Surg Today (2009) 39:811–817DOI 10.1007/s00595-008-3933-1

Reprint requests to: T. HottaReceived: May 8, 2008 / Accepted: December 8, 2008

Reconstruction of an Infected Recurrent Ventral Hernia After a Mesh Repair Using a Pedicled Tensor Fascia Lata Flap: Report of Two Cases

SHINYA HAYAMI, TSUKASA HOTTA, KATSUNARI TAKIFUJI, MAKOTO IWAHASHI, YASUYUKI MITANI, and HIROKI YAMAUE

Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan

AbstractRecently, the use of prosthetic mesh has revolutionized the repair of ventral hernias. However, the occurrence of infection related with the use of this prosthesis remains an important complication, which may result in occurrence of fi stula formation of the skin or intestine, sepsis, or reoccurrence of ventral hernia. This report presents two cases where a pedicled musculocutaneous fl ap using the tensor fascia lata (pedicled TFL fl ap) was effective as a treatment for an infectious large abdomi-nal hernia, and reviews the previous literature. Two Japanese men aged 61 and 78 years old underwent a ventral hernia repair using Composix Kugel mesh. They both developed a wound infection with methicillin-resistant Staphylococcus aureus. Conservative therapy was not successful and the defect in the abdominal wall of two patients measured 12 × 21 cm and 7 × 10 cm in length, respectively. Reoperations were performed by removing the infectious mesh and then reconstructing the abdominal wall with the bilateral and left-side pedicled TFL fl aps, respectively. No recurrence of the ventral hernia has been recognized for 50 months and 7 months after reoperation, respectively. A review of previous studies showed that no patients treated with a pedicled TFL fl ap experienced a recurrent hernia. Therefore, the pedicled TFL fl ap was considered to be effective for infectious large abdominal recurrent hernia.

Key words Composix Kugel mesh · Methicillin-resistant Staphylococcus aureus · Tensor fascia lata fl ap

Introduction

A ventral hernia is a common complication following any type of abdominal surgery. The incidence has been reported to be 1% with primary healing patients, and 11% with postoperative wound infection.1–5 Many tech-niques have been described for the repair of a ventral hernia, such as a primary suture repair, an open mesh repair, and a laparoscopic mesh repair. Recently, the use of prosthetic mesh has revolutionized the repair of ventral hernias.4 Composix Kugel mesh is two-layered with polypropylene on one side and Gore-Tex on the other, with a reinforcing ring of polyethylene tere-phthalate polymer, which prevents rolling of the mesh and allows it to hold its shape and position with a minimal number of sutures to secure it in place.6 However, the occurrence of infection related with the use of this prosthesis remains an important compli-cation, since it occurs in from 0%–9% of all cases after surgery.3,4 Infectious mesh should therefore be removed, and the reconstruction of abdominal wall defects using a pedicled musculocutaneous fl ap is an effective strategy.5

The pedicled musculocutaneous fl ap using tensor fascia lata (pedicled TFL fl ap) is one type of reconstruc-tion. The pedicled TFL fl ap was fi rst described by Nahai in 1934 as a pedicled rotation fl ap.7,8 It is well suited to abdominal repair since it provides both a semi-rigid fascial layer and adequate skin cover.

This study presented two cases with a methicillin-resistant Staphylococcus aureus (MRSA) infection in a Composix Kugel mesh, and reconstruction of abdomi-nal wall defects with a pedicled TFL fl ap, using laser-Doppler fl owmetry in order to confi rm the presence of an adequate blood fl ow. Furthermore, previous cases of treatment for infection after incisional hernia repair were also reviewed.

812 S. Hayami et al.: Reconstruction Using Pedicled TFL Flap

Case Reports

Case 1

A 61-year-old Japanese man had previously undergone a radical cystectomy and ileal urinary diversion for bladder cancer at the Department of Urology, Wakayama Medical University Hospital, in April 2003. Thereafter, he was admitted to the Second Department of Surgery of the same hospital with abdominal swelling when standing in an erect position in August 2003. In September 2003, he underwent a ventral hernia repair using Composix Kugel mesh (CR Bard, Cranston, RI, USA) in the Second Department of Surgery of the same hospital. Seven days later, he demonstrated a wound infection with fever. Methicillin-resistant Staphylococ-cus aureus was isolated from the wound area, and con-servative therapy in the inpatient department, including the administration of vancomycin hydrochloride, and washing with aqua-oxidized water and saline mixed with arbekacin sulfate, was performed for about 6 months. However, dehiscence could not be adequately achieved and therefore suppuration had to be contin-ued. The defect of the abdominal wall measured 12 × 21 cm in length (Fig. 1). Preoperative preparations were performed for about 3 weeks, including: an antibiotic infusion of vancomycin hydrochloride, lavage of the infectious wound using aqua-oxidized water, maintain-ing an adequate nutritional state, the prohibition of all smoking, and encouraging weight control.

