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2 Minimally Invasive Procedures and Prophylactic Surgery
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open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg. 2015;149:55–61, 62.e1.
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43. Bhayani SB, Pavlovich CP, Strup SE, Dahl DM, Land­man J, Fabrizio MD, etal. Laparoscopic radical pros­tatectomy: a multi-institutional study of conversion to open surgery. Urology. 2004;63:99–102.
org/10.1016/j.urology.2003.08.018
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44. Chapron C, Fauconnier A, Gofnet F, Bréart G, Dubuisson JB.Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynae­cologic pathology. Results of a meta-analysis. Hum Reprod. 2002;17:1334–42.
humrep/17.5.1334
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45. Medeiros LRF, Rosa DD, Bozzetti MC, Fachel JMG, Furness S, Garry R, etal. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev. 2009:CD004751.
https://doi.
org/10.1002/14651858.CD004751.pub3.
46. Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ. Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals. Surgery. 2010;148:625–35; discussion 635–7.
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org/10.1016/j.surg.2010.07.025.
47. Shabanzadeh DM, Sørensen LT. Laparoscopic sur­gery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Ann Surg. 2012;256:934–45.
https://doi.org/10.1097/SLA.0b013e318269a46b.
48. Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P, etal. Laparoscopic versus open colorec­tal surgery: a randomized trial on short-term outcome. Ann Surg. 2002;236:759–66; discussion 767. https://
doi.org/10.1097/01.SLA.0000036269.60340.AE
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49. Vanounou T, Steel JL, Nguyen KT, Tsung A, Marsh JW, Geller DA, Gamblin TC.Comparing the clini­cal and economic impact of laparoscopic versus open
liver resection. Ann Surg Oncol. 2010;17:998–1009.
https://doi.org/10.1245/s10434- 009- 0839- 0.
50. Attard J-AP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg. 2007;50:291–300.
51. Barmparas G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D.The incidence and risk fac­tors of post-laparotomy adhesive small bowel obstruc­tion. J Gastrointest Surg. 2010;14:1619–28.
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52. Le Huu Nho R, Mege D, Ouaïssi M, Sielezneff I, Sas­tre B.Incidence and prevention of ventral incisional hernia. J Visc Surg. 2012;149:e3–14. https://doi.
org/10.1016/j.jviscsurg.2012.05.004
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53. Torphy RJ, Chapman BC, Friedman C, Nguyen C, Bartsch CG, Meguid C, etal. Quality of life follow­ing major laparoscopic or open pancreatic resec­tion. Ann Surg Oncol. 2019;26:2985–93. https://doi.
org/10.1245/s10434- 019- 07449- x.
54. Quintana JM, Cabriada J, Aróstegui I, López de Tejada I, Bilbao A. Quality-of-life outcomes with laparoscopic vs open cholecystectomy. Surg Endosc. 2003;17:1129–34. https://doi.org/10.1007/s00464-
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55. Ihnát P, Martínek L, Mitták M, Vávra P, Ihnát Rudin­ská L, Zonča P. Quality of life after laparoscopic and open resection of colorectal cancer. Dig Surg. 2014;31:161–8. https://doi.org/10.1159/000363415.
56. Klapper J, D’Amico TA. VATS versus open sur­gery for lung cancer resection: moving toward a minimally invasive approach. J Natl Compr Can­cer Netw. 2015;13:162–4. https://doi.org/10.6004/
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2006.00971.x.
Prophylactic Approaches inAbdominal Wall Surgery: Preventing andRepairing theBurst Abdomen
RifatLati, JamesChoi, ShekharGogna, andSelmanUranues
3
3.1 Introduction
In the United States alone, roughly 350,000 ventral hernias are repaired annually [1, 2], at a cost of approximately $3.2 billion dol­lars, representing a major burden on healthcare resources. Additionally, emergency repairs and postsurgical complications associated with the procedure are signicant [3]. Although there are individuals who may live with ventral hernias for some time before considering repair, the quality of life, impaired body image, continu­ous enlargement, and further loss of abdominal wall domain, as well as the risk of acute com­plications and the need for emergency surgery, are the main reasons for prophylactic surgery in complex abdominal wall defects. If left untreated, complex abdominal hernias can lead to hospitalizations and life- threatening bowel
R. Lati (*) Department of Surgery, Westchester Medical Center and NewYork Medical College, Valhalla, NY, USA e-mail: Rifat.Lati@wmchealth.org;
Rifat_Lati@nymc.edu
J. Choi · S. Gogna Department of Surgery, New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, NY, USA e-mail: James.Choi@wmchealth.org;
Shekhar.Gogna@wmchealth.org
S. Uranues Department of Surgery, Section for Surgical Research, Medical University of Graz, Graz, Steiermark, Austria e-mail: selman.uranues@medunigraz.at
(large and small) obstruction, although the exact number of these events is unclear.
