Practice patterns in complex ventral hernia repair and place of

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
10
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 Besançon, Besançon, 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.
11
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
13
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
References
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