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374
Fig. 25.10 The onlay (prefascial) technique. After construction of the
neo-linea alba, a strip of prosthetic mesh 8–10 cm in width and 3–4 cm
longer than the abdominal wall closure is placed and secured with a
continuous peripheral suture of nonabsorbable suture material and a
continuous suture to attach the mesh to the midline closure
F. Malcher et al.
perforations down its terminal length. Two drains are used.
Each is tucked in laterally, under a right or left skin flap, to
emerge low-down on the lateral abdominal wall, and sutured
to the skin securely.
In the first 24–48 h, a bloody discharge will appear in the
drainage bottle. Thereafter the fluid will become serous. The
maximum flow of serous fluid is usually at about the fourth
to sixth day, mandating against removal of any drain before
1 week postoperatively. Because seromas can persist after
the seventh day, all drains remain in situ until day 14 postoperatively, which is the day patients receive removal of skin
sutures in the outpatient clinic. Patients can take home spare
drainage bottles, which can be changed by a nurse if large
volumes of serous fluid are discharged, in the occasional
patient. The complications of this management protocol far
outweigh the problems associated with the management of
large volumes of trapped serous fluid under the skin flaps. If
at day 14 the daily discharge is >50 cc, the drains are not
removed and the daily discharge is monitored until the flow
becomes <50 cc daily. A small number will continue to discharge serous fluid after 30 days, at which time a decision
must be made to remove the drain and manage any seroma
formation expectantly.
the subcutaneous fat for 5–7 cm to accommodate the onlay
mesh. The mesh is now cut to size being a width of 10 cm
and allowing for 3–4 cm overlap superiorly and inferiorly.
If the polypropylene or polyester mesh is allowed to be in
direct contact with the intestine, there is a risk of adhesion
formation and fistulation. There is also a risk of mesh erosion into the bowel with these types of meshes. In open
prosthetic mesh repair, there is no place for the use of newer
meshes with incorporated anti-adhesive agents placed over
the bowel as an inlay method without midline fascial closure. These dual meshes are specifically for use by laparoscopic surgeons when placed over a defect from inside the
abdomen and in which contact with the viscera is inevitable. There are no long-term studies to verify the absence of
complications seen many years after the insertion of such
meshes. However, the use of such products has been longer
than 15 years.
Use of Drains
Although seromas occur in a minority of patients, there are
no known risk factors for their postoperative occurrence.
Therefore measures should be taken to prevent seroma formation in all patients receiving a mesh repair, regardless of
the complexity of the operation. This prophylactic practice is
accomplished by the placement of drains in every patient.
Closed suction vacuum drains are used (bottle capacity
500 cc, so that changes are infrequent, minimizing contamination), which have a relatively long tube having multiple
Sublay Repairs
Retromuscular/Rives
The sublay repair places the mesh in the retromuscular space.
Rives originally described this technique more than 30 years
ago [54]. Placement of the prosthesis in the retromuscular
plane requires opening of the rectus sheath near the linea
alba to gain access to this space on both sides. After closure
of the posterior rectus sheath, the mesh is placed on top of
this behind the rectus muscles, and conclusion of the abdominal wall closure is achieved by suture of the anterior rectus
sheaths in the midline. Leaving a gap in the anterior or posterior rectus sheath achieves poor results and a high recurrence rate, and the relaxing incision in the external oblique of
“components separation” should be applied in order to gain
complete midline closure. The mesh overlap achieved is similar to the onlay technique with 5–6 cm in all directions and
gives good results [55, 56]. This repair also gives good
results in patients with large hernias with significant loss of
domain [57].
