alexa The Use of Porcine Dermal Collagen Implant in an Extremely Difficult Case of Incisional Hernia Repair | Open Access Journals
ISSN: 2165-7920
Journal of Clinical Case Reports
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

The Use of Porcine Dermal Collagen Implant in an Extremely Difficult Case of Incisional Hernia Repair

Rafał Kieszek, Kalina Jędrzejko*, Magdalena Kwapisz, Piotr Domagała, Agata Ostaszewska, Piotr Palczewski, Katarzyna Sułkowska and Artur Kwiatkowski

Department of General and Transplantation Surgery, Medical University of Warsaw, Poland

*Corresponding Author:
Kalina Jędrzejko
Department of General and Transplantation Surgery
Medical University of Warsaw, Poland
Tel: 0048225021126
Fax: 0048225022155
E-mail: kala.jedrzejko@gmail.com

Received March 02, 2016; Accepted June 15, 2016; Published June 20, 2016

Citation: Kieszek R, Jędrzejko K, Kwapisz M, Domagała P, Ostaszewska A, et al. (2016) The Use of Porcine Dermal Collagen Implant in an Extremely Difficult Case of Incisional Hernia Repair. J Clin Case Rep 6:815. doi:10.4172/2165-7920.1000815

Copyright: © 2016 Kieszek R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical Case Reports

Abstract

It is not rare, that in patients undergoing multiple laparotomies there is a tissue loss with accompanying surgical site infection that enables abdominal wall closure with the use of the standard techniques. There are no level 1 statements imposing specific procedure in such difficult situations. However, it is generally recognized that synthetic meshes should not be implanted in the contaminated field.

Keywords

Incisional hernia repair; Negative pressure wound therapy; Porcine dermal collagen implant; Permacol; Surgical site infection; Polypropylene mesh

Case Report

An obese male patient (BMI=34.6), aged 67, was admitted to the Department of General Surgery with the suspicion of the ileum obstruction, caused by incarceration of the small intestine in the incisional hernia post vertical banded gastroplasty surgery that he had undergone years before that was followed by surgical site infection (S. aureus). Three months before admission he had undergone open cholecystectomy that was also complicated by surgical site infection.

The patient was operated on due to obstruction; the operation was connected with hernioplasty with the use of 30 × 30 cm polypropylene mesh, using sublay technique.

After three days patient required another procedure, because of the recurrent obstruction. During the procedure the polypropylene mesh had been cut in order to explore the abdominal cavity and during the abdominal closure it was sutured. Six days after the second operation, eventration was stated. Exploration of the wound revealed that the fascia was infiltrated, brittle and tearing. Negative pressure wound therapy (NPWT) was applied because of the accompanying surgical site infection. The wound was not closed after that procedure. During the next dressing exchange, the contamination of the mesh had been stated and the decision of mesh removal was made.

NPWT was maintained with good results, and after four weeks, as soon as the wound was sterile and clean, confirmed by the microbiological result. The decision to implant the biological material was made. 20 × 40 cm PermacolTM was implanted on the musclefascia layer, using sublay technique (Figure 1). Two drains above the fascia were left. Moreover, sutures preventing from eventration were placed as well. Three days post PermacolTM implantation a massive leakage from the wound was noticed connected with the necrosis of the wound brims. The removal of the sutures was necessary. After wound exploration, it turned out that dissolved PermacolTM had caused the leakage. The biological mesh remained intact only on the brims (Figure 2). According to the histopathological examination of the removed PermacolTM, there were features of granulation, acute inflammation and foci of necrosis. Patient required open wound healing, connected with NPWT, nevertheless there were no microbiological cultures. NPWT was maintained for another month, during which another infection appeared. The culture of the wound revealed S. epidermidis that was treated by intravenous vancomycin therapy. The next step was the cleaning with the use of the water knife. The part of the wound was sutured, on the bottom part of the wound NPWT was implied. After another week the remaining part of the wound was sutured.

muscle-fascia-layer

Figure 1: PermacolTM was implanted on the muscle-fascia layer, using sublaytechnique.

biological-mesh-brims

Figure 2: The biological mesh remained intact only on the brims.

The patient was discharged to the outpatient clinic after 100 days. Dressing change three times a week was necessary, due to the sterile serum leakage from the wound (Figure 3). Because of the lack of progression of the wound closure, new sutures were added 2 times. After one month of unsuccessful wound closure-brims of the wound were anergic, the decision about surgical cleaning of the wound and resuturing connected with PermacolTM implantation was made (Figure 4).

Dressing-change-leakage

Figure 3: Dressing change three times a week was necessary, due to the sterile serum leakage from the wound.

Surgical-cleaning-wound

Figure 4: Surgical cleaning of the wound and resuturing connected with PermacolTM implantation.

Wound swab was sterile; patient had lost 20 kg (BMI=28.75) since the first surgery. During the procedure of the second PermacolTM implantation, the brims of the wound were refreshed; the tissues that have been included in the inflammatory infiltration were removed. The fascia was identified (Figure 5) and slightly separated from the thickened peritoneum (Figure 6). PermacolTM after previous preparation was implanted with sublay technique (Figure 7) and the fascia was closed above it. Fascia closure was possible probably due to the patient’s weight reduction. Moreover, it might have had an influence on the final results of treatment (Figures 8 and 9).

fascia-identified

Figure 5: The fascia was identified.

fascia-slightly-peritoneum

Figure 6: fascia slightly separated from the thickened peritoneum.

implanted-sublay-technique

Figure 7: PermacolTM after previous preparation was implanted with sublay technique.