In March 2004, a reoperation was performed under general anesthesia. The fl ap design was marked along

the bilateral tensor fasciae lata (TFL) muscle and ilio-tibial tract during active leg raising with the knee extended while the patient was lying in a supine posi-tion. A vascular pedicle was observed at a site approxi-mately 7 cm more caudal than the middle line of the anterior superior iliac spine and the greater trochanter. The pivot point of the fl ap was planned at this level. The caudal side is 5 cm more cranial than the lateral condyle of the tibia. The size of the fl ap was thus expected to be 12 × 21 cm, both bilaterally (Fig. 2). The patient was placed in the supine position, and the operation was started by fi rst removing the infectious mesh. The dis-section of the fl ap began with a circumferential incision down to the deep fascia, followed by the division of the iliotibial tract distally and elevation of the fascia lata from the underlying muscles progressing proximally. The vascular pedicle was identifi ed on the deep surface of the tensor muscle and traced medially as it passed deeply through the rectus femoris. A dissection ceased at the point of the lateral circumfl ex femoral artery proper. The circulation of this artery was confi rmed using laser-Doppler fl owmetry. The secondary defect was directly sutured by 2-0 Neurolon (Johnson & Johnson, Tokyo, Japan). Bilateral fl aps were raised and rotated into position on its pedicle. During wound

Fig. 1. Preoperative abdominal wound. The defect in the abdominal wall measured 12 × 21 cm in length. The wound was split apart and then the exposed mesh was replaced

KneeLeft leg

Anterior superior iliac spine

5 cm

Lateral condyle of tibia

7 cm

Greater trochanter

Flap

Fig. 2. Flap design. The fl ap design was marked along the bilateral tensor fasciae lata muscle and iliotibial tract during active leg raising with the knee extended while the patient was lying in a supine position. A vascular pedicle was observed at a site approximately 7 cm more caudal than the middle line of the anterior superior iliac spine and the greater trochanter. The pivot point of the fl ap was planned at this level. The caudal side is 5 cm more cranial than the lateral condyle of the tibia. The size of the fl ap was thus expected to be 12 × 21 cm, both bilaterally

S. Hayami et al.: Reconstruction Using Pedicled TFL Flap 813

suturing, fascia–fascia suturing was performed using 3-0 Vicryl (Johnson & Johnson), while skin–skin suturing was performed using 2-0 Neurolon, using a tension-free technique. Finally, two drains (SB VAC, Sumitomo bakelite, Tokyo, Japan) were placed on the fascia of the upper and lower portions of the wound (Fig. 3a). The total operating time was 374 min and the bleeding volume was 200 ml. The fl ap skin, the distal edge of the most cranial side, became necrotic over an area measur-ing 2 × 2 cm in width, but it was not necessary to remove the fl aps or to implant any skin. The wound thereafter healed without infection or dehiscence. As of May 2008, no recurrence of the ventral hernia has been recognized 4 years 2 months after the reconstructive surgery using the TFL fl ap (Fig. 3b).

Case 2

A 78-year-old Japanese man had previously undergone graft stenting for an abdominal aortic aneurysm in March 2007 at another hospital. Eight days later, a fascia defect was noted on postoperative computed tomography, and he underwent a ventral hernia repair using Composix Kugel mesh (CR Bard) in April 2007. However, 8 days later he demonstrated a wound infec-tion with MRSA and Pseudomonas aeruginosa, and then 5 days later he developed a recurrent hernia. Thereafter, he was admitted to the Second Department of Surgery, Wakayama Medical University Hospital, in May 2007. The defect of the abdominal wall measured 7 × 10 cm in length. The same conservative therapy used in case 1 was administered in the inpatient department for about 6 months.