Each rectus sheath is incised along its medial border
and opened in the midline to expose the anterior and posterior aspects of the rectus muscle (Fig. 25.11). With blunt
dissection the entire width of the muscle is exposed on its
undersurface superficial to the posterior rectus sheath
(Fig. 25.12). The posterior rectus sheath is now closed
with a continuous running suture of slowly resorbable
material and the mesh placed in the posterior retrorectus
25 Open Repair
Fig. 25.11 The medial border of the rectus sheath is incised along the
length of the fascial defect on both sides
375
Fig. 25.12 The bloodless plane behind the rectus muscle and anterior
to the posterior rectus sheath is dissected to the lateral limit of the rectus
muscle
position to occupy the width of the rectus muscles on both
sides (Fig. 25.13). A prosthetic mesh approximately
10 cm in width and long enough to achieve a 3–4 cm overlap superiorly and inferiorly is now placed in the retrorectus space (Fig. 25.14). To prevent migration or movement
of the mesh, a few absorbable sutures are placed between
the mesh and the posterior rectus sheath or peritoneum. It
may be advisable to place a suction drain in the retrorectus position prior to closure of the anterior rectus sheath,
Fig. 25.13 The posterior rectus sheath is closed with a nonabsorbable
suture. This should be achieved with negligible tension
Fig. 25.14 Prosthetic mesh wide enough to cover the space behind the
two rectus muscles (about 8–10 cm) and 3–4 cm longer than the midline
closure is placed and secured with a few peripheral interrupted absorbable sutures
376
F. Malcher et al.
5 mm
5mm5 mm
5 mm
Fig. 25.15 The anterior rectus sheath is closed with a slowly absorbable continuous suture to achieve 4:1 suture length-wound length ratio
(5–10 mm bites at 5 mm intervals). Suture bites do not include the
muscle
which is achieved by a continuous suture of slowly
absorbable material (Fig. 25.15).
Preperitoneal Repair
The preperitoneal repair places the mesh in the preperitoneal space, which below the arcuate line is the same space
to place the mesh described by Rives and Soppa and
pointed above [54]. The main difference is that above the
arcuate line, this is a very difficult layer to achieve due to
the thin layer of peritoneum in this area. The dissection
should be carried below the rectus sheath taking care not
to tear the peritoneum (which is normally difficult to
achieve) in order to obtain at least 5–6 cm in all directions
to have a good mesh overlap of the defect (Fig. 25.16).
After dissection of the preperitoneal space and confirming that the mesh will have the adequate overlap, the
peritoneum is closed with absorbable suture to avoid contact
between mesh and abdominal viscera. The mesh is placed in
the preperitoneal space created and should be secured with
few absorbable sutures between the mesh and the posterior
Fig. 25.16 Onlay implanted mesh with adequate 5cm overlap in all
directions
rectus sheath or peritoneum. The posterior rectus sheath is
now closed with a continuous running suture of slowly
resorbable material.
Open Intraperitoneal Prosthetic Mesh Repair
This alternative technique has been popularized in one or
two French centers [58, 59]. The initial steps of the operation are the same as for the onlay or sublay techniques
with complete excision of the peritoneal sac to the medial
edge of the rectus muscles. The mesh is placed intraperitoneally with 5–6 cm overlap and secured by nonabsorbable through-and- through sutures spaced 2 cm apart and
1 cm from the border of the mesh. The sutures transverse
the entire width of the muscular fascial abdominal wall
and also the subcutaneous layers, and each is tied through
a small incision in the skin. Protagonists of this technique
claim that the prosthesis acts as a substitute for the
abdominal wall avoiding suture of the two opposite fascial edges of the defect with tension. The muscular aponeurotic edges are closed in the midline as much as
25 Open Repair
377
possible to isolate the prosthesis from surgical skin contamination. The authors promoting this technique have
not encountered problems with enterocutaneous fistula. If
this method is used, the choice of a biologic mesh will
require the preservation of the hernial sac to be used as a
vascularized pedicle to allow for the proper resorption of
the collagen product.
New meshes were launched in the last years with the
objective of making the intraperitoneal placement and fixation easier. They have a skirted edge or pocket that allows an
easier fixation with tackers from “inside” the mesh. Some
meshes also have a rigid external ring that help the positioning and opening the mesh and are absorbed after a certain
period of time.
For the open intraperitoneal technique, after the complete
lysis of adhesions, an appropriated coated mesh should be
positioned intraperitoneally and fixated with sutures or tackers in all the peripheral edges of the mesh to avoid exposure
of the parietal surface of the mesh to the viscera. It should
have adequate overlap in all directions (at least 5 cm) and be
fixated in on side first and, after pretensioning of the midline
medially, to the other side. This maneuver aims to avoid
wrinkles in the mesh after the midline closure, in the same
fashion described above.
