R. Caiazzo j, N. Carrere k, C. Casa l, D. Collet m, S. Deguelte n, B. Dousset o, V. Dubuisson p, O. Glehen q, J.-C. Gineste r, A. Hamy l, F. Lacaine s, C. Laurent r, P.-A. Lehur t, J.-Y. Mabrut u, P. Mathieu v, M. Mathonnet w, B. Meunier x, F. Michot y, M. Ouaissi z, J.-P. Palot n, Y. Parc aa, F. Pattou j, F. Paye aa, D. Pezet ab, G. Piessen a, M. Pocard ac, N. Regenet t, J.-M. Regimbeau ad, C. Sabbagh ad, P. Zerbib ae, J.-M. Toussaint af a

Department of digestive and oncological surgery, Claude-Huriez University Hospital, place de Verdun, 59037 Lille cedex, France b Department of digestive surgery, University Hospital of Avicennes, Avicennes, France c Department of digestive surgery, University Hospital Pitié-Salpétrière, Paris, France d Department of digestive surgery, University Hospital E.-Herriot, Lyon, France e Department of digestive surgery, University Hospital of Grenoble, Grenoble, France f Department of digestive surgery, University Hospital of Kremlin-Bicêtre, Le Kremlin-Bicêtre, France g Department of digestive surgery, Nord University Hospital, Marseille, France h Department of digestive surgery, Georges-Pompidou European University Hospital, Paris, France i Department of digestive surgery, University Hospital of Strasbourg, Strasbourg, France j Department of visceral and endocrine surgery, University Hospital of Lille, Lille, France k Department of digestive surgery, University Hospital of Toulouse, Toulouse, France l Department of digestive surgery, University Hospital of Angers, Angers, France m Department of digestive surgery, Haut-Leveque University Hospital, Bordeaux, France n Department of digestive surgery, University Hospital of Reims, Reims, France o Department of digestive surgery, Cochin University Hospital, Paris, France

∗

Corresponding author. Tel.: +33 3 20 44 44 07; fax: +33 3 20 44 43 85. E-mail address: [email protected] (C. Mariette).

1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.12.001

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C. Mariette et al. p

Department of digestive surgery, Pellegrin University Hospital, Bordeaux, France Department of digestive surgery, Lyon-Sud University Hospital, Lyon, France r Department of digestive surgery, Saint-André University Hospital, Bordeaux, France s Department of digestive surgery, Tenon University Hospital, Paris, France t Department of digestive surgery, University Hospital of Nantes, Nantes, France u Department of digestive surgery, Croix-Rousse University Hospital, Lyon, France v Department of digestive surgery, University Hospital of Besanc¸on, Besanc¸on, France w Department of digestive surgery, University Hospital of Limoges, Limoges, France x Department of digestive surgery, University Hospital of Rennes, Rennes, France y Department of digestive surgery, University Hospital of Rouen, Rouen, France z Department of digestive surgery, Timone University Hospital, Marseille, France aa Department of digestive surgery, Saint-Antoine University Hospital, Paris, France ab Department of digestive surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France ac Department of digestive surgery, Lariboisière University Hospital, Paris, France ad Department of digestive surgery, Amiens University Hospital, Amiens, France ae Department of general surgery and transplantation, University Hospital of Lille, Lille, France af Hull Associates, Medtech consulting, 100 Ledgewood Place, Suite 204, Rockland, Massachusetts 02370, USA q

Available online 31 December 2013

KEYWORDS Ventral hernia repair; Contaminated field; Abdominal wall reconstruction; Prosthetic; Biologic mesh; Survey

Summary Background: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. Methods: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. Results: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). Conclusions: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications. © 2013 Elsevier Masson SAS. All rights reserved.

