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and an organised tertiary assessment is undertaken to exclude
missed injuries.
47.3.3.1 Correction ofHypothermia
The rewarming of the patient should start at the torso rather
than the extremities to avoid worsening of the acidosis and
hypotension from peripheral vasodilation. Rewarming can
be achieved with:
– Passive external warming by increasing the room tem-
perature and warming blankets
– Active external warming with warm air devices
– Active internal warming with warm uids administered
intravenously or washing out of cavities (chest, bladder, etc.)
47.3.3.2 Correction ofAcidosis
Correcting the acidosis is achieved by reversing the initial
pathology and improving oxygen delivery and consumption by tissues. This is achieved by maintaining adequate
blood pressure, weaning of inotropes, maintaining adequate haemoglobin and optimising oxygen delivery.
Lactate and base excess are used to monitor the response
to the resuscitation. As the peripheral tissues are reperfused, there is an initial increase in serum lactate, as the
lactate collected in the peripheral tissues which would
have been functioning on anaerobic metabolism enters the
circulation. The rate of clearance of lactate correlates with
mortality of the patient and might indicate ongoing bleeding, overwhelming trauma or dead tissue. There is no evidence to support the use of bicarbonate to reverse the
acidosis as it might worsen intracellular acidosis and
increase the sodium load leading to increased tissue
oedema and loss of a monitoring tool to judge your
patient’s response to your resuscitation.
47.3.3.3 Coagulopathy
Addressing the coagulopathy starts in the resuscitation area
and in theatre by adhering to haemorrhagic resuscitation
with early component resuscitation and avoiding clear uids.
As with component resuscitation, a 1:1:1 ratio of packed red
blood cells/fresh frozen plasma/platelets is recommended.
Part of the correction of the coagulopathy can be achieved by
reversing the coagulopathy and acidosis as both affect the
clotting cascades. By reversing both, the function of the
platelets and clotting factors will improve.
Currently, the use of thromboelastography (TEG) or
rotary thromboelastography (RoTEM) is recommended, to
guide specic goal-directed therapy in the coagulopathic
patient.
The toughest part of reversing the coagulopathy in ICU is
to differentiate between coagulopathy and a mechanical
bleed. If it is a mechanical bleed, the coagulopathy and physiology would just deteriorate despite optimal attempts to
resuscitate the patient, while unnecessary relook laparotomies would worsen the physiological insult. In order to facilitate continued resuscitation in ICU, adequate information
regarding the injuries is sustained, current and planned further surgical management and further resuscitation measures
are required and the overall further management plan of the
patient is critical. The critical care team should aim to reverse
any abnormal physiology including the parameters of the
“lethal triad”, as soon as possible to allow denitive
surgery.
Patients with damage control surgery are also prone to
develop abdominal compartment syndrome even despite
having an open abdomen, and the ICU staff should monitor
the patient with physiological parameters and intravesical
pressures.
47.3.4 Stage 4: Denitive Surgery
Ideally, the patient should be taken back to theatre as soon as
the endpoints of resuscitation are achieved or within the rst
24–48h. By endpoints of resuscitation, we mean:
– Reverse of acidosis, coagulopathy and hypothermia
– Mixed venous saturation>70%
– On optimal dose of inotropes that would allow safe bowel
anastomosis.
Denitive surgery implies restoration of anatomy, removal
of all packs and exclusion of possible missed injuries. If
there is still bleeding after removal of packs, repacking might
be indicated.
Restoring anatomy includes bowel anastomosis; creation
of stomas, depending on the physiological status of the
patient and nature of the injury; and denitive vascular repair.
47.3.5 Stage 5: Denitive Closure
oftheAbdomen
The decision to close the abdomen and the nature of closure
will depend on:
– Timing since initial surgery:
The longer the delay since the initial surgery, the more
the anterior abdominal wall retracts and at a stage the
sheath can’t be approximated without extreme tension,
which will lead to abdominal compartment syndrome and
probably a burst abdomen. Ideally, the abdominal wall
should be closed on completion of the initial relook procedure or at the latest after a second relook within 5days.