Postoperative Care
the need to use drains in the retromuscular space or in the
preperitoneal space. Literature lacks evidence (and especially good-quality data) regarding the need to use drains in
this space [60]. Most surgeons prefer not to use drains on this
space if there is no evidence of continuous pouring after dissection, but since there is little evidence in the literature, the
decision should be based on surgeon experience [61].
Conclusions
• Specialists who have developed an interest and experience in incisional hernia repair have significantly better
results than nonspecialists.
• Important predictors of recurrence are wound infection,
obesity, and previous repairs.
• A critical factor for a good outcome is the pre- optimization
of the patient.
• A choice of operative procedure is critical. Fascial closure
is paramount, and mesh overlap does not need to exceed
5 cm.
• Mesh fixation should be comprehensive with a continuous peripheral suture for the onlay technique, interrupted
sutures for the sublay method, and a peripheral line of
sutures or tackers in IPOM techniques.
• Where there is a risk of abdominal compartment syndrome after closure of the midline fascial layer, a components separation is essential and simple.
Immediate active mobilization is the key to rapid convalescence. In the absence of extensive handling of the intestines, there is no postoperative adynamic ileus and no need
for encumbrances such as nasogastric suction or intravenous drips. The patient is made to take deep breaths; breathing exercises and, where necessary, chest percussion are
given. As soon as possible, the patient gets up and walks.
Fluids are given for the first day, and then a light diet is
started. These patients may experience a significant amount
of pain, which will require parenteral analgesia. If this can
be controlled with oral analgesics and the patient does not
experience a significant ileus, a minimal hospital stay can
be expected. Generally, the length of stay will be 3–5 days
depending upon the size of the hernia, the amount of dissection required, and the number of comorbid conditions of
the patient.
Management of Drains
The use of drains in the onlay repair was previously discussed in this chapter. There is a lot of controversy regarding
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Component Separation of Abdominal Wall Muscles
Flavio Malcher and Leandro Totti Cavazzola
26
Introduction
The term separation of abdominal wall components refers to
the incision and dissection of muscular planes of the anterolateral musculature of the abdomen. It differs from the simple
relaxation incision often used by surgeons, since it has as a
precept on the release of the muscular planes so that the lateral components slide in the medial direction in order to affect
the closing of the midline of the abdominal wall [1–3].
Its use may occur in cases where the surgeon does not
want to use prostheses and needs to close the abdominal cavity (peritonostomies/open abdomen, infected fields, etc.) or
in cases where the midline is to be realigned in order to
restore the full function of the wall, in addition of the use of
a mesh to reinforce the defect [1].
There are many techniques described, but the following will
describe the main techniques used in our environment [2, 3].
Anterior Component Separation
Better know as Ramirez component separation, the first step
is the complete release of the adhesions of the intracavitary
contents to the abdominal wall in order to facilitate the slide
into a medial position. The healthy edges of the musculature
should be identified in all directions of the hernia defect
[1, 3]. This is done by releasing a suitable adipose- cutaneous
flap to the level of the muscular borders. Once this border has
been identified, one should continue the dissection of the
anterior aponeurosis until the lateral border of the rectus
abdominis is identified. The maneuver of grasping the rectus
abdominous between the index finger and the thumb in a
practical maneuver facilitates the identification of this limit
(Fig. 26.1). At that moment, a small incision is made 1 cm in
the lateral direction of the border of the abdominal rectum in
order to incise only the external oblique muscle fascia. No
fleshy muscular belly should be visualized at this time. Once
making sure that the internal oblique space is reached, the
dissection is continued in the caudal direction until the inguinal ligament and cephalically to the costal border. In this cranial portion, the muscle fibers section of the external oblique
muscle becomes imperative (crucial) [3].