Introduction Ventral hernias are a common complication of abdominal surgery, with a significant impact on health care utilization and costs [1]. Even if the prosthetic mesh is now recognized as the optimal repair technique in clean fields [1], the optimal technique or prosthetic for complex ventral hernias repair (CVHR), defined by contaminated/infected surgical field or patients’ comorbidites representing risk factor for recurrent incisional hernias or mesh infection, has not been identified. Additionally, the absence of a clear and consensual classification system to standardize results makes comparative analysis of publications limited. Several

attempts to classify incisional hernias based on the parietal defect and patient factors have been conducted [2,3]. In 2010, the Ventral Hernia Working Group recommended to individualize four groups of patients based on the presence of underlying patients’ comorbidities and perioperative wound contamination for defining the most appropriate prosthetic selection (synthetic versus biologic) [2]. This group recommended synthetic mesh for otherwise healthy individuals and biologic grafts for those patients with active contamination during abdominal wall reconstruction. Very recently, this proposal has been challenged with a modified 3-level grading scale that may improve the accuracy of predicting surgical site occurrence after ventral hernia

Complex ventral hernia repair strategy repair. The major modification was to categorize patients with previous wound infection with those having comorbidities and to define high-risk group based on Centers for Disease Control (CDC) definitions of wound classification [4]. Patients with comorbidities such as malnutrition, diabetes, obesity, chronic obstructive pulmonary disease, and smoking, represent a large percentage of incisional hernia patients, as these comorbidities are inherent risk factors to the formation of hernias [5,6]. However, there is little consensus as to the ideal prosthetic for such high-risk patients without the presence of contamination. The introduction of the biologic mesh to the armamentarium of the digestive surgeon has enabled one-stage repairs of contaminated and infected abdominal wall hernias [7]. Even if some retrospective or prospective studies have reported promising results, especially in contaminated fields with biologic grafts, level I of evidence is lacking and consequently established benefits remain unknown. Additionally, the lack of clear guidelines as to the most appropriate usage of such expensive products has resulted in inconsistent practice patterns amongst surgeons. We hypothesized that practice patterns for CVHR vary significantly. In order to better understand which situations or subgroups of patients may benefit from specific therapeutic strategies, including biologic mesh, we performed a national survey among French digestive academic surgeons practicing CVHR, to determine their practice patterns, conditions under which biologic mesh are being implemented, and their experience with associated complications.

Materials and methods Survey participants were practicing academic surgeons performing CVHR. Representatives of all French University Hospitals were asked to participate through an e-mail invitation. Participation was voluntary. The survey consisted of 21 questions and 6 patient case scenarios (Appendix 1) to be answered through a secure website. The survey was proofread, edited, and validated by three surgeons (C.M., P.W., C.T.) prior to implementation. The survey asked questions regarding surgical techniques usually used in ventral and parastomal hernia repair, experience, frequency and indications for using synthetic/biologic meshes in the setting of CVHR, factors influencing synthetic and biologic mesh use, observed biologic graft complications, technique of placing biologic graft, and an assessment of satisfaction with biologic grafts. In order to give strength to the survey answers, additional 6 case patient scenarios were presented asking surgeons how they would treat the patient. The scenarios differed by the size of the ventral hernia and the degree of wound contamination. A 3-week period of time during May 2013 was given to surgeons for answering the survey. In case of inconsistency in answers or missing data, surgeons were contacted individually on an e-mail basis for obtaining additional information. Consensus among respondents was defined as an agreement of more than 50%, strong consensus as an agreement of more than 75%. Data were collected and analyzed using Excel statistical system. Data analysis included descriptive statistics, chi-squared test of Fischer’s exact test when appropriate with a P value of < 0.05 considered significant. An educational grant was received from Lifecell EMEA. The funding source had no role in data analysis or interpretation, neither in the redaction of the manuscript. Additionally the scientific committee did not allow any commercial questions during the survey.

