Research Article| Volume 65, ISSUE 3, P333-341, March 2012

Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: The “Pork Sandwich” herniorraphy

Published:October 17, 2011DOI:



      The repair of large ventral hernias is a challenging problem. This study investigated the use of decellularized, chemically cross-linked porcine dermal xenograft in conjunction with component separation (a.k.a. the “Pork Sandwich” Herniorraphy) in the repair of abdominal wall defects.

      Materials and methods

      We prospectively collected data over a 3-year period. Primary or near-total primary fascial closure was our goal in operative repair. A cross-linked porcine dermal xenograft mesh underlay and overlay were used to provide maximal reinforcement of the repair. Outcomes were compared with a case-controlled cohort of 84 patients who underwent ventral hernia repairs with alternative methods at our institution.


      Nineteen patients were included. Mean age was 55 years old, and mean body mass index (BMI) was 30 kg/m2. Mean defect size was 321 cm2. Post-operative complications were observed in ten out of 19 patients. Complications included seroma (n = 2), wound infection (n = 2), abscess (n = 1), skin necrosis (n = 6), and fistula formation (n = 3). Seven patients required re-operation. Statistically significant factors (p < 0.05) that contributed to increased post-operative complications or re-operation rates included smoking, presence of pre-operative enterocutaneous fistulae, extended post-operative hospital stay (>2 weeks), and a defect size greater than 300 cm2. There were no hernia recurrences in our “Pork Sandwich” group, which contrasted favorably to the retrospective case-control group in which the hernia recurrence rate was 19% (p = 0.038).


      For the repair of abdominal hernias, primary closure, with component separation as needed, with an underlay and overlay of cross-liked porcine xenograft should be considered to minimize risk of recurrent herniation. Additional long-term prospective comparative studies are needed for further validation of the optimal method and material for repair.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mudge M.
        • Hughes L.E.
        Incisional hernia: a 10 year prospective study of incidence and attitudes.
        Br J Surg. 1985; 72: 70-71
        • Santora T.A.
        • Roslyn J.J.
        Incisional hernia.
        Surg Clin North Am. 1993; 73: 557-570
        • Lamont P.M.
        • Ellis H.
        Incisional hernia in re-opened abdominal incisions: an overlooked risk factor.
        Br J Surg. 1988; 75: 374-376
        • George C.D.
        • Ellis H.
        The results of incisional hernia repair: a twelve year review.
        Ann R Coll Surg Engl. 1986; 68: 185-187
        • Ger R.
        • Duboys E.
        The prevention and repair of large abdominal-wall defects by muscle transposition: a preliminary communication.
        Plast Reconstr Surg. 1983; 72: 170-178
        • Houston G.C.
        • Drew G.S.
        • Vazquez B.
        • Given K.S.
        The extended latissimus dorsi flap in repair of anterior abdominal wall defects.
        Plast Reconstr Surg. 1988; 81: 917-924
        • Caulfield W.H.
        • Curtsinger L.
        • Powell G.
        • Pederson W.C.
        Donor leg morbidity after pedicled rectus femoris muscle flap transfer for abdominal wall and pelvic reconstruction.
        Ann Plast Surg. 1994; 32: 377-382
        • Ramirez O.M.
        • Ruas E.
        • Dellon A.L.
        “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study.
        Plast Reconstr Surg. 1990; 86: 519-526
        • de Vries Reilingh T.S.
        • van Goor H.
        • Rosman C.
        • et al.
        “Components separation technique” for the repair of large abdominal wall hernias.
        J Am Coll Surg. 2003; 196: 32-37
        • Lowe 3rd, J.B.
        • Lowe J.B.
        • Baty J.D.
        • Garza J.R.
        Risks associated with “components separation” for closure of complex abdominal wall defects.
        Plast Reconstr Surg. 2003; 111 (quiz 84–5; discussion 86–8): 1276-1283
        • Hiles M.
        • Record Ritchie R.D.
        • Altizer A.M.
        Are biologic grafts effective for hernia repair?: a systematic review of the literature.
        Surg Innov. 2009; 16: 26-37
        • Eberli D.
        • Rodriguez S.
        • Atala A.
        • Yoo J.J.
        In vivo evaluation of acellular human dermis for abdominal wall repair.
        J Biomed Mater Res A. 2010; 93: 1527-1538
        • Blatnik J.
        • Jin J.
        • Rosen M.
        Abdominal hernia repair with bridging acellular dermal matrix–an expensive hernia sac.
        Am J Surg. 2008; 196: 47-50
        • Adedeji O.A.
        • Bailey C.A.
        • Varma J.S.
        Porcine dermal collagen graft in abdominal-wall reconstruction.
        Br J Plast Surg. 2002; 55: 85-86
        • Hsu P.W.
        • Salgado C.J.
        • Kent K.
        • et al.
        Evaluation of porcine dermal collagen (Permacol) used in abdominal wall reconstruction.
        J Plast Reconstr Aesthet Surg. 2009; 62: 1484-1489
        • Parker D.M.
        • Armstrong P.J.
        • Frizzi J.D.
        • North Jr., J.H.
        Porcine dermal collagen (Permacol) for abdominal wall reconstruction.
        Curr Surg. 2006; 63: 255-258
        • Liyanage S.H.
        • Purohit G.S.
        • Frye J.N.
        • Giordano P.
        Anterior abdominal wall reconstruction with a Permacol implant.
        J Plast Reconstr Aesthet Surg. 2006; 59: 553-555
        • Harper C.
        Permacol: clinical experience with a new biomaterial.
        Hosp Med. 2001; 62: 90-95
        • Catena F.
        • Ansaloni L.
        • Gazzotti F.
        • et al.
        Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields.
        Hernia. 2007; 11: 57-60
        • Zheng F.
        • Lin Y.
        • Verbeken E.
        • et al.
        Host response after reconstruction of abdominal wall defects with porcine dermal collagen in a rat model.
        Am J Obstet Gynecol. 2004; 191: 1961-1970
        • Jarman-Smith M.L.
        • Bodamyali T.
        • Stevens C.
        • Howell J.A.
        • Horrocks M.
        • Chaudhuri J.B.
        Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation.
        J Mater Sci Mater Med. 2004; 15: 925-932
        • Mulier K.E.
        • Nguyen A.H.
        • Delaney J.P.
        • Marquez S.
        Comparison of Permacol and Strattice for the repair of abdominal wall defects.
        Hernia. 2011; 15: 315-319
        • Kolker A.R.
        • Brown D.J.
        • Redstone J.S.
        • Scarpinato V.M.
        • Wallack M.K.
        Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation.
        Ann Plast Surg. 2005; 55 (discussion-2): 36-41
        • Macleod T.M.
        • Williams G.
        • Sanders R.
        • Green C.J.
        Histological evaluation of Permacol as a subcutaneous implant over a 20-week period in the rat model.
        Br J Plast Surg. 2005; 58: 518-532
        • O’Brien J.A.
        • Ignotz R.
        • Montilla R.
        • Broderick G.B.
        • Christakis A.
        • Dunn R.M.
        Long-term histologic and mechanical results of a Permacol abdominal wall explant.
        Hernia. 2010;
        • Misra S.
        • Raj P.K.
        • Tarr S.M.
        • Treat R.C.
        Results of AlloDerm use in abdominal hernia repair.
        Hernia. 2008; 12: 247-250
        • Hesselink V.J.
        • Luijendijk R.W.
        • de Wilt J.H.
        • Heide R.
        • Jeekel J.
        An evaluation of risk factors in incisional hernia recurrence.
        Surg Gynecol Obstet. 1993; 176: 228-234