Fascia-closure-weight

Figure 8: Fascia was closed above it. Fascia closure was possible probably due to the patient’s weight reduction.

influence-results-treatment

Figure 9: It might have had an influence on the final results of treatment.

One week after the second repair surgery magnetic resonance imaging was done in order to visualise the presence of the biological material (Figures 10 and 11). There was a small amount of fluid along the whole implanted material. After the 4 months of treatment patient was successfully discharged with completely healed wound and without abdominal hernia.

Figure

Figure 10: One week after the second repair surgery magnetic resonance imaging was done in order to visualise the presence of the biological material.

fluid-implanted-material

Figure 11: There was a small amount of fluid along the whole implanted material.

Discussion

There are different approaches toward dealing with cases connected with difficult wound healing and complex abdominal wall defect. Reconstruction of a large defect of fascia in patients suffering from other diseases, e.g. obesity, cardiovascular problems or in patients who are taking immunosuppressive drugs is a challenging problem for the majority of surgeons. The primary suture repair is associated with the lowest risk of infection, but firstly, recurrence rate of hernia in this way of repair exceeds up to 60% [1-5] and secondly, huge fascia defect often makes is technically impossible to close the wound without excessive tension.

PermacolTM is a laminar mesh derived from porcine dermal collagen, crosslinked with hexamethylene diisocyanate and consists mostly of type I collagen, 5% type III collagen and elastin. There is a conviction that PermacolTM may be used in the contaminated field, though there is no level 1 evidence [3] confirmation of that thesis. For that reason, many authors support that statement with the stipulation that it should be reserved for the multicomplicated cases only.

It is commonly believed that biological materials have lower affinity for bacterial colonization [4], which is contradictory to the examination performed by Perez-Kohler et al. who claims that the conventional nonabsorbable polymer materials are better option for use in contaminated surgical fields [1]. In our case, PermacolTM was implanted in the sterile field. The reason of the first failure of PermacolTM implantation in our patient was the lysis of the biomaterial for the unknown reason and it seems it is not connected with microbiological infection. As Novitzky [2] noticed in his research, implantation of the biological material induces cell infiltration, which was confirmed in our histopathology examination.

Because of the former polypropylene mesh infection, we decided not to implant the polypropylene mesh again. Moreover, biologic implants are believed to have less potential for bowel adherence [6] that is extremely important while placing the graft with the use of intraperitoneal sublay technique with bridging.

Another putative advantage of PermacolTM is its flexibility that does not prevent from the neovascularization. One of the probable reasons of the mesh lysis in our case might have been the material disintegration or poor mash incorporation. Those complications were described by Harth [7,8].

There are cases describing the successful usage of PermacolTM in the contaminated field [7]. According to our centre experience, we are in agreement with that statement.

Relying on our centre experience, PermacolTM can also be safely used in the post transplantational patients who are put on immunosuppressive therapy.

There are no standard procedures for coping with such difficult cases, but without any doubts the commonly recognized risk factors as accompanying infection, diabetes mellitus or obesity have a negative impact on the wound healing and abdominal wall closure. Furthermore, it is extremely important to treat each patient individually.

Conclusion

Our goal was to present the case of coping with extremely difficult wound healing case and the very rare entity of PermacolTM dissolving.

One may notice, that from time to time the simplest option is the best option (in that case closure of the subcutaneous layer and the skin, with the adjournment of the abdominal plasty). Planning tworound treatment turned out to be the best option in that specific case, nevertheless it did not preclude the reuse of PermacolTM with good effect.

The results of use of biological material are not ideal, however biological materials may be useful in the selected group of patients. Further examination regarding the use of biological materials should be performed.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • Global Experts meeting on Oncology Case Reports
    Aug 29-31, 2017 London, UK
  • Global Experts Meeting on Case Reports
    Osaka, Japan October 09-11, 2017
  • 6th Global Experts Meeting on Medical Case Reports
    October 16-18, 2017 San Francisco, California, USA

Article Usage

  • Total views: 8088
  • [From(publication date):
    June-2016 - Jul 25, 2017]
  • Breakdown by view type
  • HTML page views : 8051
  • PDF downloads :37
 
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

agrifoodaquavet@omicsonline.com

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

clinical_biochem@omicsonline.com

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

business@omicsonline.com

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

chemicaleng_chemistry@omicsonline.com

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

environmentalsci@omicsonline.com

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

engineering@omicsonline.com

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

generalsci_healthcare@omicsonline.com

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

genetics_molbio@omicsonline.com

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

immuno_microbio@omicsonline.com

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

omics@omicsonline.com

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

materialsci@omicsonline.com

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

mathematics_physics@omicsonline.com

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

medical@omicsonline.com

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

neuro_psychology@omicsonline.com

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

pharma@omicsonline.com

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

social_politicalsci@omicsonline.com

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version