Another factor that limits the possibly of denitive closure of the abdomen is the development of intra- abdominal
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R. Pretorius et al.
a
b
c
Fig. 47.10 (a) Application of split skin graft on “granulated abdomen”. (b) The resulting incisional hernia. (c) The outcome after component
separation
oedema. As part of the resuscitation, over-administration
of uids in association with the leaky capillaries causes
the bowel to become oedematous, again predisposing
abdominal compartment syndrome, if the abdomen is primarily closed. Improved resuscitation strategies, using
blood and blood products early to replace lost blood and
avoiding crystalloids as well as colloids, have resulted in
higher abdominal closure rates.
In delayed presentation with severe contamination,
early closure is not possible due to intra-abdominal collections, and multiple relooks might be indicated to wash
out the abdomen.
the pressures during closure can indicate whether primary
closure is appropriate. Patients should be monitored postoperatively for possible development of abdominal compartment syndrome.
– Closure by mesh:
If the patient’s sheath cannot be approximated for primary closure, a mesh can be used. We prefer the use of
absorbable mesh due to the risk of infection and stula
formation. When granulation tissue develops over the
mesh, this can be covered with a split skin graft. The
resulting ventral hernia will be repaired at a later stage,
usually after 4–6 months, when the presence of the
“pinch sign” shows that the skin graft can be separated
Closure of the abdomen could be managed as:
easily from the underlying viscera. Complete mobilisation of the viscera from the abdominal wall, as well as
– Initial primary closure:
This can be achieved if the abdominal domain and
patient’s physiology allow comfortable approximation of
the application of release incisions, can well result in
approximation of the sheath without tension. If this is
not possible, closure of the abdomen can be successful
the sheath. In volume control, ventilation monitoring of
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by proceeding to an anterior or posterior component
separation with or without a permanent mesh
(Fig.47.10a–c).
47.4 Conclusion
Damage control surgery has been proven to improve mortality but can be associated with signicant morbidity and longer hospital stay. Therefore, an effort should be made to
select the patients, in whom damage control surgery is the
only option for survival.
Important Points
• The lethal triad consists of hypothermia, acidosis and
coagulopathy, and the purpose of damage control surgery
is to break their vicious cycle. Hypocalcaemia may
become the fourth factor changing the well known lethal
triad to the diamond of death.
• All penetrating trauma patients, irrespective of the severity, must undergo hypotensive and haemostatic
resuscitation.
• Early identication of patients with ongoing haemorrhage
and the need for blood transfusion is essential so that the
massive transfusion protocol can be activated.
• Patient selection for damage control surgery is based on
physiological and anatomical parameters.
• At initial operation, the aim is operative control of haemorrhage and contamination, with the least negative physiological impact.
Suggested Reading
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penetrating trauma: a randomized, controlled trial. World J Surg.
2006;30(6):1074–80.
Cotton BA, Reddy NBS, Hatch QM.Damage control resuscitation is
associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomies. Ann Surg.
2011;254(4):598–605.
Guidry C, Gleeson E, Simms E. Initial assessment on the impact of
crystalloids versus colloids during damage control resuscitation. J
Surg Res. 2013;185:294–9.
Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, Ziemba M, Lati
R, Kulvatunyou N, Rhee P.Damage control laparotomy: a vital tool
once overused. J Trauma. 2010;69:53–9.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, et al. Transfusion of
plasma, platelets, and red blood cells in a 1:1:1 vs. a 1:1:2 ratio
and mortality in patients with severe trauma. PROPPR Random Clin
Trail. JAMA. 2015;313(5):471–82.
Kaafarani HMA, Velmahos GC. Damage control resuscitation in
trauma. Scand J Surg. 2014;103(2):81–8.
Kashuk JL, Moore EE, Millikan JS, Moore JB. The bloody vicious
cycle. J Trauma. 1982;22:672–9.
Martinelli T, Thony F, Declety P.Intra-aortic balloon occlusion to sal-
vage patients with life-threatening hemorrhagic shock from pelvic
fractures. J Trauma. 2010;68:942–8.