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Results Completed questionnaires were received from 40 surgeons among 54 e-mailings, resulting in a response rate of 74%. All surgeons were digestive surgeons from academic centers, mainly located in Paris (n = 9), Lille (n = 6), Bordeaux (n = 4) and Lyon (n = 3). Respondents were involved in surgical practice for less than 5 years (n = 2), between 5 to 10 years (n = 5), between 11 to 15 years (n = 11), between 16 to 20 years (n = 9) or more than 20 years (n = 13). Respondents were more frequently male (85%), general and abdominal surgeons (80%), senior surgeons (82.5%) and full professor of surgery (60%). There were 36 of the 40 respondents (90%) who indicated having experience of biologic mesh placement. Number of ventral hernia repairs per month was between 0 and 2 in 37.5% of cases, 3 to 4 in 17.5%, between 5 to 10 in 25.0% and 11 cases or more in 20.0% of cases. Over the last year, 5 surgeons declared having stopped using biologic mesh, with no explanation reported. Regarding the techniques used for CVHR, primary closure without mesh use was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh used as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. From those who had used biologic mesh in the last year (34/40, 85.0%), frequency of biologic graft use was as follows: low-volume users, less than 5 times, 67.6%; medium-volume users, between 5 to 10 times, 26.5%; high-volume users, between 10 to 20 times, 5.9%. Indications for primary closure repair based on CDC wound classification (clean, clean-contaminated, contaminated or dirty) were quite varied and there was a lack of consensus among surgeons, except in the case of clean surgery for which 62.5% of respondents would not recommend primary closure without a mesh (Fig. 1). Regarding indications of synthetic mesh according to the wound classification, all surgeons (100%, n = 40) agreed for not using it in contaminated or dirty fields, but for placing it in clean settings. In clean-contaminated surgery, there was no consensus for using synthetic mesh in CVHR (Fig. 2). Looking at the indications of biologic mesh use based on wound classification, there was a strong consensus between respondents for using it in contaminated (82.5%, n = 33) or infected (77.5%, n = 31) fields and for not using it in clean setting (95%, n = 38). For clean-contaminated field, there was no consensus among respondents (Fig. 3). Summary of the

Figure 1. Percentages of agreement among respondents for primary repair without mesh reinforcement in ventral hernia repair according to wound classification.

12 Table 1

C. Mariette et al. Type of repair that would be recommended by respondents according to the wound classification.

Clean Clean-contaminated Contaminated Dirty

Biologic mesh

Synthetic mesh

Primary closure w/o mesh

— No consensus ++++ +++

+++++ No consensus — —

— No consensus No consensus No consensus

The more +, the higher the consensus.

Figure 2. Percentages of agreement among respondents for using synthetic mesh in ventral hernia repair according to wound classification.

type of repair that would be recommended by respondents according to wound classification is presented in Table 1. The Ventral Hernia Group Classification was known by 38% of the respondents. Among those reporting to be biologic mesh users (n = 36), multiples techniques have been used over time to place these materials. Whereas the intraperitoneal placement was the most used (89.0%, n = 32) and preferred (67.0%, n = 24) technique, retromuscular placement has been also used for 44% of respondents. Among the 39/40 surgeons that answered this question, 75.3% closed defects with a fascia closure technique (43.7% using a component separation technique, 31.6% using primary fascia closure), whereas no fascia closure was provided by 24.7% of respondents (16.5% using the bridge technique and 8.2% reducing the defect size by aponeurotomy incisions). Surgeons reported to use a biologic mesh for defects with a

Figure 3. Percentages of agreement among respondents for using biologic mesh in ventral hernia repair according to wound classification.

