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426
L.R. Beffa and A.M. Carbonell
abdomen, near the costal margin where the transversus
abdominis muscle is more robust; however, the TAR can also
be initiated in the lower abdomen. The division of the muscle
is then extended inferiorly along the length of the entire dissection where it becomes less muscular and more aponeurotic. Again, it is critical to note that the line of division of
the transversus abdominis muscle is medial to the neurovascular perforators (Fig. 31.8).
Once the muscle is divided, the transversalis fascia will be
exposed; deep to that layer, lays the peritoneum (Fig. 31.9).
Lateral dissection can continue in either of the pretransversalis fascia or pre-peritoneal planes. The preperitoneal plane usually separates more easily, but the
peritoneum can be extremely thin. The pre-transversalis plane
is more difficult to develop but may be necessary if the peritoneum is too thin. Blunt dissection is performed from medial
to lateral, peeling the peritoneum or transversalis fascia away
from the posterior aspect of the cut transversus abdominis
muscle.
This space is dissected, lateral, until the peritoneal flap,
with the attached posterior sheath, rests without tension,
upon the visceral contents below. This will create an
extensive medialization of the posterior rectus sheath with
peritoneum attached, laterally, for visceral sac closure later
in the procedure. Small tears in the peritoneum during this
dissection may be repaired with absorbable suture.
At this point, a similar configuration of trocars is placed
on the contralateral side. Sizing of the retromuscular pocket,
and thus the proposed mesh size, is now performed. The
entire vertical dimension of the pocket is measured intracorporeally with a metric ruler. This will be the exact vertical
dimension of the mesh. The horizontal measurement is made
from the lateral most extent of the dissection to the lateral
edge of the hernia defect or rectus muscle. The resulting
measurement must then be doubled to reflect the similar dissection, which will be performed on the contralateral side.
A large-pore, mid-weight uncoated polypropylene mesh is
cut to the measured size. The mesh is rolled along its vertical
axis, leaving a 2 cm portion of mesh unrolled. An absorbable
suture is placed into the mesh roll to prevent unrolling of the
mesh during positioning. The mesh roll is now introduced into
the dissected space through the contralateral 12 mm cannula
on the left (Fig. 31.10). The mesh is positioned so that the
unrolled edge lies under the contralateral cannula. The edge is
secured to the lateral abdominal wall with absorbable suture.
The robot is then undocked from the right-sided trocars, the
patient bed is pivoted 180 degrees, and the robot is re- docked
with the left-sided trocars. The retrorectus and TAR dissection
is carried out, identically, on the contralateral side. As this
opposite dissection is carried out, the initial trocars, which
were placed intraperitoneally, will need to be pulled back and
repositioned pre-peritoneally, as dissection of the peritoneal
flap continues lateral to them. The resulting peritoneal defects
from these ports are closed with absorbable sutures.
The posterior rectus sheaths are now suture approximated
in the midline, utilizing a 23 cm, 2-0, absorbable, selffixating, barbed suture on a GS-22 needle (V-Loc™ 180,
Covidien, Minneapolis, Minnesota, USA) (Fig. 31.11). The
Fig. 31.9 Developing the TAR (A. cut edge of transversus abdominis
fascia; B. cut edge of transversus abdominis muscle; C. transversalis
fascia; D. pre-peritoneal plane)
Fig. 31.8 Beginning the TAR with incision of the posterior sheath (A.
posterior sheath; B. incision along posterior sheath; C. rectus muscle
anteriorly)
Fig. 31.10 Mesh positioning
31 Component Separation: Robotic Approach
posterior sheath and peritoneal flap are inspected a final time
to identify any holes that were created or missed during dissection and closed with absorbable suture. At this juncture,
the visceral sac is completely closed.
The suture holding the mesh roll is cut, and the mesh is
unrolled toward the patient’s right side (Fig. 31.12). The
mesh should lie flat against the closed posterior sheath and
occupy the entire retromuscular dissected space. Similar to
the left side, the right edge of the mesh is secured to the lateral abdominal wall with absorbable suture. Additional superior and inferior fixation of the mesh is performed, as needed.
427
Closure
The anterior rectus sheath and hernia defect are now suture
approximated with a 45 cm, #1, absorbable, self-fixating, barbed
suture on a CT-1 needle (Stratafix™ Symmetric PDS™ Plus;
Ethicon™, Somerville, New Jersey, USA). Every third bite of
the fascia should incorporate a bite of the hernia sac to help
obliterate the dead space and reduce the size of the resulting
seroma. Decreasing the intra-abdominal pressure to 8–10 mmHg
Fig. 31.11 Closing of posterior sheaths and thus visceral sac
Fig. 31.13 Final mesh position
will help to facilitate fascial closure. Should there be excessive
tension, the bedside assistant may place two to three figure-ofeight sutures with a suture passer device to bring the defect
together, facilitating the running suture closure.