Mayberry J, Fabricant L, Anton A.Management of full-thickness duode-
nal laceration in the damage control era: evolution to primary repair
without diversion or decompression. Am Surg. 2011;77:681–5.
Morrison CA, Carrick MM, Norman MA, etal. Hypotensive resusci-
tation strategy reduce transfusion requirements and severe postoperative coagulopathy in trauma patients with haemorrhagic shock:
preliminary results of a randomized controlled trial. J Trauma.
2011;70(3):652–63.
Wang P, Wei X, etal. Inuences of intestinal ligation on bacterial trans-
location and inammatory responses in rats with haemorrhagic
shock: implications for damage control surgery. J Investig Surg.
2008;21(5):244.
White CE, Hsu JR, Holocomb JB.Haemodynamically unstable pelvic
fracture. Injury. 2008;40:1023–30.
Yilmax TH, Degiannis E, Doll D.Temporary treatment of uncontrolled
intrathoracic haemorrhaging with abdominal towels in combination
with a rescue procedure. Damage control procedure of the chest.
Unfallchirurg. 2012;115(1):71–4.
Abrams ST, Zhang N, Manson J.Circulating histones are mediators
of trauma-associated lung injury. Am J Respir Crit Care Med.
2013;187(2):160–9.
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Abdominal Wall Reconstruction
andComplex Hernia Repair
RifatLati
48
Reconstruction of complex abdominal wall defects and recreating functional abdominal walls following damage control surgery (DCS) that may result in loss of domain or major
abdominal wall defects represent a major challenge, often
requiring surgical creativity and a strategy that involves different aspects of care along the various stages of treatment.
Damage control concepts and techniques have been part of
our clinical armamentarium in trauma for decades, but
recently DCS has expanded to other surgical disciplines:
emergency general surgery; neurosurgery (craniectomies);
orthopedics surgery, particularly for trauma; thoracic surgery; vascular surgery; liver transplant surgery; and other
surgical elds. DCS is characterized by the termination of
the surgical intervention after control of bleeding and contamination, followed by hemostatic resuscitation and denitive management. It is a staged approach that takes into
consideration the physiologic reserves of the patient, and it is
designed to avoid or treat the lethal triad of hypothermia,
acidosis, and coagulopathy. The decision to perform DCS is
complex and requires solid knowledge of the physiology of
the patient as well as the associated injuries or comorbid disease. Moreover, it takes a complete situational awareness of
the patient, his/her physiology, all end-point resuscitation,
and surgical team dynamics and skills.
Most of us agree that hemodynamic instability, hypother-
mia (<35°C), coagulopathy, severe metabolic acidosis (pH
<7.2 or base decit >8), multiple injuries, massive transfusion requirements (>10 units packed red blood cells), and
long operative time (>90min) for trauma or emergency are a
basic indication for abbreviating the procedure and some sort
of temporal abdominal closure. However, often the decision
for DCS is a personal decision of the operating surgeon, and
not necessary one has to have all the above criteria to decide
DCS.
48.1 Temporary Closure Techniques
While there have been a number of descriptions of temporal
abdominal closure (TAC), often suggesting expensive wound
vacuum-assisted closures (VACs), for the initial TAC, I use
the so-called “poor man’s VAC” (Figs.48.1, 48.2, 48.3, and
48.4). If you expect to bring the patient back to the operating
room within 12–24 h, do not use expensive VAC. Instead,
you can cover the intestines with and sterile intestinal bag.
You need to make a number of cuts on the bag to allow uid
R. Lati (*)
Department of Surgery, Westchester Medical Center, New York
Medical College, Valhalla, NY, USA
e-mail: Rifat.Lati@wmchealth.org Fig. 48.1 Intestines are covered with a sterile plastic bag
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_48
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Fig. 48.2 Cuts are made on the plastic bag to allow better drainage of
uid
R. Lati
Fig. 48.4 Finally the gauze and the drains are covered with sticky
plastic
Fig. 48.3 A moist Kerlix gauze is placed over the plastic bag, and two
drains are placed between the gauzes
egression through the bag. Use two Kerlix gauzes to cover
the intestinal bag and put two or three drains (usually JP #
10) between the gauzes and exit them superiorly so that they
are easily connected to wall suction. Cover the gauze with
sterile adhesive material and place the drains to active wall
suctioning.