maximum width or height from 10 to 20 cm, possibly influenced by the biologic graft sizes available. In case of CVHR with the use of a biologic graft in a contaminated field, one step surgery was the preferred strategy for 45.0% of surgeons, whereas 20.0% of respondents would provide a two step strategy. Other strategies reported were a primary closure without mesh for 25.0%, a rapid absorbable mesh use (such as a Vicryl® mesh) for 7.5% and a synthetic mesh use in 2.5%. Types of patients and abdominal wall defects for which a biologic mesh has been used were patients with co-morbid conditions in 22.4% of cases, infected mesh removal with active infection in 19.3% of cases, contaminated recurrent hernia repair in 19.0% of cases, enterocutaneous fistula repair in 10.2% of cases, contaminated open incisional hernia in 9.1% of cases and others in 20.0% of cases. For parastomal hernia repair, techniques used were the keyhole repair (32.5%, with the use of a synthetic mesh in 10% or a biologic mesh in 22.5%), the stomy transposition (30.0%, with controlateral positioning in 22.5% and ipsilateral positioning in 5.0% or other in 2.5%), the Sugarbaker technique (25.0%, with the use of a synthetic mesh in 20.0% or a biologic mesh in 5.0%), the laparoscopic approach (7.5%) and others (5.0%). For parastomal hernia, a synthetic or a biologic mesh was provided to be the preferred device for repair in 27.5% and 27.5% of respondents, respectively, whereas 45.0% of surgeons would not use any prosthesis. All respondents reported at least one complication after having used biologic grafts. An average of 2.4 (range 1—55) biologic mesh-related complications was reported. Infection was the most frequent complications reported (58.0% of respondents), followed by poor incorporation or extrusion of the mesh (50.0%), mesh disintegration (36.0%), seroma (36.0%), fistula (19.0%), mechanical failure (19.0%) and others (14.0%). The most commonly reported influences for the use of biologic grafts among surgeons included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%), cost (40.0%), availability (28.0%), and representative information (13.0%). Of those who ever used a biologic graft (n = 36), 61.1% of surgeons were satisfied, 36.1% neutral and 2.8% unsatisfied. We identified a significant correlation between the level of satisfaction and the number of complications reported (P < 0.001) with a median number of 4 complications reported in unsatisfied surgeons compared to 2.2 and 2.6 in satisfied and neutral surgeons, respectively. Patient case scenarios are presented in Fig. 1. In each scenario, patient was obese and current smoker. The scenarios differed by the size of the hernia (small or large) and by the degree of contamination (contaminated or infected field). Main results are presented in Table 2. In summary, surgeons would choose the type of mesh (synthetic

Complex ventral hernia repair strategy

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Table 2

Summary of patient case scenarios.

Case no.

Scenario

Response

1 2 3 4 5 6

Large incisional hernia in an obese smoker with contamination Large incisional hernia in an obese smoker with infection Small incisional hernia in an obese smoker without contamination Small incisional hernia in an obese smoker without infection Small incisional hernia in an obese smoker with contamination Small incisional hernia in an obese smoker with infection

62% 92% 85% 82% 57% 72%

or biologic) mainly based on the degree of parietal contamination. The synthetic mesh is the preferred technique for patients without any contamination or infection. Approximately 60% of surgeons would use a biologic graft in case of wound contamination with a very little impact of the defect size on the decision. For infected CVHR, the vast majority of surgeons would recommend the use of a biologic graft, more frequently for large hernia (92%) when compared to small hernia (72%).

