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Atlas of
KWWSERRNVPHGLFRVRUJ
Abdominal Wall
Reconstruction
Michael J. Rosen, MD, FACS
Associate Professor of Surgery
Chief, Division of GI and General Surgery
Case Western Reserve University
Case Medical Center
Cleveland, Ohio, USA
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF ABDOMINAL WALL RECONSTRUCTION ISBN: 978-1-4377-2751-7
Copyright © 2012 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission
in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notice
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Library of Congress Cataloging-in-Publication Data
Atlas of abdominal wall reconstruction / [edited by] Michael J. Rosen. -- 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-2751-7 (hardcover : alk. paper)
1. Hernia--Surgery--Atlases. 2. Abdominal wall--Surgery--Atlases. I. Rosen, Michael J., MD.
[DNLM: 1. Hernia, Ventral--surgery--Atlases. 2. Abdominal Wall--surgery--Atlases.
3. Laparoscopy--methods--Atlases. WI 17]
RD621.A85 2012
617.5’59059--dc23 2011014084
Acquisitions Editor: Judith Fletcher
Developmental Editor: Roxanne Halpine Ward
Publishing Services Manager: Jeff Patterson
Project Manager: Bill Drone
Design Direction: Steve Stave
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
I would like to dedicate this atlas to my wife Deb, my lovely children Samantha, Alexandra, and
Zachary who have always supported my endeavors as a surgeon, and to all of the surgeons who
have so graciously participated in my training throughout the years.
Contributors
Charles E. Butler, MD
Professor
Department of Plastic Surgery
The University of Texas M.D. Anderson Cancer Center
Houston, Texas, USA
Modified Minimally Invasive Component Separation
Alfredo M. Carbonell, DO, FACS, FACOS
Associate Professor of Clinical Surgery
The Hernia Center and Division of Minimal Access
and Bariatric Surgery
Greenville Hospital System
University Medical Center
University of South Carolina School of Medicine -
Greenville
Greenville, South Carolina, USA
Progressive Preoperative Pneumoperitoneum for Hernias with
Loss of Abdominal Domain
Harvey Chim, MD
Resident
Department of Plastic Surgery
Case Western Reserve University
Cleveland, Ohio, USA
Abdominal Wall Anatomy and Vascular Supply
William S. Cobb IV, MD
Associate Professor of Clinical Surgery
Department of Surgery
University of South Carolina School of Medicine
Director, Division of Minimal Access and Bariatric
Surgery, and Co-Director, The Hernia Center
Department of Surgery
Greenville Hospital System University Medical
Group
Greenville, South Carolina, USA
Laparoscopic Ventral Hernia Repair-Standard
George DeNoto III, MD, FACS
Associate Professor of Surgery
Hofstra North Shore-LIJ School of Medicine
Chief, Division of Minimally Invasive Surgery
North Shore University Hospital at Manhasset
Director
North Shore-LIJ Minimally Invasive Surgery
Fellowship
North Shore Long Island Jewish Health System
Manhasset, New York, USA
Periumbilical Perforator Sparing Components Separation
Karen Kim Evans, MD
Chief of Plastic Surgery
Department of Surgery
Veterans Affairs Medical Center
Assistant Professor
Department of Plastic Surgery
Georgetown University Medical Center
Washington, District of Columbia, USA
Abdominal Wall Anatomy and Vascular Supply
Michael G. Franz, MD
Associate Professor of Surgery
Chief, Division of Minimally Invasive Surgery
Department of Surgery
University of Michigan
Ann Arbor, Michigan, USA
Biologic Mesh Choices for Surgical Repair
Ron Israeli, MD, FACS
Clinical Assistant Professor
Department of Surgery
Division of Plastic Surgery
Hofstra University School of Medicine in partnership
with the North Shore LIJ Health System
Hempstead, New York, USA
Periumbilical Perforator Sparing Components Separation
Arjun Khosla, MD
Postdoctoral Research Fellow
Department of Surgery
Division of Pediatric Surgery
Rainbow Babies and Children’s Hospital
University Hospitals Case Medical Center
Cleveland, Ohio, USA
Managing Pediatric and Neonatal Abdominal Wall Defects
Samir Mardini, MD
Professor of Surgery
Mayo Clinic College of Medicine
Program Director
Division of Plastic Surgery
Department of Surgery
Mayo Clinic
Rochester, Minnesota, USA
Abdominal Wall Anatomy and Vascular Supply
vii
viii Contributors
Daniel A. Medalie, MD
Assistant Professor of Surgery
