Key factors for successful outcomes of abdominal wall reconstruction with biologic implant

We read with interest the article by Fayezizadeh and colleagues titled “Outcomes of Retromuscular Porcine Biologic Mesh Repairs Using Transversus Abdominis Release Reconstruction.”1 In a consecutive series of 77 patients undergoing abdominal wall reconstruction (AWR), the authors reported a surgical site infection rate of 28.6% and hernia recurrence in rate of 12.5% (8 of 64 patients). These results are certainly favorable and we agree with the authors when they suppose that the restoration of linea alba, performing transversus abdominis release reconstruction when necessary, and retrorectus placement of biologic implant appear paramount to successful outcomes. In our comment to Abdelfatah and colleagues’ report,2,3 we stressed the superiority of sublay repair when compared with underlay or bridging repairs, especially when biologic implants are required. In fact, the retromuscular plane offers a much more vascularized anatomic environment than the intraperitoneal space, and provides the basis for implant’s ingrowth and integration. 4 But operative technique and mesh positioning are not the only key factors for successful outcomes of AWR with biologics. Indications and selection of the proper implant are equally important. Our experience with AWR with biologics started in 2005. The use of biologic implants did not modify the surgical technique (Rives-Stoppa procedure plus posterior component separation when necessary) we have been using routinely since the mid 1980s. In other words, in patients at risk for wound infection, we changed the mesh but not the surgical technique.