Discussion CVHR, defined by contaminated/infected surgical field or patients’ comorbidites representing risk factor for recurrent incisional hernias or mesh infection, is a challenging situation. The use of biologic mesh in this setting has been widely adopted by surgeons despite the lack of randomized controlled trials, no long-term outcomes published and very small experiences. The present survey identifies a strong consensus among academic French surgeons for not using synthetic mesh in contaminated or dirty fields, and for recommending it in clean settings. This was confirmed with a strong consensus between respondents for using biologic mesh in contaminated or infected fields and for not using it in clean setting. However, no clear consensus was reached for clean-contaminated field. Despite the lack of level I evidence evaluating biologic mesh in the setting of contamination, it is generally accepted that biologic mesh is appropriate [2,4]. The degree of bacterial burden that is acceptable at the time of biologic mesh placement, however, is unclear. Recent clinical reports suggest that biologic mesh perform poorly in the setting of dirty wounds [8], whereas in an animal model the ability of biologic grafts to clear bacterial load in the different wound classifications was shown [9]. An ongoing phase III randomized trial in France, the Simbiose study, is looking at the impact of biologic mesh in infected CVHR compared to a control arm with standard practice. The primary aim of this national trial is the incidence of wound infection/recurrent ventral hernia at 6 months after surgery [10]. There is much anticipation of the results from this trial since it is the first testing the concept of biological mesh in the field of infected CVHR. On the other end of the spectrum, there is no study indicating that these costly materials should replace cheaper synthetic materials in clean settings. In the field of contaminated or infected setting, not only the wound classification is used for surgical decision making in relation to the use of biologic graft. In fact, 22.4% of respondents would consider patients’ morbid conditions, such as obesity, immunosuppression, smoking, and prior wound infection, as key decision factors for choosing a biologic graft. These factors have been shown to be linked with higher incidence of

of of of of of of

respondents respondents respondents respondents respondents respondents

chose chose chose chose chose chose

biological biological biological biological biological biological

mesh mesh mesh mesh mesh mesh

surgical site infections, even in a clean field [2,5]. Interestingly, even if these factors have been shown to increase the risk of wound infection in clean surgery, respondents would not favor the use of biologic graft for such patients. This attitude appears reasonable in absence of clinical evidence supporting their use. The traditional approach to contaminated CVHR repair includes a two-stage operation to initially control infection and later provide a more durable hernia repair [11]. The introduction of biologics into the hernia market has challenged this approach. Even if the one step approach will be evaluated in the Simbiose study, a transition in surgical practice has already occurred. This is clearly illustrated in the present survey with 45% of surgeons preferring a singlestage operation in the setting of contamination. One of the potentials advantages of biologic graft use in this setting is that the mesh may not need to be explanted if infection persists, as that potentially can be managed thereafter as an open wound. The ultimate outcome of these grafts remains unknown in such challenging situation, and likely some degree of disintegration/degradation occurs and may lead to increased hernia recurrences, particularly in the bridged repairs. However the absence of an infected permanent synthetic material that may require removal at any time might still provide benefits. In the absence of strong published data, careful consideration is needed in order to precisely identify which cases benefit the most from the use of biologic meshes. Multiple factors may be associated with biologic meshrelated complications but placement and surgical technique certainly are important considerations. Various techniques for mesh placement have been described both for synthetic and biologic meshes. Based on the survey result, the intraperitoneal placement was the most commonly used technique for 89% of surgeons for biologic mesh implantation, the retromuscular placement for 44%. This is consistent with a recent study looking at the appropriate anatomical plane for an underlay repair technique, suggesting that there were no difference in wound infections, seromas, or hematomas between retrorectus and intraperitoneal mesh placement [12]. It should be underlined however that recurrent hernias were identified in only 10% of retrorectus repairs and 30% of intraperitoneal repairs. Why retrorectus mesh placement may improve outcomes might be explained by a better blood supply in the retromuscular position, leading thus to a greater neoavascularization for biologic meshes in this position. Interestingly, 39% acknowledge using a bridge technique despite evidence to suggest there are higher recurrence rates associated with such an approach [13,14]. This might be explained partly by having treated large and complicated ventral hernias in which primary fascia closure was not possible despite the use of aponeurotomy incisions. Another explanation could be to avoid additional