Abdominal wall (incisional) hernias are common. A large retrospective study of 2983 patients followed over a 10-year period found that in 31.5% of cases incisional hernias occurred 6 months after abdominal surgery. This number increases to as high as 88.9% after 5years [4]. The further a patient is from their original date of surgery, the higher the risk for hernia recurrence.
Should an incisional hernia occur, the risk of incarceration and strangulation is dependent on the size of the defect. Signicant factors that contribute to incisional hernia are age >45years, BMI >25, and male gender. Patient comorbidi­ties, technical factors of surgery (large vs. small suture bites), and disease factors (wound infec­tion, defect size) also contribute to the etiology of incisional hernia occurrence. Other patient factors, such as smoking and diabetes mellitus, have also been shown to decrease wound heal­ing and increase hernia recurrence. Yet, in our opinion, the most common causes of recurrent hernia are the experience of the surgeon and the technique used for repair [5]. A detailed description of techniques used in repairing the abdominal wall defects is beyond the scope of this chapter, as there are numerous textbooks and papers describing various approaches: from open to laparoscopic, to robotically assisted repair.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_3
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3.2 The Burst Abdomen
An acute postoperative open abdominal wall (POAW), also known as a burst abdomen, is a postoperative complication associated with mortality rates as high as 45% [6, 7]. Overall, the incidence of this abdominal complication may vary from 0.5 to 3% of all laparotomies, but the postoperative incisional hernia rate is at an alarming 40–60% [8–10]. Emergency operations, wound infections, elderly age, or persistent increases in intra-abdominal pressure postoperatively (such as coughing or retching) are only some of many predisposing factors that can increase the risk of the development of POAW [11]. The most common cause of acute burst abdomen is poor surgical technique or unrecognized intra-abdominal hypertension syndrome. Other major causes are intra-abdom­inal infections or postoperative catastrophes. Although a burst abdomen may occur within 24h after surgery, POAWs are generally seen an average of 7days postoperation [12].
Treatment for POAWs remains patient­specic but several options have been studied. For patients with incomplete dehiscence with­out the presence of adherent bowels, primary fascial closure using absorbable monolament has been suggested [13]. We disagree with this approach, and perform denitive closure of the abdomen to avoid further catastrophes such as open abdomen, entero-cutaneous or entero­atmospheric stulas, and other major compli­cations of an open abdomen [14–17]. In the absence of intra- abdominal infection (in cases when the burst abdomen is a result of poor sur­gical technique), synthetic mesh may be used to reinforce these abdominal wall closures. The use of biological mesh in contaminated or clean-contaminated elds in this patient popula­tion has been limited. In recent years, our group has been using biologic mesh in all contami­nated or clean- contaminated cases [16, 18, 19]. In dirty or contaminated wound, we do not close primary the skin edges. Instead we use delayed primary closure technique and negative pressure therapy systems (Prevena™) [6].
3.3 Prophylactic Mesh Placement
3.3.1 Elective Surgery
Current European guidelines state that abdominal wall closure should be achieved using a slowly absorbable suture in a running technique [20]. However, the type of optimal suture material has not been established. The STITCH trial was a multicenter randomized clinical trial looking at small versus large bites in surgical and gyneco­logical departments to close elective laparosto­mies. In the end, a small bite suture technique (5mm bite every 5mm) was regarded as more effective for the prevention of incisional hernias for midline abdominal wall incisions. In this study, the incisional hernia rate after 1year was found to be 13% in the small bite group versus 21% in the large bite group [21], which in our opinion is very high for elective surgery. Another study performed in animal models showed that risk of dehiscence is lower when stitches are placed 3–6mm from the wound edge compared to 10mm [22]. This technique has also been bene­cial in multiple other studies such as the MATCH (Meta-analysis on Materials and Techniques for Laparotomy Closure) review [23]. Unfortunately, even after a running, slowly absorbable suture closure of the abdominal wall, there is a 10 and 30% risk of incisional hernia on long-term fol­low-up [24, 25]. In our practice, we perform “en masse” continuous closure using slowly absorb­able sutures. In cases of a burst abdomen, or patients with a high risk of dehiscence, we will perform denitive abdominal wall closure using posterior component separation technique, or sublay placement of biologic mesh [16].
