Complex Abdominal-Wall Repair
Seance of wednesday 15 january 2020 (Prévenir et traiter une éventration)
DOI number : 10.26299/dgn4-3n23/emem.2018.3.009
Abstract
There is no precise definition of a complex eventration, but all the authors agree the three parameters which make it possible to define an eventration as such are the patient's frailty (in particular in terms of infectious risk), size of the eventration and contamination of the operating field. It is estimated that around 20 % of the eventrations can be considered complex. Their human and societal cost is very high. Their management mobilizes a lot of resources.
Management strategy. At present, it is clear that a lasting wall repair cannot be imagined without a reinforcement prosthesis. Without this the risk of recurrence is very high and it is established that in the same patient the risk of recurrence increases with each repair. This is why it is essential to put all the elements (pre-empowerment of the patient, surgical technique, appropriate reinforcement) to succeed the first time. On the other hand, the best-known prostheses (synthetics) seem dangerous in a contaminated environment. Traditionally, in these situations, we relied on strategies in several stages to sanitize the wall before the use of a prosthetic reinforcement.
New materials have arrived on the market in the last 10 years, supposed to be suitable for a contaminated environment. Scientific data concerning them are still limited. The question of the cost of these new reinforcements must also be included in the reflection, as well as that of the reimbursement of this activity in France, currently far below the costs generated. When evaluating the results of the complex venting treatment, the most appropriate criteria seem to be recurrence and the need for re-intervention afterwards, since they sum up all the other complications in them.
Conclusions. For the management of complex eventrations it seems logical to centralize patients in teams with experience of this type of intervention. It is necessary to master the pre-operative risk factors for therapeutic failure through pre-treatment, as well as to have available the technical and material resources which allow the best possible results to be obtained.
Management strategy. At present, it is clear that a lasting wall repair cannot be imagined without a reinforcement prosthesis. Without this the risk of recurrence is very high and it is established that in the same patient the risk of recurrence increases with each repair. This is why it is essential to put all the elements (pre-empowerment of the patient, surgical technique, appropriate reinforcement) to succeed the first time. On the other hand, the best-known prostheses (synthetics) seem dangerous in a contaminated environment. Traditionally, in these situations, we relied on strategies in several stages to sanitize the wall before the use of a prosthetic reinforcement.
New materials have arrived on the market in the last 10 years, supposed to be suitable for a contaminated environment. Scientific data concerning them are still limited. The question of the cost of these new reinforcements must also be included in the reflection, as well as that of the reimbursement of this activity in France, currently far below the costs generated. When evaluating the results of the complex venting treatment, the most appropriate criteria seem to be recurrence and the need for re-intervention afterwards, since they sum up all the other complications in them.
Conclusions. For the management of complex eventrations it seems logical to centralize patients in teams with experience of this type of intervention. It is necessary to master the pre-operative risk factors for therapeutic failure through pre-treatment, as well as to have available the technical and material resources which allow the best possible results to be obtained.