14 morbidity related to the component separation technique, such as pain, hematoma or infection in dissected planes, especially in the presence of infection. Given the challenging cases that biologic mesh is typically being utilized in, it is not surprising that surgeons experienced an average of 2.4 biologic mesh-associated complications. Some of the complications reported are significant and concerning, as they are not commonly associated with biologic grafts, such as poor incorporation or extrusion of the mesh (50.0%) and mesh disintegration, reported in 50.0% and 36.0% of cases, respectively. The relationship between biologic graft placement and some complications such as fistulae or infection may be more difficult to interpret, since that was frequently the primary condition for which the patient benefits from the biological graft. It should be also underlined that the anonymous nature of the survey, the elimination bias to only report favorable outcomes as well as the complex nature of the majority of patients in which biologic graft is placed likely increases the level of complications experienced. Despite very little data on long-term outcomes with biologic mesh for abdominal wall reconstruction, survey respondents stated that literature evidence was the first factor, before personal experience, in influencing their use of biologic mesh. This underlined that while personal experience is certainly an important factor influencing surgeon choice, they recognize that some level of data should substantiate these decisions. The ongoing Simbiose study in France may have impacted surgeons’ answers for CVHR in infected fields [10]. However this highlights also the need for some randomized controlled studies to look at the benefit of biologic mesh in other subgroups of patients with high risk of infection/recurrence, taking into consideration degree of wound contamination, patients’ comorbidities and the underlying pathology. However, clear identification of such high-risk subgroups does not exist at that time and is urgently needed to justify the product cost. Surprisingly, only 40% of the surveyed surgeons were influenced by the cost of these materials. Maybe the cost-effectiveness of single-stage approaches to avoid additional CVHR appears favorable, even if there is still a critical need for its demonstration. Even if some medical and medico-economic answers will come from the SIMBIOSE study, it is expected that testing the benefit of biological grafts in other subgroups of patients exposed to high risk of wound infection and/or recurrence should be an optimal way for defining appropriate indications and economic conditions for their use. This study has some limitations. As this is a voluntary survey, one should certainly consider response bias. However, the exceptionally high response rate for such methodology may have limited such an effect. Having involved only academic surgeons may have placed biologic in a common use regarding CVHR. However, CVHR are frequently addressed to referral centers and such costly biologic mesh can be only funded by large institutions. Finally, it is difficult to associate reported complications with the setting under which they were placed. To summarize, this survey highlights that, despite the lack of level I evidence, there is consensus in France for providing specific surgical strategy in case of contaminated or dirty fields, including biologic graft implementation. Wound classification appears as the main risk factor to be considered for mesh placement, but patients’ comorbidities appear to be also a decisional factor. Patients with high risk of infection and/or recurrence after ventral hernia repair

C. Mariette et al. need urgently to be identified for stressing optimal therapeutic strategy and exhibiting any potential benefit of biologic mesh use.

Disclosure of interest Christophe Mariette, Philippe Wind, Renato Micelli Lupinacci and Christophe Tresallet received an education grant from LifeCell EMEA for conducting this survey, interpreting the data and writing the report. Funding source: An educational grant was received from Lifecell EMEA. The funding source had no role in data analysis or interpretation, neither in the redaction of the manuscript.

Appendix 1/Supplementary material. Questionnaire 1. Quelle est votre spécialité chirurgicale ? a. Chirurgie générale et digestive b. Chirurgie traumatologique c. Chirurgie colorectale d. Chirurgie hépatobiliaire e. Chirurgie de transplantation f. Chirurgie plastique g. Autre 2. Depuis combien d’années exercez-vous ? a. < 5 ans b. 5 à 10 ans c. 11 à 15 ans d. > 20 ans 3. Combien de hernies ventrales et d’éventrations (défects de la paroi abdominale) réparez-vous par mois ? a. 0 à 2 b. 3—4 c. 5 à 10 d. 11 et plus 4. Utilisez-vous actuellement la technique d’incisions de décharge/aponévrotomies pour la chirurgie de la paroi abdominale ? a. Oui b. Non 5. Avez-vous utilisé des matrices biologiques entre 2002 et 2013 ? a. Oui b. Non 6. Utilisez-vous toujours actuellement des matrices biologiques ? a. Oui b. Non 7. Combien de fois avez-vous utilisé des matrices biologiques au cours de l’année dernière ? a. Aucune b. 1—4 c. 5—9 d. 10—20 e. > 20 8. Pour chaque classification d’éventration, veuillez cocher si vous pensez qu’une matrice biologique est indiquée :

Complex ventral hernia repair strategy D’accord Neutre Pas d’accord a. b. c. d.