However, despite these various technical advancements in primary abdominal wall closure, the incidence rate of postoperative incisional her­nias can be as high as 13% [26]. In recent years, the technique of prophylactic mesh placement in elective abdominal wall procedures has become more common [27, 28]. Prophylactic abdominal wall surgery is dened as the placement of mesh placement during the time of elective abdominal
3 Prophylactic Approaches inAbdominal Wall Surgery: Preventing andRepairing theBurst Abdomen
25
surgery. A randomized control trial conducted by Payne et al. reviewed the use of synthetic mesh to reinforce midline laparotomy incisions in 169 patients undergoing elective abdominal surgeries [29]. Although there was no differ­ence in rates of surgical site infection (SSI), the incidence of hernia recurrence was signicantly less after 1–3 years. Not surprisingly, the time to complete wound healing in patients with SSIs was signicantly longer. Currently, the European Hernia Society suggests that prophylactic mesh reinforcement can be performed for elective midline laparotomies even in high-risk patients (i.e., abdominal aortic aneurysm or patient with BMI >30), however the evidence to support this approach is weak [20]. We believe that this acceptable adjunct procedure will prevent major hernias in this group of patients.
The PRIMA (Prevention of Incisional Hernia With Prophylactic Onlay and Sublay Mesh Reinforcement Versus Primary Suture Only in Midline Laparotomies) trial was a 2-year, mul­ticenter, randomized control study covering 11 hospitals from Austria, Germany, and the Netherlands [30]. The primary goal was to evalu­ate the long-term incidence recurrence rates after elective midline laparotomy. Patients had an abdominal aortic aneurysm or body mass index ≥27 kg/m2. Onlay and sublay mesh placement was compared with primary closure technique. Of the patients who were found to have incisional hernias, those who underwent primary closure exhibited the largest rates at 30%, followed by sublay (18%) and onlay (13%). Wound infection rates were similar among the groups; however, seromas were more frequently observed in onlay mesh placement.
A systematic review conducted in 2017 found that prophylactic synthetic mesh placement in elective abdominal wall surgery decreased the risk of postoperative incisional hernia by 85% when compared to primary closure alone [31]. Patients of prophylactic mesh placement were also at an increased risk of chronic surgical site pain compared to primary closure. Similar to the PRIMA trial, onlay synthetic mesh position was associated with an increased risk of seroma for-
mation. For these two reasons, we prefer the use of biologic mesh, although long-term data on this are lacking [32].
3.3.2 Emergency Surgery andProphylactic Mesh Placement
It has already been shown that the use of pros­thetic mesh at the time of laparotomy can reduce the incidence of postoperative incisional her­nias [1, 28–31, 33]. However, the use of mesh in emergency surgery is a matter of great debate. At the heart of the argument is whether the place­ment of nonabsorbable materials should be used in potentially infected elds, i.e., after intestinal resection, bile duct operations, or parastomal hernias repairs. Finding the correct indication in these situations remains a difcult task. In situations where frank contamination is pres­ent, the general consensus is to avoid the use of prosthetic material all-together [34]. However, there has been a lack of consistent evidence in regard to mesh placement during simultaneous operations on the gastrointestinal tract, espe­cially in the emergent setting. The Ventral Hernia Working Group (VHWG) guidelines recommend against the use of synthetic mesh if the risks of wound complications are high, a sentiment that is echoed by the European Hernia Society [20, 35]. However, a recent prospective multicenter study conducted in the Netherlands examined bio­logical mesh closure versus temporary abdomi­nal closure in emergent nontraumatic patients. Although the sample size was 20 patients in each group, they found that closure with bio­logical mesh resulted in a signicant reduction of ICU length of stay and reoperations [36]. At the senior author’s (RL) busy practice, there has been a paradigm shift regarding early abdominal wall closure using biological mesh after trauma, intra-abdominal catastrophe, and damage control surgery [37]. Figure3.1 illustrates a chronically infected abdominal wall wound extending to the abdominal fascia, which was excised and under­went a posterior component separation with bio-
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Fig. 3.1 Chronically infected abdominal wall wound extending to the abdominal fascia with undermining to the left lower quadrant
R. Lati et al.
logical mesh placement during the same time as her wound debridement (Fig.3.2).