Case Western Reserve and MetroHealth Medical
Center
Department of Plastic Surgery, MetroHealth Medical
Center
Case Western Reserve Medical School
Assistant Professor of Plastic Surgery
Department of Surgery, MetroHealth Medical Center
Assistant Professor of Plastic Surgery
Department of Surgery
University Hospital
Cleveland, Ohio, USA
Tissue and Fascial Expansion of the Abdominal Wall
Maurice Y. Nahabedian, MD, FACS
Associate Professor of Plastic Surgery
Department of Plastic Surgery
Georgetown University Hospital
Johns Hopkins University
Washington, District of Columbia, USA
Panniculectomy and Abdominal Wall Reconstruction
Yuri W. Novitsky, MD, FACS
Assistant Professor
Department of Surgery
Director, Connecticut Comprehensive Center for
Hernia Repair
University of Connecticut Health Center
Farmington, Connecticut, USA
Open Retromuscular Ventral Hernia Repair; Synthetic Mesh
Choices for Surgical Repair
Sean B. Orenstein, MD
General Surgery Resident
Department of Surgery
University of Connecticut School of Medicine
Farmington, Connecticut, USA
Synthetic Mesh Choices for Surgical Repair
Melissa S. Phillips, MD
Laparoendoscopic Clinical Fellow
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio, USA
Open Flank Hernia Repair
Todd A. Ponsky, MD
Assistant Professor
Department of Surgery
Division of Pediatric Surgery
Rainbow Babies and Children’s Hospital
University Hospitals Case Medical Center
Cleveland, Ohio, USA
Managing Pediatric and Neonatal Abdominal Wall Defects
Benjamin K. Poulose, MD, MPH
Assistant Professor
Division of Surgery
Vanderbilt University School of Medicine
Vanderbilt University Medical Center
Nashville, Tennessee, USA
Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxyphoid,
and Lumbar
Harry L. Reynolds Jr., MD, FACS, FASCRS
Associate Professor of Surgery
Department of Surgery
Division of Colon and Rectal Surgery
Case Western Reserve University
Cleveland, Ohio, USA
Open Repair of Parastomal Hernias
Michael J. Rosen, MD, FACS
Associate Professor of Surgery
Chief, Division of GI and General Surgery
Case Western Reserve University
Case Medical Center
Cleveland, Ohio, USA
Open Flank Hernia Repair; Endoscopic Component Separation
Alan A. Saber, MD, FACS
Associate Professor
Department of Surgery
Case Western Reserve University
Cleveland, Ohio, USA
Laparoscopic Repair of Parastomal Hernias
Christopher J. Salgado, MD
Associate Professor of Surgery
Department of Surgery
University of Miami/Miller School of Medicine
Miami, Florida, USA
Abdominal Wall Anatomy and Vascular Supply
Ronald P. Silverman, MD, FACS
Associate Professor of Surgery
Division of Plastic Surgery
University of Maryland School of Medicine
Adjunct Professor of Plastic Surgery
Department of Plastic Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland, USA
Open Component Separation
Hooman Soltanian, MD, FACS
Assistant Professor
Division Chief, Breast Plastic Surgery
Department of Plastic Surgery
Case Medical Center
Cleveland, Ohio, USA
Rotational and Free Flap Closure of the Abdominal Wall
Contributors ix
Daniel Vargo, MD
Program Director, Surgery
Associate Professor
Department of Surgery
University of Utah School of Medicine
Salt Lake City, Utah, USA
Managing the Open Abdomen
Christopher G. Zochowski, MD
Department of Plastic and Reconstructive Surgery
Case Western Reserve University
Cleveland, Ohio, USA
Rotational and Free Flap Closure of the Abdominal Wall
Introduction
Abdominal wall reconstruction represents a broad spectrum of patients, defect characteristics and surgical options. Several innovative minimally invasive reconstructive
techniques and the exponential growth of bioprosthetics
have revolutionized abdominal wall reconstruction. The
surgical approaches to these problems have evolved from
simply patching the defect to reconstructing functional
dynamic abdominal walls. It is important to point out that
the reconstructive surgeon must individualize his or her
approach to abdominal wall reconstruction. It is likely no
single technique or prosthetic will accomplish the goals
for all repairs. As this field has continued to expand, it
now represents a collaborative effort among general surgeons, plastic surgeons, trauma surgeons, and herniologists. This atlas represents the compilation of these efforts
and, like reconstructive surgery, would not be possible
without each of their respective contributions.