Once the patient is resuscitated, he or she should be taken
back to the operating room for denitive treatment and closure. Continue to attempt to perform a denitive closure at
the rst take back, the second take back, or even on the third
or fourth take back. Sequential closure of the fascia should
be attempted as well when unable to close at once. Starting
at the most inferior and superior portion of the midline will
make the closing process less difcult. If nothing else, you
will reduce the defect and make it easier to eventually close
it completely. On occasion, the intestines are so swollen, or
there is a continuation of intra-abdominal pathology that you
are unable to close the fascia at all. In such cases, you can use
a temporary Vicryl mesh over the omentum or often directly
over the intestines. If you have the ability to close the skin
and subcutaneous tissue over the fascial defect, without
major tension, this will be the preferred method, knowing
that there will be a major hernia that you will deal with at a
later time. Once you have committed to open abdomen management, it is very reasonable to use the wound
VAC.Depending on the infectious status of the wound, the
VAC can be changed every 2–3days. In these situations, I
prefer to use irrigation. In many patients, you may need to
eventually cover the defect with a skin graft.
On occasions, you may be able to close fascia primarily
by performing adjunct procedures such as lateral compartment release. This is a potentially risky procedure at this
stage, as it may be complicated with skin and subcutaneous
necrosis and you “burn the bridge” for future reconstructions. For this reason, I rarely perform lateral compartment
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release in the early stages of the management of the open
abdomen. While there is always an option of using biologic
mesh at this stage as a bridge, this should be your last resort
of action.
48.2 General Principles ofManagement
ofPost-DCS Consequences
Post-DCS consequences can be challenging but should be
understood by each surgeon who embarks on it. As described
in the previous section, the process of closing the abdomen
should start when the DCS is performed. There are several
questions that need to be answered in this process, but the
main ones are as follows: how to redene the anatomy and
new “physiology,” when should we perform the denitive
surgery, how to plan and execute the operation and the intraoperative decisions, how to predict/prevent and how to deal
with postoperative complications, how to ensure full recovery of the patient to normal functional status, and nally how
long we need to follow up the patients?
While it is clear that there are many ways to manage these
patients, the basic principles are the same, but the specic
approaches to these complex patients depend on the concurrent presence of enterocutaneous stulas (ECF) and/or
enteroatmospheric stulas (EAF), obesity, stomas, malnutrition, infection, and sepsis, as well as the overall physiology
of the patient.
All these factors will dictate your surgical approach.
However, whatever surgical approach you use and whenever
you attempt to close the abdomen, the management of these
patients should be done in a stepwise fashion. Each phase
should be well planned and understood by the surgeon and
surgical team, including the nursing and anesthesia team.
Oftentimes these patients are operated on in the same hospital, so nursing and other services know these patients well;
thus it is important to keep them in the loop.
While there is always room for exibility in surgical
approach for individual surgeons, disciplined protocols and a
well-planned surgical strategy, particularly in patients with
large abdominal wall defects complicated by stulas or stomas, make the operative management process easier and may
improve postoperative outcomes. Such a strategy has been
described in a six-step strategy for the management of enterocutaneous stulas, known as “SOWATS” (S=sepsis control,
O = nutrition optimization, W = wound care, T = timing,
A = anatomy, and S = surgery). We have expanded this
approach to a nine-step strategy and call it “ISOWATS PL”
where I=identication and diagnosis of the postoperative stula, S=sepsis and source control, O=optimization of nutrition, W=providing and ensuring wound care, A=redening
the anatomy and understanding the pathology at hand,
T=timing of denitive surgery and/or takedown of stulas,
S=denitive surgery and surgical creativity, P=postoperative care, and L=long-term follow-up. Adhering to all nine
steps of the “ISOWATS PL” may be difcult at times as certain patients often require emergency surgery and you do not
have the luxury to plan the entire process, but all attempts
should be made as the process of re-operations are planned,
structured, and executed carefully.