In October 2007, under general anesthesia, the infec-tious mesh was removed along with a portion of the small intestine attached to it, and then the abdominal wall was reconstructed using a left-side pedicled TFL fl ap alone because the fascia defect of this case was smaller than that in case 1 (Fig. 4). The total operating time was 261 min and the bleeding volume was 160 ml. As of May, 2008, no recurrence of the ventral hernia had been recognized 7 months after the reconstructive surgery using a TFL fl ap.

Literature Review of Treatment for Infection After Hernia Repair

Eighty-nine reports have documented treatment for infected mesh after a hernia repair, including 82 in English and 7 in Japanese, between 1986 and 2004. Thirty-nine case reports were reviewed in which

Fig. 3. a Surgical fi ndings of case 1. Along the inguinal tract, an incision was made and the bilateral fl aps were raised and rotated into position on its pedicle. b Wound fi nding forty months after the second surgery. The wound healed without infection or dehiscence. No recurrence of the ventral hernia has been recognized for 40 months after the second surgery

Fig. 4. Surgical fi ndings of case 2. The infectious mesh was removed and a local resection of the small intestine attached to it was performed, and then the abdominal wall was recon-structed using a left-side pedicled tensor fascia lata fl ap alone

814 S. Hayami et al.: Reconstruction Using Pedicled TFL Flap

Tabl

e 1.

Lit

erat

ure

revi

ew o

f tr

eatm

ent

for

infe

ctio

n af

ter

a he

rnia

rep

air

Age

(y

ears

)Se

xTy

pe o

f he

rnia

Occ

urre

nce

tim

e of

infe

ctio

n af

ter

1st

surg

ery

(mon

ths)

Bac

teri

olog

yC

onse

rvat

ive

trea

tmen

t

Tim

e in

terv

al

to 2

nd

surg

ery

(mon

ths)

Dur

atio

n of

co

nser

vati

ve

trea

tmen

t (m

onth

s)R

eope

rati

on

met

hod

Rec

urre

nce

of h

erni

aR

efer

ence

ND

ND

Inci

sion

al h

erni

aN

DG

roup

D

Stap

hylo

cocc

usA

ntib

ioti

csN

DN

DN

ot—

1

ND

ND

Inci

sion

al h

erni

a1.

3G

roup

D

Stap

hylo

cocc

us,

MR

SA

Dra

inag

eN

DN

DV

acuu

m-

assi

sted

cl

osur

e

—1

73M

Ingu

inal

her

nia

3St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

2118

Rem

oval

—2

ND

ND

Ingu

inal

her

nia

1St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

54

Rem

oval

3N

DN

DIn

guin

al h

erni

a3

Non

eA

ntib

ioti

cs6

3R

emov

al3

ND

ND

Ingu

inal

her

nia

28N

one

Ant

ibio

tics

291

Rem

oval

3N

DN

DIn

cisi

onal

her

nia

13St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

6249

Rem

oval

3N

DN

DIn

guin

al h

erni

a35

Non

eA

ntib

ioti

cs44

9R

emov

al3

ND

ND

Ingu

inal

her

nia

9N

one

Ant

ibio

tics

3625

Rem

oval

3N

DN

DIn

guin

al h

erni

a7

Non

eA

ntib

ioti

cs8

1R

emov

al2/

14 (

+)3

ND

ND

Ingu

inal

her

nia

4N

one

Ant

ibio

tics

3026

Rem

oval

3N

DN

DIn

guin

al h

erni

a8

Stap

hylo

cocc

us a

ureu

sA

ntib

ioti

cs11

3R

emov

al3

ND

ND

Ingu

inal

her

nia

13N

one

Ant

ibio

tics

174

Rem

oval

3N

DN

DIn

guin

al h

erni

a7

Stap

hylo

cocc

us a

ureu

sA

ntib

ioti

cs17

10R

emov

al3

ND

ND

Ingu

inal

her

nia

25St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

294

Rem

oval

3N

DN

DIn

guin

al h

erni

a6

Stap

hylo

cocc

us a

ureu

sA

ntib

ioti

cs12

6R

emov

al3

ND

ND

Ingu

inal

her

nia

1N

one

Ant

ibio

tics

21

Rem

oval

373

MIn

guin

al h

erni

a13

.5St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

14.5

1C

ompl

ete

rem

oval

ND

4

61M

Ingu

inal

her

nia

0.5

Stap

hylo

cocc

us a

ureu

s, P

seud

omon

as

aeru

gino

sa,

Aci

neto

bact

er i

wof

fi

Ant

ibio

tics

32.