Once the fascial defect is closed, the robot is undocked,
and the laparoscope is inserted to inspect and ensure the
mesh is lying flat. The trocars are then removed and the procedure ended. The trocar sites do not require fascial closure,
since the mesh extends beyond the fascial incisions in the
retromuscular plane (Fig. 31.13). The skin is re- approximated
with absorbable sutures and skin glue.
Single-Dock Rives-Stoppa Retromuscular Technique for Epigastric and Suprapubic Hernias
Patient Positioning and Theater Setup
This approach can be used for epigastric or suprapubic
defects, which are amenable to a robotic approach. The
patient is positioned supine with the arms at 90 degrees. The
patient bed is flexed to allow the angle between the rib cage
and pelvis to widen. This maneuver will increase the angle
between the robotic arms and the patient’s body which prevents the robotic arms from colliding with the patient’s chest
when performing suprapubic hernia repair. For subxiphoid
defects, the patient is placed in a split-leg position and also
flexed to prevent robotic arm collisions with the legs. The
robot is then positioned parallel to the bed, and the arms are
swung over the patient to dock to the ports.
Fig. 31.12 Deployment of mesh
Initial Access and Port Placement
For suprapubic defects, the initial port is placed in the right
upper quadrant along the costal margin to gain entry into the
428
abdominal cavity. This port is upsized to a 12 mm assistant
port. Next, three ports are then placed in a straight line across
the upper abdomen: one in the right upper quadrant (8 mm
robotic port), one immediately off-midline (12 mm), and one
in the left upper quadrant (8 mm robotic port). The 12 mm
trocar for the camera is placed off-midline, directly through
the rectus muscle, thus avoiding the linea alba, which is the
thinnest portion of the abdominal wall (Figs. 31.14 and
31.15). For epigastric defects, the ports are essentially mir-
rored to go across the lower abdomen except for the assistant
port, which is placed in the lower abdomen on the opposite
side of the robot (Fig. 31.16). The robot is docked parallel to
the patient, and arms are maneuvered to the ports.
Operative Steps
After adhesiolysis is complete and the abdomen surveyed,
dissection starts with a transverse incision of the posterior
rectus sheath from semilunar line to semilunar line using
monopolar scissors. The transverse incision must be made at
least 5 cm from the edge of the defect as to allow for adequate mesh overlap. This dissection is carried medially
toward the linea alba, and once the linea alba is encountered,
the posterior sheath is incised. Dissection then continues
within the pre-peritoneal plane. When the contralateral side
is reached, the posterior sheath is incised on the contralateral
side, and the retrorectus dissection continues toward the lateral border of the rectus (Fig. 31.17). It is important to preserve the linea alba when crossing from the underside of one
rectus muscle to the next. The dissection is then carried
toward and around the hernia defect. Once the hernia defect
is encountered, dissection around the hernia sac begins by
pulling the sac down from the abdominal wall and continuing dissection more anteriorly. If dissection becomes too dif-
L.R. Beffa and A.M. Carbonell
Fig. 31.15 Schematic of port placement and robotic docking for
suprapubic defect
Fig. 31.14 Suprapubic hernia port placement
Fig. 31.16 Schematic of port placement and robotic docking for epi-
gastric defect
31 Component Separation: Robotic Approach
429
postoperative narcotic use. Urinary catheters are removed in
the operating room. A postoperative, intravenous, low-dose
ketamine infusion is utilized, in addition to intravenous acetaminophen and ketorolac. The ketamine infusion is discontinued on postoperative day 1 depending on the patient’s
level of pain control, and oral analgesics begun.
The patients and floor nursing staff are instructed to
ambulate the patient as soon as possible following surgery,
typically within a couple hours of arriving to the surgical
ward. Diet is advanced as tolerated. Both mechanical and
chemical venous thromboembolic prophylaxes are continued
through the hospital stay. Most patients achieve adequate
oral pain control on either postoperative day 1 or 2, resulting
in an average length of stay between 1 and 2 days.
Fig. 31.17 Dissection of both sides of posterior rectus sheath and preperitoneal plane (A. pre-peritoneal plane; B. both sides of posterior rectus sheath mobilized off rectus muscle)
ficult here, the hernia sac can be transected; however, enough
redundant hernia sac must be left behind for closure of the
posterior sheath later.