48.3 Redening theAnatomy andNew
Physiology
Most patients undergo some form of radiologic study, CT
scan being most predominant. In our recent study of 176
patients, the most common preoperative investigation performed was a computed tomography (CT) scan, followed by
an MRI (Unpublished study performed at the University of
Arizona by the author). Although nearly 15% of the patient
population in our above-mentioned study, presented with
coexisting stula, a stulogram was rarely performed.
Barium studies and/or upper GI with small bowel followthrough has been mostly substituted with CT scan, although
barium study has its relevance, particularly in colonic stulas, stomas, or when there is suspicion for other pathology of
the colon.
48.4 Timing toDenitive Repair
We have previously described that the decision if and when
to re-operate on patients with complex abdominal wall
defects should be individualized and represents one of the
most important steps in the surgical management of these
patients. We base this decision on many factors particularly
on the comorbid diseases and on the anatomy of the surgical
problem. In addition to considering the clinical status and
physiology of the patient, one has to remember that these
large defects can be functionally devastating and lead to further weight gain and more problems and potentially may
lead to major morbidity. Patients with serious comorbid diseases such as extreme obesity, severe heart disease, highgrade liver cirrhosis, or lung disease (dependent upon oxygen
therapy at home), unless they have symptoms of gastrointestinal obstructions, should be carefully evaluated before the
decision of whether to operate is made.
I believe that at times, the strategy for these patients
should be “more is better,” and often the denitive surgery is
the only choice in the management. The denitive surgery
should be performed earlier rather than later, assuming that
the patient is not prohibitively at high risk for major
complications.
While timing when to repair large abdominal wall hernias
is less debatable, timing of taking down stulas is more con-
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R. Lati
tentious. Delaying surgery anywhere from 12 to 36months
to improve the outcomes in patients with ECF has been suggested, although prolonging surgery for longer than 1year
following ECF diagnosis doubles the risk of postoperative
restulization. Waiting longer than 36 weeks increases the
reported risk for stula recurrence to 36%, compared to 12%
if the operation is performed prior to 36weeks. There are
data or clinical predictive models to guide such decisions,
and thus the individual patient’s condition is the main factor
that should be used as a guide.
In our experience, the optimal time for abdominal wall
reconstruction is 6–12months after the rst procedure (when
adhesions are less prominent), but this is at best an estimation. The presence of the so-called pinch sign (i.e., easy
retraction of the skin or skin graft over the defect) is a good
indicator that the adhesions are subsiding and that it is appropriate to schedule the abdominal reconstruction.
48.5 Operative Approach
The decision to operate is made jointly by the patient and the
surgeon; a denitive reconstruction technique is the next
challenge to be faced. Most patients who have previously
undergone large abdominal surgeries have a midline abdominal incision, so their lateral abdominal wall is usually free of
scars and defects, thereby providing a well-vascularized soft
tissue donor site unless the patient has had lateral incision(s)
or stoma(s). Unless the patient has a giant hernia with loss of
abdominal domain, the abdominal wall can be anatomically
restored with minimal tension and without compromising the
integrity of the abdominal muscles, vessels, and nerves. The
goals of the operation are to establish gastrointestinal (GI)
tract continuity; obtain full closure of the abdominal wall;
avoid the postoperative abdominal compartment syndrome;
minimize recurrence of stulas, hernias, and wound infections; and strive to restore the patient’s functionality. In
patients with a frozen abdomen or when a split-thickness skin
graft (STSG) exists, dealing with adhesions, resecting stulas, and performing the anastomosis requires experience, and
even entering the abdomen may prove challenging.
48.6 Denitive Abdominal Wall
Reconstruction
Creating a new abdominal wall may represent a serious surgical challenge, and both the surgeon and the patient should
be prepared for a lengthy procedure (i.e., entering the abdomen, taking down the adhesions, resecting the stulas, and
performing the anastomosis). Some authors have suggested
that reconstruction should be performed by another team,
such as plastic surgeons. On occasion, I have used the principle of “damage control on demand” by abbreviating the
operation and returning the next day or so to completely
inspect the previous work such as anastomosis again, and
ensuring that there are no missed enterotomies before performing the nal closure.