5C

ompl

ete

rem

oval

ND

4

77M

Inci

sion

al h

erni

a18

Cit

roba

cter

kos

eri

Ant

ibio

tics

191

Par

tial

rem

oval

ND

423

FIn

guin

al h

erni

a2.

5St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

2.8

0.3

Com

plet

e re

mov

alN

D4

70F

Inci

sion

al h

erni

a0.

3St

aphy

loco

ccus

au

reus

, P

seud

omon

as

aeru

gino

sa

Ant

ibio

tics

0.3

0C

ompl

ete

rem

oval

ND

4

68M

Inci

sion

al h

erni

a6

Myc

obac

teri

um

fort

uitu

mA

ntib

ioti

cs,

drai

nage

, de

brid

emen

t

1812

Com

plet

e re

mov

al—

9

S. Hayami et al.: Reconstruction Using Pedicled TFL Flap 81569

MIn

guin

al h

erni

a28

ND

Ant

ibio

tics

, dr

aina

geN

DN

DC

ompl

ete

rem

oval

ND

10

74F

Ingu

inal

her

nia

2.5

G(−

) E

nter

ic r

odA

ntib

ioti

cs,

drai

nage

, la

vage

4.5

2C

ompl

ete

rem

oval

ND

10

34M

Ingu

inal

her

nia

0.5

ND

Ant

ibio

tics

, dr

aina

ge1.

51

Com

plet

e re

mov

alN

D10

67M

Ingu

inal

her

nia

0.5

MR

SAA

ntib

ioti

cs,

drai

nage

20

19.5

Com

plet

e re

mov

alN

D11

59F

Inci

sion

al h

erni

a18

Stap

hylo

cocc

us a

ureu

sA

ntib

ioti

cs18

.50.

5R

emov

alN

D12

51F

Inci

sion

al h

erni

a0.

5St

aphy

loco

ccus

aur

eus

Ant

ibio

tics

, dr

aina

ge1.

51

Rem

oval

ND

13

36M

Inci

sion

al h

erni

a2

Stap

hylo

cocc

us a

ureu

sN

one

20

Rem

oval

ND

1337

FIn

cisi

onal

her

nia

4M

RSA

Ant

ibio

tics

, va

cuum

su

ctio

n

4.5

0.5

Par

tial

rem

oval

—14

65M

Ingu

inal

her

nia

0.6

Myc

obac

teri

um g

oodi

eA

ntib

ioti

cs0.

70.

1R

emov

alN

D15

39M

Ingu

inal

her

nia

0.7

Myc

obac

teri

um

chel

onae

Ant

ibio

tics

1.5

0.8

Rem

oval

, dr

aina

geN

D16

76F

Inci

sion

al h

erni

a0.

5C

andi

da n

orve

gens

isA

ntib

ioti

cs0.

50

Rem

oval

, dr

aina

geN

D17

70M

Inci

sion

al h

erni

aN

DSt

aphy

loco

ccus

aur

eus

Deb

ride

men

t, lo

cal

dres

sing

10N

DR

emov

al,

pedi

cled

TF

L

fl ap

—8

68M

Inci

sion

al h

erni

aN

DE

sche

rich

ia c

oli

Deb

ride

men

t, lo

cal

dres

sing

ND

(>3

)3

Rem

oval

, pe

dicl

ed T

FL

fl a

p

—8

68M

Inci

sion

al h

erni

aN

DSt

aphy

loco

ccus

aur

eus

Loc

al d

ress

ing

ND

(>1

)1

Ped

icle

d T

FL

fl a

p—

8

61M

Inci

sion

al h

erni

a0.

2M

RSA

Ant

ibio

tics

, dr

aina

ge,

debr

idem

ent

6.6

6.4

Rem

oval

, pe

dicl

ed T

FL

fl a

p

—C

ase

1

78M

Inci

sion

al h

erni

a0.

3M

RSA

, Pse

udom

onas

ae

rugi

nosa

Ant

ibio

tics

, dr

aina

ge6.

05.