Atlas of Abdominal Wall Reconstruction focuses
The
on many of the technical aspects of ventral hernia repair.
We have paid particular attention to key anatomic planes
in each of these procedures, as well as preserving the
neurovascular anatomy when reconstructing the abdominal wall. Each of these procedures has been described in
detail, with particular attention to avoiding common surgical pitfalls and employing strategies to deal with technical challenges once they are encountered. In addition,
each chapter is accompanied by a representative video
of the reconstructive approach to guide the surgeon in
the technical nuances of the procedure. In this textbook,
three approaches are de scribed: laparoscopic, open, and
hybrid. This atlas will provide the surgeon with the skills
necessary to repair not only straightforward defects but
also some of the most complex reconstructive challenges,
including loss of domain, contaminated ventral hernia
repair, and dealing with reconstruction in the setting of
major tissue loss.
While there are often many ways to repair an abdominal wall defect, this atlas describes a multitude of safe and
effective strategies to deal with these challenging problems across the entire spectrum of ventral hernia repair as
described by experts in the field. In addition, a clear and
clinically relevant summary of the available synthetic and
biologic grafts will aid the surgeon in appropriate prosthetic selection. I hope that this atlas provides the practicing surgeon with a useful guide to optimize outcomes for
their patients.
xi
1. Clinical Anatomy
C HAPT E R
1
Abdominal Wall Anatomy
and Vascular Supply
Harvey Chim, MD, Karen Kim Evans, MD, Christopher J. Salgado, MD,
and Samir Mardini, MD
1. Overview
s
s
2. Superficial Fascial Layers (see Figs. 1-1 and 1-2)
s
s
s
s
The anterior abdominal wall (Figs. 1-1 to 1-3) is a hexagonal area defined superiorly by the
costal margin and xiphoid process; laterally by the midaxillary line; and inferiorly by the
symphysis pubis, pubic tubercle, inguinal ligament, anterior superior iliac spine, and iliac
crest.
Layers of the anterior abdominal wall include skin, subcutaneous tissue, superficial fascia,
deep fascia, muscle, extraperitoneal fascia, and peritoneum.
The superficial fascia of the abdominal wall consists of a single layer above the umbilicus,
consisting of the fused Camper and Scarpa fasciae.
Below the umbilicus the superficial fascia consists of a fatty outer layer (Camper fascia) and
a membranous inner layer (Scarpa fascia).
Camper fascia is continuous inferiorly with the superficial thigh fascia and extends inferi-
orly to the scrotum in males and labia majora in females.
Scarpa fascia fuses inferiorly with the fascia lata of the thigh and continues posteriorly to
the perineum, where it is called Colles fascia.
2
Chapter 1 • Abdominal Wall Anatomy and Vascular Supply 3
Xiphoid process
Costal margin
Parietal
peritoneum
Extraperitoneal
(subserosa) fascia
Transversalis fascia
Transversus
abdominis muscle
Posterior rectus sheath
(above arcuate line)
• Transversalis fascia
• Internal oblique fascia
Internal oblique muscle
External oblique muscle
Anterior rectus sheath
(above arcuate line)
• Internal oblique fascia
• External oblique fascia
Superficial fascia
• Camper fascia
• Scarpa fascia
Fascia lata
Superficial epigastric and
circumflex iliac arteries
Femoral vessels
Figure 1-1.
5
6
7
8
9
10
Intercrural fibers
Pectoralis major
muscle
Serratus anterior
muscles
Rectus
abdominis
muscles
Linea alba
Linea semilunaris
Tendinous inscriptions
Midaxillary line
External oblique
muscle and
aponeurosis
Iliac crest
Anterior superior iliac
spine (ASIS)
Umbilicus
Arcuate line
Inguinal ligament
Pyramidalis muscle
Pubic tubercle
Symphysis pubis
Pectoralis major
Serratus anterior
muscles
Midaxillary line
Latissimus dorsi muscle
Iliac crest
Anterior superior iliac
spine (ASIS)
Figure 1-2.
muscle
10
11
12
Inguinal ligament
External oblique aponeurosis
External oblique
muscle
5
Xiphoid process
6
7
8
9
Costal margin
Linea alba
Rectus abdominis
muscles
Umbilicus
Tendinous inscriptions
Linea semilunaris
Arcuate line
Pubic tubercle