Propre : Propre-contaminée : Contaminée : Souillée :

9. Pour chaque classification d’éventration, veuillez cocher si vous pensez qu’une prothèse synthétique est indiquée : D’accord Neutre Pas d’accord a. b. c. d.

Propre : Propre-contaminée : Contaminée : Souillée :

10. Pour chaque classification d’éventration, veuillez cocher si vous pensez qu’une fermeture primaire sans prothèse est indiquée : D’accord Neutre Pas d’accord a. b. c. d.

Propre : Propre-contaminée : Contaminée : Souillée :

11. Connaissez-vous bien le système de classification du Ventral Hernia Working Group (groupe de travail sur les hernies ventrales) ? a. Oui b. Non 12. Pour la réparation d’une éventration péristomiale, que préférez-vous comme prise en charge chirurgicale ? a. Réparation par abord péristomial sans prothèse synthétique b. Réparation par abord péristomial avec matrice biologique c. Transpostion de la stomie : repositionnement ipsilatérale d. Transposition de la stomie : repositionnement controlatérale e. Sugarbaker avec prothèse synthétique f. Sugarbaker avec matrice biologique g. Laparoscopie avec prothèse synthétique h. Laparoscopie avec matrice biologique i. Autre 13. Qu’est ce qui influence votre choix d’utilisation d’une matrice biologique ? Veuillez sélectionner toutes les propositions applicables a. Littérature, congrès, contact avec d’autres chirurgiens b. Expérience personnelle c. Informations fournies par le représentant commercial d. Coût e. Disponibilité 14. Avez-vous observé une ou plusieurs des complications suivantes associées à l’utilisation d’une matrice biologique ? Veuillez sélectionner toutes les propositions applicables a. Défaillance mécanique (déchirures de la matrice) b. Désintégration de la matrice c. Mauvaise incorporation/extrusion enkystement d. Infection e. Lymphocèle/sérome f. Douleur g. Fistule digestive h. Réaction allergique i. Je n’utilise jamais de matrice biologique

15 j. Autre 15. Pour la cure d’une éventration, quelle technique avezvous utilisé pour poser une matrice biologique ? Veuillez sélectionner toutes les propositions applicables a. Je n’utilise pas de matrice biologique b. Prothèse préaponévrotique (sous cutanée) c. Prothèse rétromusculaire d. Réparation par pontage avec recouvrement de 3 à 5 cm sur l’aponévrose musculaire (prothèse en bridge) e. Prothèse intrapéritonéale 16. En cas de cure d’éventration en milieu contaminé, quelle technique préférez-vous utiliser ? a. Réparation en une seule étape : traitement de la contamination (par réparation de la continuité digestive par exemple) et cure d’éventration sans prothèse b. Réparation en une seule étape : idem avec cure d’éventration par prothèse synthétique c. Réparation en une seule étape : idem avec cure d’éventration par matrice biologique d. Réparation à plusieurs étapes : dans les cas contaminés rétablissement de la continuité digestive par exemple dans un premier temps mais traitement de l’éventration lors d’une deuxième intervention à distance de la première e. Autre 17. Veuillez évaluer votre degré de satisfaction concernant le résultat chirurgical global obtenu avec une matrice biologique a. Aucune utilisation de matrice biologique b. Satisfait c. Neutre d. Insatisfait 18. Chez quel type de patients avec un défect de la paroi abdominale avez-vous utilisé une matrice biologique en renforcement pariétale au cours des 2 dernières années ? Veuillez indiquer les pourcentages de cas pour chaque type, le cas échéant. > Pourcentage des cas (%) a. Patients en bonne santé, sans complications ni antécédents d’infection b. Patients ayant des pathologies concomitantes (par ex. tabagisme actif) c. Immunosuppression, obésité, diabète, BPCO, hypoxémie, malnutrition, antécédents de radiothérapie sur le site opératoire, infection active, antécédents d’infection des tissus mous, insuffisance organique chronique d. Éventration ouverte contaminée e. Réparation de hernie récurrente contaminée Éventration récidivé contaminée : f. Retrait de matrice infectée (infection active) g. Échec de réparation herniaire laparoscopique h. Abdomen ouvert (laparostomie) < 2 semaines i. Abdomen ouvert (laparostomie) < 1 mois j. Abdomen ouvert (laparostomie) > 1 mois k. Éviscération postopératoire l. Réparation de fistule m. Autre 19. Quelle a été, en moyenne la largeur ou la longueur minimale de défect des patients chez lesquels vous avez utilisé une matrice biologique pour renforcer la réparation ? a. < 10 cm b. 10—20 cm c. > 20 cm