Once this relaxation incision is created, the avascular
interoblique plane should be freed by lateral blunt dissection
in order to allow all possible sliding of the medial compartment (Fig. 26.2). After performing these surgical steps bilaterally, the midline alignment can be tested. The release of the
posterior sheath of the abdominal recesses can be done bilaterally as usual for the retromuscular repair of Rives-Stoppa
to achieve additional sliding and/or to allow the prosthesis to
be placed in this space [1, 3].
The midline is then closed in the usual manner by the surgeon (Fig. 26.3), and a prosthesis can be placed in an onlay
F. Malcher (*)
Celebration Center for Surgery, Celebration, FL, USA
e-mail: flaviomalcher@gmail.com
L.T. Cavazzola
Universidade Federal do Rio Grande do Sul and Hospital de
Clínicas de Porto Alegre, Porto Alegre, Brazil
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_26
Fig. 26.1 Grasping of the rectus muscle to identify the lateral limit of
its sheath (Published with kind permission of © Yuri Novitsky 2017.
All Rights Reserved.)
381
382
Fig. 26.2 Presentation of the separation area after sectioning the external oblique muscle and creating the interoblique space. Note the medial
traction and the medial and lateral edge of the incision made (arrows)
(Published with kind permission of © Flavio Malcher 2017. All Rights
Reserved.)
F. Malcher and L.T. Cavazzola
Fig. 26.4 Onlay mesh and drains (Published with kind permission of
© Flavio Malcher 2017. All Rights Reserved.)
Fig. 26.3 Final appearance after the midline closure (Published with
kind permission of © Flavio Malcher 2017. All Rights Reserved.)
position, covering the separation area, since this area may allow
bulging due to lack of a muscular plane (Fig. 26.4). Drainage of
dead space should be done with closed systems at the discretion of the surgical team [1, 3].
A slide of up to 8 cm is expected unilaterally at umbilical
level and up to 3–4 cm in the epigastrium and suprapubic
region.
Postoperative concerns are summarized as abdominal
compartment syndrome in cases of tight closure, ischemia,
and necrosis of adipose-cutaneous flaps (all care must be
taken not to create excessive or non-vascularized flaps) and
surgical wound infection (Fig. 26.5) [3].
Fig. 26.5 Ischemia, necrosis, infection, and exposure of the mesh after
extensive adipose-cutaneous flap (Published with kind permission of ©
Yuri Novitsky 2017. All Rights Reserved.)
A variant of this technique is the anterior separation of
components with periumbilical preservation of the perforating vessels [4]. The vascularization of the subcutaneous cellular tissue and skin is made in the abdominal wall by the
superior and inferior epigastric and thoracoabdominal
vessels [5]. Studies have shown that periumbilical perforating vessels are fundamental for the viability of this region,
which is the most sensitive to the creation of flaps [5]. Thus,
an alternative for anterior separation would be to not perform
the adipocutaneous flap in this region. Surgery should follow
the steps described above, except for this flap in the region,
performing it only in the epigastric and hypogastric regions.
From there, a tunnel is made at the height of the section of
the external oblique muscle for the previous separation [4].
Another alternative, aiming once again to avoid the adipose
flaps, is the so-called endoscopic separation of components
26 Component Separation of Abdominal Wall Muscles
described by Rosen [6]. This surgery begins with a subcostal
transverse incision at the level of the midclavicular line in the
lateral portion of the abdomen, with the open puncture only of
the external oblique muscle to allow the placement of a dissector balloon used to create the preperitoneal space in laparoscopic TEP (totally extraperitoneal) inguinal herniorrhaphy.
The inflation of this device in the interoblique plane creates
the separation between the muscles and allows the placement
of two more 5 mm trocars for the use of hook and/or scissors
to incise the “ceiling” of this operative field that is the external
oblique muscle. This alternative allows a smaller slide, since
all the subcutaneous cellular tissue remains fixed in the musculature but has the great advantage of decreasing the risk of
seromas, ischemia, and/or necrosis in the postoperative period
[6]. Adding a laparoscopic ventral hernia repair with transfascial sutures closing the midline after the endoscopic component separation can lead to a totally endoscopic procedure
with restoration of the abdominal wall function in a minimally
invasive way even in complex cases [7].