After developing the entire retrorectus plane on both sides
to the costal margin for epigastric defects or Cooper’s ligaments for suprapubic defects, the hernia defect of the anterior abdominal wall is closed in a fashion similar to the
double-dock technique. The large retromuscular space is
then measured intracorporeally. Any defect in the posterior
sheath or bridging peritoneum is closed with absorbable
suture. The measurement of the dissected space allows tailoring of the mesh to exact dimensions for maximal mesh
overlap. The mesh is brought into the field through the
12 mm assistant port and deployed against the anterior
abdominal wall and fixated at its four corners with absorbable suture. Finally, the initial, horizontal flap, created by
incising both posterior rectus sheaths, is closed utilizing a
23 cm, 2-0, absorbable, self-fixating, barbed suture on a
GS-22 needle (V-Loc™ 180, Covidien, Minneapolis,
Minnesota, USA).
Once this is complete, the robot is undocked, and the
12 mm port sites are closed with an absorbable suture utilizing a suture passer device. The skin is re-approximated with
absorbable suture and skin glue.
Postoperative Management
All patients who undergo ventral hernia repairs receive the
enhanced recovery after surgery protocol. This is a collaborative effort between surgeons, anesthesiologists, nurses,
and therapists with the overall goal being to eliminate intraoperative administration of narcotics and significantly limit
Tips and Pitfalls
– Patient selection is important. Midline defects 10 cm or
less are quite amendable to robotic retromuscular ventral
hernia repair.
– Patients who have a higher risk of wound complications
(i.e., obesity, diabetes, smoking) will benefit from robotic
repairs and a minimally invasive approach.
– Patients with wide and dystrophic scars or skin grafts
should be repaired in an open fashion to allow for scar
revision/removal.
– Proper patient positioning, trocar placement, and robotic
docking will avoid situations such as instrument collisions or instrument movement limitations which make
completing the repair difficult.
– Identification of the retrorectus neurovascular bundles
provides an important landmark during dissection, marking the lateral border of the rectus muscle where the TAR
should begin.
– Preservation of the blood supply and innervation to the
rectus muscles allow for proper muscle function. If the
TAR incision is made lateral to the perforating neurovascular bundle of the rectus muscle, there runs the risk of
division of the semilunar line and separation of the
oblique muscle attachments to the rectus muscle creating
a more dysfunctional abdominal wall and large lateral
hernia.
– Tears in the peritoneum and posterior sheath larger than
1 cm should be repaired to avoid intraparietal herniation
or mesh exposure to the underlying viscera.
– An extensive lateral dissection should be performed,
allowing for significant medialization of the posterior
myofascial flap, creating a large space to place mesh in
order to encompass the entire visceral sac.
– An enhanced recovery pathway will improve patient sat-
isfaction; allow for a multimodal approach to analgesia,
thus decreasing narcotic use; and shorten length of stay.
430
L.R. Beffa and A.M. Carbonell
References
1. Rives J, et al. Treatment of large eventrations (apropos of 133
cases). Minerva Chir. 1977;32(11):749–56.
2. Ramirez OM, Ruas E, Dellon AL. “Components separation”
method for closure of abdominal-wall defects: an anatomic and
clinical study. Plast Reconstr Surg. 1990;86(3):519–26.
3. Novitsky YW, et al. Transversus abdominis muscle release: a novel
approach to posterior component separation during complex
abdominal wall reconstruction. Am J Surg. 2012;204(5):709–16.
4. Abdalla RZ, et al. Modified robot assisted Rives/Stoppa videosurgery for midline ventral hernia repair. Arq Bras Cir Dig.
2012;25(2):129–32.
5. Warren JA, Cobb W, Ewing J, Carbonell AM. Prospective observational cohort study of robotic vs open Rives-Stoppa retrorectus
incisional hernia repair. Hernia. 2015;19:S177–86.
6. Warren JA, et al. Standard laparoscopic versus robotic retromuscular ventral hernia repair. Surg Endosc. 2016;31(1):1–9.
Postpartum Divarication Navel-Sparing Treatment by Multidisciplinary Approach
Fien Decuypere, Rudolf Vertriest, Iris Kyle-Leinhase,
and Filip Muysoms
32
Introduction
PPAWI (postpartum abdominal wall insufficiency) is an
acronym first introduced during the 35th Annual Congress of
European Hernia Society in Gdansk, Poland, May 2013. It is
a pathological condition induced by abdominal distension
during pregnancy. It consists of general laxity of the anterior
abdominal wall because of diastasis of the rectus abdominis
muscles and of excess skin and panniculus. This has important repercussion on abdominal wall function and its aesthetics. The abdominal wall function is impaired with loss of
integrity of myofascial systems with reduced thickness of
rectus muscles. Typically, there is an altered angle of
attachment.
