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17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
a
b
c
225
d
e
Fig. 17.4 Planes of dissection for component separation of the abdominal wall. Dissection begins
with resection of the hernia sac, lysis of adhesions, and development of skin aps past the linea
semilunaris. (a) The external oblique aponeurosis is incised approximately 2cm lateral to the linea
semilunaris. (b) The posterior rectus sheath may also be incised for further advancement.
(c) Complete fascial coaptation is achieved in the midline to avoid a bridged defect. (d) Fascial
closure following ventral hernias frequently benets from the addition of mesh reinforcement
placed in an underlay position (e) or retrorectus position
226
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Fig. 17.5 Patient example
of a minimally invasive
component separation.
Sixty-two-year-old male
presented with a 10cm
midline ventral hernia
M. W. Clemens and C. E. Butler
Fig. 17.6 Skin aps are
elevated off the anterior
rectus fascia
circumferentially around
the defect leaving intact
periumbilical perforators
from the rectus abdominis
complexes. Note that a
subcutaneous tunnel is
created at the costal margin
with dissection laterally to
the linea semilunaris
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
Fig. 17.7 Once the
external oblique fascia is
incised, the plane of
dissection is easily
visualized by using a
Yankauer suction device.
Release of the external
oblique fascia should
extend from above the
costal margin down to the
pelvis. Note in the gure
that Alice clamps are
attached to the cut edge of
the external oblique fascia
to demonstrate the
components separation
Fig. 17.8 Figure
demonstrates complete
release of the external
oblique fascia. Note in the
gure that Alice clamps are
attached to the cut edge of
the external oblique fascia
to demonstrate the
components separation
227
Fig. 17.9 Additional
advancement of the rectus
complexes to the midline
can be achieved by
dissection laterally
between the external
oblique and internal
oblique muscles
228
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Fig. 17.10 Once
component separations are
performed, mesh
reinforcement of the
midline fascial closure is
important for decreasing
hernia recurrence rates.
The gure demonstrates
placement of mesh in an
underlay position with
transxing sutures placed
circumferentially
Fig. 17.11 Circumferential
sutures are placed under
tension allowing for a
tensionless closure of the
fascia in the midline
M. W. Clemens and C. E. Butler
Fig. 17.12 Liberal use of
drains as well as quilting
sutures of the skin aps
obliterates dead space and
helps prevent postoperative
uid collections
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
Fig. 17.13 Midline fascial
closure is performed with
gure of eight permanent
sutures followed by a
running permanent suture.
Note despite the large
original defect, midline
closure of the fascia is now
without tension following
bilateral components
separation and mesh
reinforcement
229
Posterior Technique
A posterior components separation is based on the retromuscular Rives-Stoppa
approach to ventral hernia repair (Fig.17.16). Unlike the Ramirez components separation focusing on external oblique aponeurosis release, the posterior components
separation focuses on transversus abdominis aponeurosis release. As previously
mentioned, the transversus abdominis aponeurosis actually forms the posterior rectus sheath in the upper two-thirds of the abdomen. By incising this myofascial aponeurosis, the surgeon accesses the preperitoneal space. This provides substantial
advancement of both the posterior fascial ap and the anterior myofascial compartment. The initial release is completed by incising the posterior rectus sheath approximately 1cm lateral to the linea alba, and the posterior rectus sheath is separated
from the overlying rectus muscle. The transversus abdominis muscle is incised just
medial to the intercostal nerves, and the underlying transversalis fascia and peritoneum are identied. This myofascial release is extended the entire length of the
posterior rectus sheath. The potential space between the transversus abdominis
muscle and the peritoneum is developed as far laterally as necessary, even to the
psoas muscle if needed. This plane can be extended superiorly to the costal margin,
retrosternally above the xiphoid, and inferiorly into the space of Retzius. The
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Fig. 17.14 Complete
fascial closure is achieved to
minimize hernia recurrence.
Skin edges should be
debrided back to healthy
bleeding tissue prior to skin
closure
M. W. Clemens and C. E. Butler
posterior sheath is then closed, to completely exclude any mesh from the viscera.
An adequately sized piece of mesh is then secured, similar to a standard retromuscular repair, but with greater overlap. The midline musculo-fascia is then reapproximated if possible.