48.6.1 Use ofNative Tissue
You should strive to use native tissue to repair major defects
if this does not create undue tension. If that is not possible,
you should use a synthetic or biological prosthesis. In most
patients, some sort of combination of reconstruction techniques will be needed, that is, reducing the defect by transposing native tissue toward midline and the reinforcing it
with a prosthesis. If the midline tissue cannot be easily
approximated or if mesh reinforcement is needed (as it is in
almost all abdominal wall defects larger than 6 cm), then
other techniques must be considered. For example, if midline
tissue cannot be easily approximated, then bilateral lateral
component release should be done and a neo-abdominal wall
reestablished. Tissue transposition of myocutaneous aps
through lateral component separation is the procedure of
choice in my practice.
48.6.2 Other Adjunct Procedures
Other methods can be used to reconstruct the complex
abdominal wall defects such as local advancement or regional
aps, distant aps, or combined ap and mesh; however,
which technique is used will depend on the pathology at
hand and your expertise. In Type I defects with stable skin
coverage, bridging the fascial gap with prosthetic material or
autologous tissue is sufcient, whereas in Type II defects
with absent or unstable skin coverage, fascial repair alone is
inadequate, and the repair must be done with tissue utilizing
more complex reconstruction techniques (e.g., regional or
distant aps, either alone or in combination with mesh).
Vascularized aps provide healthy autologous tissue coverage and usually do not require any implantation of foreign
material at the closure site. Small and midsize defects can be
repaired with pedicle aps within the arch of the rotation of
the ap. In extensive upper midline abdominal wall and thoracoabdominal defects, a free ap that offers a completely
autologous, single-stage reconstructive solution is the best
option available.
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48.6.3 The Component Separation Technique
Component separation results in medial advancement of
intact rectus myofascial units bilaterally, enabling the closure
of defects of up to 10cm in the upper abdomen, 20cm in the
mid-abdomen, and 6–8cm in the lower abdomen. The component separation technique is based on an enlargement of
the abdominal wall surface by separating and advancing the
muscular layers. Some form of component separation, alone
or in combination with other adjunct procedures, has become
common practice. During the component separation technique (CST) for abdominal wall reconstruction, you should
dissect out and develop anterior abdominal skin aps laterally from the chest wall to the anterior superior spine. After
that, you need to divide the aponeurosis of the external
oblique muscle longitudinally 2 cm laterally to the lateral
edge of the rectus sheath, which will allow the mobilized
rectus myofascial component to be mobilized medially and
facilitate the approximation of the midline with sutures
(Figs. 48.5, 48.6, 48.7, and 48.8). Every effort should be
405
Fig. 48.5 Following anterior component separation, try to approximate the edges of the fascia
Fig. 48.6 Secured underlay mesh needs to be tight when all sutures are
placed under some tension and pulled laterally
made to preserve the skin perforators as you dissect and create the mucocutaneous aps. This will greatly reduce skin
and subcutaneous necrosis.
There are various modications to the component separation procedures. Some authors perform this procedure using
minimally invasive surgical techniques, but the rates of
recurrence of hernia are similar.
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Fig. 48.7 Completed closure of the abdominal defect after underlay
mesh placement and bilateral component release
Fig. 48.8 Drains are placed under the skin and subcutaneous tissue to
reduce seromas
R. Lati
48.7 Posterior Component Separation
withTransversus Abdominis Release
(TAR)
The retrorectus repair for large midline hernias has become a
technique of choice for many of us for many reasons, but
reduction of complication is the main one. Although many
surgeons are familiar with anterior component separation
(ACS), in recent years posterior component separation (PCS)
with transversus abdominis release (TAR) has become popular. Detailed technical aspects of this procedure paying particular attention to the surgical anatomy have been recently
outlined.