3.3.3 Use ofBiologic Mesh
As the techniques of abdominal wall hernia repair continue to advance, the focus on nding the ideal mesh material also continues alongside these developments. While synthetic mesh reinforce­ment has been shown to be more cost- effective when compared to the burden of readmissions
a
c d
b
Fig. 3.2 (a and b) Subsequent abdominoplasty on the patient in Fig.3.1 followed by (c and d): posterior component separation and abdominal wall reconstruction with sublay biological mesh
3 Prophylactic Approaches inAbdominal Wall Surgery: Preventing andRepairing theBurst Abdomen
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and postoperative complications that arise from primary closure, its use in contaminated or con­taminated repairs is controversial [38]. Current VHWG guidelines advise against the use of syn­thetic mesh when the risk of wound complica­tions is deemed too high [35]. Biological mesh was created to address these concerns. While there have been several case reports on the use of biological mesh in infected elds (with no indi­cation of hernia recurrence at 4–5 years [39]), the evidence in scientic literature requires more time for the results to bear out. As of 2018, there are 21 ongoing randomized trials and observa­tional studies using biological mesh [38]. In our practice, biological mesh had been shown to be effective in elderly patients (age ≥65years old) undergoing complex abdominal wall reconstruc­tion, with comparable outcomes to non-elderly patients [18].
3.4 Adjunct Procedures inComplex Abdominal Wall Reconstruction
3.4.1 Component Separation
Abdominal wall hernias nd their roots with Dr. Albanese who described the rst use of com­ponent separation technique on a large ventral hernia in 1951 [40, 41]. This technique was eventually popularized into what is now known as the “classic component separation technique.” This technique required midline to lateral ante­rior fasciotomies of the rectus abdominus and release of the external oblique aponeurosis [42]. This release allowed for the coverage of 20cm wide defects using autologous tissue. The next evolution in component separation arrived with the Rives-Stoppa technique, which was described as a “posterior placement of mesh in a retro rectus fashion” rather than the classic ante-
rior component separation [43]. An additional component of transverse abdominus release, or TAR, was added several years later. It provided additional defect coverage [44]. Since that time, there have been multiple iterations used through­out abdominal wall surgery, including different placements of synthetic or biological mesh, along with the introduction of laparoscopic and robotic approaches to these techniques.
3.4.2 Anterior Component Separation
In the classic anterior component separation technique [35, 38], a midline laparotomy inci­sion is made that encapsulates the hernia. During the anterior component separation (ACS) for abdominal wall reconstruction, dissection and development of the anterior abdominal skin aps is mobilized laterally from the chest wall to the anterior superior spine. Fascial release is achieved towards the semilunaris, extend­ing towards the ribs and groin. Next, division of the external oblique muscle aponeurosis occurs longitudinally, 2 cm lateral to the lateral edge of the rectus sheath, which will allow the mobi­lized rectus myofascial component to be brought medially and will facilitate the approximation of the midline with sutures. If the rectus abdo­minus is unable to be brought together, the inter­nal oblique muscles can be divided bilaterally. Adequate chemical paralyzation is important during this procedure. Moreover, most benecial will be the separation of oblique muscles (exter­nal and internal). Every effort should be made to preserve the skin perforators during dissection in order to create the mucocutaneous aps. This will greatly reduce skin and subcutaneous necrosis.
Care is given to avoid injury to the internal oblique fascia including the innervations to the rectus muscles. Once the external oblique is
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R. Lati et al.
freed, the area created is considered the anterior muscular space. The compound ap containing rectus abdominus, internal oblique, and transver­sus abdominus is mobilized medially and reap­proximated, forming the anterior rectus repair. Synthetic or biological mesh can be used to reinforce this closure and secured using 0 PDS sutures. It must be ensured that onlay (very rarely used) or inlay mesh covers the newly made space, and sutures should extend past the dissection and incorporate the borders of the dissected plane.