There is a reported incidence of rectus diastasis of 66%
during third trimester [1]. This is induced by the combination of abdominal distension (elevated intra-abdominal pressure) and biomechanical and structural changes of the rectus
muscles and linea alba. These are also induced by hormonal
influences [2, 3].
Women with severe impaired abdominal wall function
often complain about loss of the abdominal muscle strength
and endurance. This can also result in low back pain caused
by overcompensating of the back muscles. Loss of the pelvic
stabilization has also been reported. Aesthetic problems
related to the shape of the abdomen are a problem. Women
look like they are still pregnant.
The diagnosis is based on physical examination. During
the examination, there is a weakness of abdominal wall musculature with prominent diastasis of the rectus abdominis
muscles and panniculus of lower abdomen. Imaging can
confirm the diagnosis. CT scan and ultrasound are both valid
imaging studies to objectify the rectus diastasis.
F. Decuypere, MD • I. Kyle-Leinhase, PhD
F. Muysoms, MD, PhD (
Department of Surgery, Maria Middelares, Ghent, Belgium
e-mail: filip.muysoms@gmail.com
R. Vertriest, MD
Department of Plastic Surgery, Maria Middelares, Ghent, Belgium
*)
We propose our one-step multidisciplinary surgical
approach to treat PPAWI. During this surgery, the panniculectomy to address the excess of skin is done by a plastic surgeon. The mesh augmentation of the abdominal wall to treat
the rectus diastasis is done by the abdominal wall surgeon.
Indications
Surgery is advised when the impaired abdominal wall function is symptomatic and/or the women have aesthetic problems. We propose a mesh augmentation when the maximum
inter-recti distance (IRD) is more than 4 cm in width measured by ultrasound or if there is a concomitant umbilical or
epigastric hernia. PPAWI patients with an IRD less than
4 cm and no concomitant hernia are treated with panniculectomy and reeving of the diastasis by the plastic surgeons
without mesh augmentation.
Preoperative Considerations
Physical exercise can diminish the excess of skin and panniculus but will never be sufficient to treat the postpartum
rectus diastasis. We perform an ultrasound preoperative to
measure the IRD and detect umbilical or epigastric hernia.
The women should have a clear statement that they have no
intention for a subsequent pregnancy. Smoking cessation
should be advised to smokers.
Patient Positioning and Theater Setup
Preoperatively the plastic surgeon makes his drawings on the
standing patient. The midline and the incision for the horizontal abdominoplasty are marked (Fig. 32.1). When liposuction is indicated, the zones are also denoted.
The patient is brought under general anesthesia. A nasogastric tube and a bladder catheter are placed. Antibiotic pro-
© 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_32
431
432
Fig. 32.1 Preoperative markings by the plastic surgeon (AZ Maria
Middelares, Ghent, Belgium)
phylaxis with cefazolin is given. The patient is positioned in
dorsal decubitus with the arms in 90° abduction. The patient
should be positioned on an operating table which can be set
in beach chair position. Disinfection and sterile covering of
the abdomen are done. This operation will usually take
around 180 min. During the surgery, a normal systolic blood
pressure is maintained.
F. Decuypere et al.
Operative Steps
After the horizontal abdominoplasty, the abdominal wall surgeon starts with the mesh augmentation:
1. Make two separate incisions in the linea alba with coagu-
lation: one beneath the navel (±3 cm beneath) and one
above the navel (±3 cm above). This while preserving the
vascularization of the navel at maximum (Fig. 32.3).
2. Connect both retro-muscular dissections under in situ
umbilicus by making a tunnel (Fig. 32.4).
3. Free the posterior fascia by dissection. Approximate the
posterior fascia using a Kocher. Close the posterior layer
using running suture with a slowly absorbable suture
(Monomax 2.0) using a small bites technique (Fig. 32.5).
4. Mark the middle of the mesh (Parietex Progrip® self-
fixating mesh (10 × 30 cm)). Fold the edges of the mesh
to the center of the mesh. Place the mesh retro-muscular
with the hooks orientated upward. Unfold the mesh.
Medialization of rectus muscles on top of self-fixating
hooks (Fig. 32.6).
5. Close the anterior fascia using a running slowly absorb-
able suture (Monomax 2.0) (Fig. 32.7).
6. Tighten the abdominal wall by reefing rectus fascia with
nonabsorbable multifilament figure of eight sutures
(Mersuture 1.0) (Fig. 32.8).