The main principle of PCS is that the perforating vessels
are spared and the mesh is placed between the rectus muscle
anteriorly and posterior rectus fascia/peritoneum/preperitoneum posteriorly. Once you have dealt with all adhesions
and other concomitant procedures, such as reconstitution of
GI tract or other procedures, the posterior approach to the
retrorectus space is performed by incising the medial edge of
the posterior rectus sheath at the medial edge of the rectus
abdominis muscle. The edge of the transected posterior rectus sheath is grasped with clamps and retracted medially and
posteriorly, allowing easy lateral dissection of the retrorectus
space. During this stage of the operation, one has to be cognizant not to injure intercostal nerves that perforate rectus
muscle. 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.
You should start this segment of the dissection as cranially as you can. At the point of transition of posterior lamina
of the internal oblique fascia, you will be able to see the
medial aspect of the transversus abdominis 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,
but if you do, make sure to identify and close with absorbable suture. Transection of TAM can be done in a number of
ways, but I agree with these authors that the transection of
the TAM should start as far cranially as possible where these
muscle bers are prominent and progressing caudally aids
markedly this part of the component separation. This extraperitoneal space now can be extended laterally and caudally
in order to make space for the prosthesis. This dissection is
facilitated greatly with sweeping move of your hand. I prefer
that this space extend to the costal margin and join the central tendon of the diaphragm in the midline. Once the space
is created to your satisfaction, the posterior rectus sheaths are
approximated with running absorbable suture. Fixation of
the mesh superiorly, inferiorly, and laterally with sutures will
help you position the mesh appropriately. A number of techniques can be used to place the rest of the sutures. I prefer to
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use a Carter-Thomason suture passer, but other suture passers are just as good for xing the mesh to the anterior abdominal wall.
The benets of PCS with TAR have been demonstrated
with the superiority when compared with ACS by a 50%
decrease in wound morbidity with the posterior approach.
Most large series report signicantly lower morbidity with
the PCS approach. Moreover, this technique has been suggested for a patient who previously had ACS but has a recurrence of the hernia.
48.7.1 Mesh Placement
Most authors recommend reinforcement of repair of the
defect with synthetic or biologic mesh, even with lateral
component release. The question of whether the mesh should
be biologic or synthetic mesh depends mostly on its availability and patient’s infectious status and should be given
special consideration. I use one of the three mesh placement
techniques: onlay, underlay, and interposition or bridge
placement, depending on the anatomy at hand (Figs. 48.6,
48.9, 48.10, and 48.11). However, for the most part, I have
switched entirely to underlay. In all patients who have had
major abdominal wound contamination in the past or have
concurrent infections at the time of reconstruction, I prefer
using the biologic mesh. Each of these techniques has its
own pros and cons and should be used based on one’s surgical expertise and patient selection.
Fig. 48.10 Underlay placement during complex abdominal wall
reconstruction
407
48.7.1.1 Onlay Mesh Placement
From a surgical technique standpoint, onlay mesh placement
is the easiest (Fig.48.9). When the abdominal wall edges are
already approximated and there is no contamination, I would
use synthetic mesh, although there is a concern for a higher
risk of seroma formation with onlay mesh placement. There
is always a risk of wound infection as well, and one needs to
remove the mesh if it gets infected. Most surgeons would use
Fig. 48.9 Overlay mesh placement illustration. (Reproduced with permission by LifeCell Corporation)
Fig. 48.11 On rare occasions, a bridge technique needs to be used to
create a new abdominal wall. An illustration of a patient with major
abdominal wall domain loss
synthetic mesh if possible due to the higher cost of biologic
mesh. You need to make sure that there is complete hemostasis before you place the mesh. Fix the mesh both laterally
and over the edge of the midline on both sides of the ridge.
You can x the mesh to the fascia using absorbable sutures
(Vicryl 2.0 or 3.0) in a continuous “tacking” style. Sutures do
not need to be placed deep into the abdominal wall, but simply to x the mesh in place and reduce the space between the
mesh and tissue. Use three or four large, closed suction
drains (19 French) under the subcutaneous tissue and keep
the drains in until the individual drain output is less than
25 mL over 24h. Fix the drain using 4.0 or 5.0 chromic
sutures so they stay in place and do not move around the
subcutaneous tissue.
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