Postoperative Management
In general, abdominal wall reconstruction patients have prolonged postoperative
healing periods due to the dynamic function and mobility of the abdominal musculature. Based upon specic unique indications, each patient’s postoperative
care regimen should be individually tailored to allow for sufcient healing of the
surgical site. Sequential compression devices and early ambulation should be utilized with low-molecular weight fractionated heparins administered postoperatively for DVT prophylaxis as indicated [22]. Perioperative antibiotics are
indicated with violation of the gastrointestinal tract and should include broad
coverage for anaerobic as well as Gram-negative bacteria. For ventral hernia,
closed-suction drains are used liberally and are kept in place on average 1–2weeks
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
231
a
b
d
c
f
e
h
g
Fig. 17.15 Hernia repair. Patient is a 62-year-old female with a history of colon cancer, morbid
obesity with BMI 46, and previous midline hernia repair with mesh reinforcement. She presents
with a recurrent hernia 12 cm in greatest diameter. (a, b) Intraoperative evaluation demonstrates
mesh failure. (c) Bilateral minimally invasive components separation was performed (d) which
allowed for complete fascial coaptation (e). Postoperative evaluation is seen at 1 month (f, g) and by
computerized tomography scan at 1 year (h)
232
ab
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M. W. Clemens and C. E. Butler
d
c
f
e
Fig. 17.16 Posterior component separation. (a) The initial release is completed by incising the
posterior rectus sheath approximately 1cm lateral to the linea alba, and the posterior rectus sheath
is separated from the overlying rectus abdominis muscle. Dissection is carried to the lateral border
of the rectus muscle, and the perforating intercostal nerves are identied, marking the linea semilunaris. (b) Next, the transversus abdominis muscle is incised just medial to the intercostal nerves,
and the underlying transversalis fascia and peritoneum are identied. This myofascial release is
extended the entire length of the posterior rectus sheath. The potential space between the transversus abdominis muscle and the peritoneum is developed as far laterally as necessary (Adapted with
permission from Rosen MJ.Atlas of Abdominal Wall Reconstruction, Elsevier 2011)
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
233
g
i
Fig. 17.16 (continued)
h
until less than 30 cm3 per day. Abdominal wall reconstruction patients should
refrain from strenuous activities and exercises that isolate the abdominal core for
at least 6–12weeks. Patients may gain comfort from the use of an abdominal
binder for 3months and then with any expected heavy physical activity thereafter.
Routine follow-up includes a physical examination in an outpatient clinic, often
performed weekly for 1month after discharge, then every 3months for 1 year,
and then annually thereafter.
Complications
Infection
Surgical site infections are common after abdominal wall reconstruction.
Categorization of the intraoperative level of wound contamination based on CDC
criteria into clean, clean- contaminated, contaminated, and dirty wounds is important to appropriately stratify patients by risk of surgical site infection. The most
common infectious organism is S. aureus, seen in up to 81% of infections; this suggests skin ora contamination during reconstruction [23]. However, Gram-negative
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M. W. Clemens and C. E. Butler
organisms, such as Klebsiella and Proteus spp., have been implicated in up to 17%
of abdominal wall infections. Culture-directed antibiotics and operative debridement when indicated are the mainstay of treatment.
Seroma
Seroma formation can occur following abdominal wall reconstruction particularly
in cases involving large undermined aps, which create signicant dead space. If
symptomatic, seromas can be aspirated percutaneously or under ultrasound guidance. In most cases, small seromas will be reabsorbed over time. Resection of a
previous hernia sac is important to prevent seroma formation. In open ventral hernia
repair, drains are often placed in an attempt to obliterate the dead space caused by
the hernia and tissue dissection [24]. Seroma formation is common after abdominal
components separation and muscle aps of the trunk owing to extensive tissue dissection, and drains may be necessary for up to 4–6weeks. Intraoperative techniques,
such as quilting sutures, brin sealant, and postoperative abdominal binders may
help to prevent or reduce seroma formation.
Results
Estimated incidences of hernia recurrence have a wide range from 2 to 54%,
depending on the type of repair (mesh 2–36% versus suture repair alone 25–54%),
patient comorbidities, and surgical technique [12, 13, 25–27]. The number of prior
attempts of hernia repair is predictive of the relative risk of recurrence. In a study
of approximately 10,000 patients, 5-year reoperative rate was 23.8% after a primary repair, 35.3% following a secondary repair, and 38.7% after a tertiary repair
[28, 29]. There are few comparative data to suggest the superiority of one myofas-
cial advancement approach over another, and likely each has a role in abdominal
wall reconstruction. Open components separation often allows tension-free closure of large defects, and recurrence rates as low as 20% have been reported with
the use of open components separation and mesh reinforcement in large hernias.
Recognizing the high recurrence rates with components separation alone, several
authors have reported series of bioprosthetic or synthetic mesh reinforcement of
these repairs, although to date, no randomized controlled trials have demonstrated
lower hernia recurrence rates with a specic mesh type [30]. Comparative data
have shown laparoscopic components separation to result in a lower rate of wound
morbidity than open components separation. One series reported a signicant
reduction in wound morbidity with the periumbilical perforator-sparing technique
compared with the standard open components separation technique (2% vs 20%;
p < 0.05) [31]. A controlled study demonstrated that patients had signicantly
fewer wound-healing complications (32% vs 14%, p = 0.026) and skin dehiscences (28% vs 11%, p=0.01) with MICS than with traditional open components
separation [27]. These improved wound-healing outcomes are likely due to
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