Incision and Access
The plastic surgeon starts with a navel sparing horizontal
high-tension abdominoplasty following the previous markings. An incision with a 24 blade is made from hip to hip
just above the pubic area. Another incision is made vertically on the midline to free the navel from the surrounding
skin using a circular incision around the navel. For this circular incision, skin hooks are used to stretch the skin of the
navel. The abdominal skin is detached from the abdominal
wall using coagulation. Detachment of the skin and subcutis
is done up to the xiphoid bone, in order to sufficiently mobilize the skin downward. In this way, a narrow tunnel is made
from the navel to the xiphoid bone. This leaves most of the
abdominal skin tethered to the muscle and its blood supply
(with the perforating arteries). In order to estimate the
amount of tissue to be resected, a Lockwood abdominal
demarcator is used. Removal of excess skin and subcutis is
done with a 24 bladed knife and meticulous control of
hemostasis (Fig. 32.2a and b).
The abdominoplasty can also be done with sparing of the
perforators in order to prevent flap ischemia. This is done by
a discontinuous dissection of the skin and subcutis.
Closure
Liposuction can be used to refine the transition zones of the
abdominal sculpture. The closure is done in beach chair position. The skin is stretched out to the primary incision place.
A circular incision is made on the skin in order to reinsert the
navel (fixation of the navel using Vicryl 3.0).
Close the subcutis with separate sutures Vicryl 3.0. Two
subcutaneous drains are placed and fixated with Ethilon.
Control of hemostasis. Closure of the dermis with separate
sutures Monocryl 3.0. Closure intradermal of the skin with
running sutures Monocryl 4.0 with loops. Application of
skin glue (Dermabond). Dressings. An elastic abdominal
binder is put immediately after surgery.
Postoperative Management
The gastric tube can be removed immediately after the
operation. The patient stays in beach chair position postoperative during the length of the hospital stay. The bladder catheter can be removed the next day. The two
32 Postpartum Divarication Navel-Sparing Treatment by Multidisciplinary Approach
433
Fig. 32.2 (a) Abdominoplasty
performed by the plastic
surgeon (AZ Maria Middelares,
Ghent, Belgium). (b)
Lockwood abdominal
demarcator
Fig. 32.3 Incision in the
linea alba by the abdominal
surgeon (AZ Maria
Middelares, Ghent, Belgium)
ab
Fig. 32.4 Connecting retro-muscular dissection by the abdominal surgeon (AZ Maria Middelares, Ghent, Belgium)
subcutaneous drains can be removed the next day if the
output is less than 30 cc. Most patients stay 2 days in the
hospital for adequate analgesia. All women should wear an
elastic medical abdominal binder for a minimum of
3 weeks. Postoperative dry and aseptic wound care with
removal of the sutures (the loops of the Monocryl 4.0)
after 10 days. Pain management with paracetamol, 1 g
with a maximum of four times a day. Thrombosis prophylaxis with low molecular weight heparin for 10 days. Most
patients are able to return to work in 3 weeks (if the work
is not too physically strenuous). A surgery follow-up
should be done after 6 weeks. Another is done after
6 months and at 1 year.
Tips and Pitfalls
• Use a self-fixating mesh.
• If there is a concomitant hernia (epigastric or umbili-
cal), they will be treated by the mesh augmentation
as well.
• When you free the navel during the abdominoplasty, mark
the cranial side of the navel; in that way, the rotation of
the navel can be easily preserved.
• When folding the self-fixating mesh, make sure to not
fold it too tight in order to easily unfold it
retro-muscular.
434
Fig. 32.5 Closure of the posterior fascia by the abdominal surgeon (AZ Maria Middelares, Ghent, Belgium)
F. Decuypere et al.
Fig. 32.6 Positioning of the Parietex Progrip self-fixating mesh by the abdominal surgeon (AZ Maria Middelares, Ghent, Belgium)
Fig. 32.7 Closure of the anterior fascia by the abdominal surgeon (AZ
Maria Middelares, Ghent, Belgium)
Fig. 32.8 Reefing of the
abdominal wall by the plastic
surgeon (AZ Maria
Middelares, Ghent, Belgium)
32 Postpartum Divarication Navel-Sparing Treatment by Multidisciplinary Approach
435
References
1. Boissonnault JS, Blaschak MJ. Incidence of diastasis
recti abdominis during the childbearing year. Phys Ther.
1988;68(7):1082–6.
2. Barbosa S, De Sa RA, Coca Velarde LG. Diastasis of rectus
abdominis in the immediate puerperium: correlation between
imaging diagnosis and clinical examination. Arch Gynecol Obstet.
2013;228(2):299–303.
3. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba
and rectus sheaths. J Surg Res. 2001;96(2):239–45.