16 20. Quelle a été, en moyenne la largeur ou la longueur maximale de défect des patients chez lesquels vous avez utilisé une matrice biologique pour renforcer la réparation ? a. 10—20 cm b. > 20 cm c. Autre 21. Comment avez-vous fermé les défects au cours des 2 dernières années, en indiquant le pourcentage ? Pourcentage des cas (%) a. Pas de fermeture, pontage du défect (prothèse en bridge) b. Pas de fermeture, réduction de la taille du défect par la technique des incisions de décharge aponévrotiques c. Fermeture aponévrotique primaire d. Fermeture aponévrotique complète avec technique des incisions de décharge aponévrotiques Case scenarios 22. Quelle technique utiliseriez-vous pour une réparation ouverte d’une éventration de grande taille chez un fumeur obèse avec présence d’une contamination ? a. Réparation par pontage avec prothèse synthétique b. Réparation par pontage avec matériau de réparation biologique c. Réparation par suture primaire après incisions de décharge/aponévrotomies (pas de prothèse/matrice) d. Incisions de décharge/aponévrotomies + prothèse synthétique e. Incisions de décharge/aponévrotomies + matériau de réparation biologique 23. Quelle technique utiliseriez-vous pour une réparation ouverte d’une éventration de grande taille chez un fumeur obèse avec présence d’une infection ? a. Réparation par pontage avec prothèse synthétique b. Réparation par pontage avec matériau de réparation biologique c. Réparation par suture primaire après incisions de décharge/aponévrotomies (pas de prothèse/matrice) d. Incisions de décharge/aponévrotomies + prothèse synthétique e. Incisions de décharge/aponévrotomies + matériau de réparation biologique 24. Quel matériau utiliseriez-vous pour une réparation ouverte d’une éventration de petite taille chez un fumeur obèse sans présence d’une contamination ? a. Réparation par suture primaire (pas de prothèse/matrice) b. Prothèse synthétique c. Matériau de réparation biologique 25. Quel matériau utiliseriez-vous pour une réparation ouverte d’une éventration de petite taille chez un fumeur obèse sans présence d’une infection ? a. Réparation par suture primaire (pas de prothèse/matrice) b. Prothèse synthétique c. Matériau de réparation biologique 26. Quel matériau utiliseriez-vous pour une réparation ouverte d’une éventration de petite taille chez un fumeur obèse avec présence d’une contamination ?

C. Mariette et al. a. Réparation par suture primaire (pas de prothèse/matrice) b. Prothèse synthétique c. Matériau de réparation biologique 27. Quel matériau utiliseriez-vous pour une réparation ouverte d’une éventration de petite taille chez un fumeur obèse avec présence d’une infection ? a. Réparation par suture primaire (pas de prothèse/matrice) b. Prothèse synthétique c. Matériau de réparation biologique

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