Another alternative is the subcutaneous anterior component
separation described by Jorge Daes, where, after the lateral incision, the same dissection balloon is inflated anterior to the fascia, in the SC space. Additional trocars are positioned, and the
external oblique muscle is incised, and the separation is completed in the same fashion of the traditional open technique [4].
383
Fig. 26.6 Release of all adhesions to the abdominal wall (Published
with kind permission of © Yuri Novitsky 2017. All Rights Reserved.)
Posterior Component Separation
The posterior separation of components can be performed in
two ways: with intramuscular dissection or with release of
the transverse abdominal muscle [3, 8–12].
The initial stage is the same in both techniques and in the
previous separation technique it consists of releasing all the
adhesions from the viscera to the anterolateral and pelvic
abdominal wall and identifying the healthy medial border of
the rectus abdominis muscle (Fig. 26.6) [8–12]. After this, a
longitudinal incision is made at this border, and the retromuscular space is dissected between the rectus muscle and the
posterior sheath, medial to the semilunar line, as traditionally
in Rives’s retromuscular technique (Figs. 26.7 and 26.8) [8–
12]. In intramuscular dissection described by Carbonell, the
aponeurosis of the internal oblique muscle is sectioned, which
allows access to the plane between the internal oblique muscle and the transverse abdomen. The problem with this technique is that in this plane it passes the neurovascular
(intercostal) bundle of the abdominal musculature (Fig. 26.9)
and that it is sacrificed [8]. In the posterior separation with
release of the transverse abdominal muscle, Novitsky
described technique, about 0.5–1.0 cm medial to the semilunar line, when one can already see the nerve and vascular
branches reaching the rectus abdominis, a longitudinal
Fig. 26.7 Incision of the rectus sheath to create the retromuscular
space (Published with kind permission of © Yuri Novitsky 2017. All
Rights Reserved.)
Fig. 26.8 Retromuscular space creation until the semilunar line. Note
the medial traction of the medial border of the posterior sheet (Published
with kind permission of © Yuri Novitsky 2017. All Rights Reserved.)
384
External oblique muscle
a
Rectus abdominis
Perforating branches
Internal oblique muscle
Transverse abdominis
Intercostal nerve
F. Malcher and L.T. Cavazzola
b
Fig. 26.9 Intercostal nerve path way between the internal oblique and
transverse muscles [5]
incision in the posterior sheath of the rectus, exposes the
transverse muscle just below. This muscle is then divided
along the entire border with electrocautery (Fig. 26.10a and
b). From there, with blunt dissection, the space between this
muscle and the fascia transversalis and peritoneum (layer is
extremely thin and delicate) is accessed. That is, the transverse abdominal muscle, lateral to the semilunar line, remains
attached to the internal oblique muscle, and the neurovascular
Fig. 26.10 (a) Posterior sheath incision with transverse muscle. (b)
Final aspect after complete transverse release (Published with kind permission of © Yuri Novitsky 2017. All Rights Reserved.)
bundle remains intact (Fig. 26.11). This lateral detachment
can extend to the psoas, superiorly to the xiphoid and inferiorly to Cooper’s ligaments [9–12]. Due to the role of the
transversus abdominis muscle acting as a “corset” in the
abdomen, its section allows the release of this circumferential
tension and results in a satisfactory medial advancement [13].
The posterior sheaths are approached and closed
(Fig. 26.12), and the mesh is placed in the sublay position,
lying below the rectus abdominis muscle and above the posterior rectus sheath and transverse fascia, fixed with transfascial sutures. The area of detachment and placement of the
mesh is drained with drains in a closed system, which should
remain until a drainage around 50 mL in 24 h. Because it
does not require cutaneous adipose detachment, the technique of posterior separation results in less formation of
seromas and necrosis of tissues [12, 14, 15].
It is important not to associate previous separation with posterior separation of components, since the lateral wall of the
abdomen becomes very fragile, maintained only by the internal
oblique muscle and will eventually bulge outward [12–14].
Fig. 26.11 Medial traction of the posterior sheet. Note the thin peritoneum and transversalis fascia layer (Published with kind permission of
© Yuri Novitsky 2017. All Rights Reserved.)