3.4.3 Posterior Component Separation With/Without Transversus Abdominis Release (TAR)
The open posterior component separation tech­nique begins with a midline laparotomy incision. The retromuscular space is created by incising the posterior rectus sheath and releasing the rec­tus muscle. The lateral dissection can continue by dividing the posterior aponeurotic sheath of the internal oblique muscle [37]. Doing so will allow access to the plane between the transversus abdominis and internal oblique.
Posterior component separation (PCS), with or without transversus abdominus release (TAR), has become popular for large midline hernias, particularly with loss of abdominal wall domain, and has become a technique of choice for com­plex abdominal wall reconstruction (CAWR) for many of us for several reasons. These are mainly because of advances in surgical techniques and the reduction of skin and subcutaneous complica­tions. The main principles of PCS are the sparing of the neurovascular bundle and mesh placement posterior to the rectus muscle in a sublay position.
Once the lysis of adhesions and other con­comitant procedures, such as reconstitution of the GI tract, are completed, PCS can begin by incising the medial edge of the posterior rectus sheath 1cm lateral to the linea alba. The edge of the transected posterior rectus sheath is grasped with clamps and retracted medially and posteri­orly, while the rectus muscle is gently elevated anteriorly, allowing easy lateral dissection of the retrorectus space (Fig.3.3). During this stage of the operation, the surgeon must be cognizant in preserving the neurovascular bundle. The mul­tiple perforators and the epigastric vessel (supe­riorly and inferiorly) are fragile vessels that can be easily injured at any stage of the operation.
a b
Fig. 3.3 (a) Posterior component separation—Kocher clamps on the rectus abdominus muscles with the posterior rectus sheath reapproximated. (b) Biological mesh placed in a sublay fashion (posterior to the rectus abdominus)
3 Prophylactic Approaches inAbdominal Wall Surgery: Preventing andRepairing theBurst Abdomen
29
The posterior lamina of the internal oblique apo­neurosis is incised just medial to the entry of the intercostal nerves as they enter the rectus muscle posteriorly. Dissection of this segment should begin as cranially as possible.
In cases of post liver transplant hernias, it does not make much sense to try to separate the liver from the posterior rectus sheath (PRS) and risk entering the liver during the dissec­tion. Instead, the preferred procedure is to drop the PCS together with the liver, in order to cre­ate the space for it should be possible to see the medial aspect of the transversus abdominus muscle (TAM). The muscle bers and fascia of TAM can be separated from the underlying thin posterior transversus abdominis fascia and peri­toneum with a right- angle clamp. However, this separation requires a careful dissection under the muscle bers of TAM.One has to be careful not to enter the peritoneum. If this occurs, the defect must be identied and immediately closed with absorbable suture. We prefer to conduct this por­tion of the operation sharply (with electrocautery or scissors), but always under direct vision. Blunt dissection should be avoided as it may cause bleeding. Once the space is satisfactorily created, the posterior rectus sheaths are approximated with running absorbable suture (0-Vicryl). At this stage, the mesh size is fashioned according to the size of the space, but it must be ensured that the mesh (irrespective of what kind) is not folded in on itself. Fixation of the mesh superiorly, inferi­orly, and laterally with sutures will help position the mesh appropriately (Fig.3.3). Several tech­niques can be used to place the sutures. We refer to use a Carter-Thomason suture passer, but other suture passers are adequate to x the mesh to the anterior abdominal wall.
At our institution, we have an ongoing pro­spective observational study examining the technique of open complex abdominal wall recon­struction using porcine-derived acellular matrix (Strattice™). Initial placement of the biological mesh was used in the underlay (intraperitoneal) position using anterior component separation. However, since 2017, our group has gradually changed to using a posterior component separa­tion approach with or without transversus abdo-
minus muscle release. Mesh placement has also changed to the sublay (retrorectus) position. Our approach incorporates the sparring of all neu­rovascular bundles, and the linea alba is closed over the mesh whenever possible. We also place two or three 19-French Blake drains below the fascia-adipocutaneous aps to prevent the risk of seroma formation [18].
3.5 Conclusion
There have been major advances in abdominal wall surgery. Fundamental knowledge of abdom­inal wall surgery and a plethora of well-dened prophylactic surgical techniques are now widely recognized and employed, with each having its own learning curve. The prophylactic approaches are useful while dealing with complex reopera­tive cases, and hernia surgeons should decide wisely based on their own experience guided by scientic evidence. In high-risk patients, there should be a prophylactic mesh placement.
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