7R

emov

al,

pedi

cled

TF

L

fl ap

—C

ase

2

Cas

es w

ith

inci

sion

al h

erni

as a

re e

xpre

ssed

in b

old

font

ND

, not

des

crib

ed; M

RSA

, met

hici

llin-

resi

stan

t St

aphy

loco

ccus

aur

eus;

TF

L, t

enso

r fa

scia

lata

816 S. Hayami et al.: Reconstruction Using Pedicled TFL Flap

reoperations were described, including the two current cases (Table 1). There were 16 patients with incisional hernias including 11 patients treated without a TFL fl ap and 5 patients treated with a TFL fl ap. In patients with an incisional hernia, the duration of conservative treat-ment in patients without a TFL fl ap ranged from 0 to 49.0 months (7.1 ± 16.2 months; median, 0.5 months), whereas that in patients with a TFL fl ap ranged from 1.0 to 6.4 months (4.0 ± 2.5 months; median, 4.4 months). In patients with incisional hernias, the time interval before the second surgery in patients without a TFL fl ap ranged from 0.3 to 62.0 months (14.0 ± 19.8 months; median, 4.5 months), whereas that in patients with a TFL fl ap ranged from 6.0 to 10.0 months (7.5 ± 2.2 months; median, 6.6 months). In patients with incisional hernia, there were no differences in terms of these vari-ables between patients treated with and without a TFL fl ap. Two cases of incisional hernia with infected MRSA excluding the current cases were reported. One of them had a short duration of conservative treatment. In patients with incisional hernias, the occurrence of a recurrent hernia after a reoperation without TFL fl ap was not fully documented. On the other hand, no patients treated with a pedicled TFL fl ap experienced a recurrent hernia.

Discussion

Mathes et al.5 defi ned the specifi c criteria to identify patients who may require a special closure technique for an abdominal wall defect as: large size (>40 cm2), the absence of stable skin coverage, the recurrence of defects after prior closure attempts, infected or exposed mesh, patients who are systemically compromised, such as malignancy, compromised local abdominal tissue, such as that due to irradiation or corticosteroid depen-dence, and concomitant visceral complications such as enterocutaneous fi stula. In the current cases, the defects of the abdominal wall measured approximately 250 cm2 and 70 cm2 in width, and the wounds were infected by MRSA and the mesh was exposed. These factors cor-related with the Mathes’ criteria, and therefore these cases were considered to require radical therapy.

Since a pedicled TFL fl ap can be extended from the midline anteriorly to the midline posteriorly in the thigh, and from a point above the anterior superior iliac spine superiorly to approximately 5 cm above the knee joint inferiorly, an area of approximately 25 × 40 cm can thus be covered with this fl ap. It has a single constant vascular supply via the ascending branch of the lateral circumfl ex femoral artery that enters the muscle on its deep surface below the iliac crest at the level of the greater trochanter.7,8 It is important to maintain a good blood supply for the fl aps. Laser-Doppler fl owmetry

was used so that suffi cient blood fl ow was maintained for this fl ap.

Well-vascularized muscle tissue may possess an inher-ent potential to aid in the eradication of infection, and provides soft-tissue coverage, therefore this tissue may be used in infectious conditions, such as osteomyelitis bone coverage with vascularized muscle fl ap and infected prosthetic grafts salvaged with a rotational muscle fl ap in vascular surgery.8 Therefore, the pedicled TFL fl ap may be effective in the infectious state.

Williams et al.7 reported that patients who undergo an abdominal wall repair using a TFL fl ap might have fl ap complications such as distal tip necrosis, fascial dehiscence, hematoma, and seroma, as well as donor site complications such as large donor site defects, dehiscence between skin and underlying muscle at the donor site which might require skin grafting, and meral-gia paresthesia. In one of the current cases, tip necrosis was recognized, but it was not necessary to remove the fl aps or to implant any skin, and there were no donor site complications.

Recently, Jezupors et al.4 reported that the reconva-lescence in patients with mesh infection was achieved only after removal of the infected mesh. On the other hand, wound infections have also been reported to improve by conservative therapy.4 Conservative treat-ment was attempted in the current cases. However, only the surgical strategy was found to result in prolonged healing.

A literature review identifi ed two previous cases of incisional hernia with infected MRSA. One of them underwent a short duration of conservative treatment. Surgical treatment prior to the spread of the MRSA infection all over the mesh may be better for an inci-sional hernia infected with MRSA. No patients treated with a pedicled TFL fl ap experienced a recurrent hernia. To conclude therefore, this study demonstrated two cases where a pedicled TFL fl ap was an effective treatment for an infectious large abdominal recurrent hernia.

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