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86 Section III • Open Repairs
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Posterior Layer Reconstruction
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Once release is performed on both sides, the posterior rectus sheaths are reapproximated
in the midline with a running monofilament suture (Fig. 5-11, A and B). Interrupted figure-of-8 sutures may be used if there is significant tension or pulmonary plateau pressures
increase by 5 mm Hg or more.
Fenestrations in the posterior fascia and/or peritoneum laterally are closed primarily or
buttressed with native tissue (i.e., omentum), absorbable, biodegradable, or biologic mesh.
Hemostasis is ensured.
Copious antibiotic-laden pulse lavage of the newly created extraperitoneal space is
performed.
Chapter 5 • Open Retromuscular Ventral Hernia Repair 87
A1
Bilateral transversus
abdominis release (TAR)
B1
Figure 5-11.
Posterior rectus sheaths
reapproximated
Peritoneum /
Transversalis fascia
Transversus
abdominis
Reflected rectus
abdominis muscle
B2
88 Section III • Open Repairs
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Mesh Fixation
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The mesh is placed as a sublay in the retromuscular space (Fig. 5-12).
The inferior edge of the mesh is secured to both Cooper’s ligament using 2 to 4 interrupted
monofilament sutures. The mesh may be positioned to also reinforce both myopectineal
orifices.
Superiorly, the mesh could be placed in beyond the costal margin and in the retroxiphoid
space. It is secured with interrupted sutures around the xiphoid process. Those sutures are
placed 4 to 5 cm off the edge of the mesh to allow for large overlap, especially for subxi-
phoid defects. Similarly, even though the mesh edge may be significantly beyond the costal
margin, fixation is performed below the margin to reduce the risks of lung injury.
The mesh is then fixated circumferentially with full-thickness, transabdominal sutures
using the Reverdin needle (Figs. 5-13 and 5-14, A and B).
Chapter 5 • Open Retromuscular Ventral Hernia Repair 89
Bilateral released edges of
transversus abdominis muscle
Figure 5-12.
Mesh as sublay
in retromuscular space
Reverdine needle
Figure 5-13.
90 Section III • Open Repairs
Circumferential placement
of full thickness,
transabdominal sutures
with Reverdin needle
A1
Sublay mesh placement
in the retromuscular space
A2
Buried sutures
B1
Figure 5-14.
B2
Chapter 5 • Open Retromuscular Ventral Hernia Repair 91
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Reconstruction of the Linea Alba
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The mesh should be placed under appropriate “physiologic” tension. Laxity is of particular
concern if biologic mesh is used because mesh “wrinkling” would lead to seromas, infections, and possible mesh degradation and/or weakening. The transfascial sutures should
be placed under physiologic tension, so that when they are secured, they provide medialization of the rectus muscles. In doing so, the midline fascia is reapproximated while the
mesh is taut, preventing wrinkling when closing the fascia. Alternatively, if the mesh is
placed “tension free” and then the fascia is closed, the prosthetic will buckle.
Drainage: Closed suction drains are placed ventral to the mesh. Subcutaneous drains are
used selectively.
The anterior rectus sheaths are then reapproximated in the midline to restore the linea
alba. A running, slowly absorbable suture is used. Alternatively, interrupted figure-of-8
stitches can be used, especially when there is a potential predisposition to the abdominal
compartment syndrome.
In rare instances when the anterior rectus sheath cannot be reapproximated, external
oblique fascia release (open or endoscopic) may be performed. However, it is important to
not combine the anterior external oblique release with a transversus abdominus release. If
both muscle layers are released, the lateral abdominal wall can become destabilized.
4. Postoperative Care
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General
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Intraoperative hemodynamics and airway pressures affect postoperative care. Overnight
intensive care unit admission is recommended for patients undergoing major abdominal
wall reconstructions. Long operative times and prolonged exposure of the abdominal cavity to room air lead to significant insensible losses and predispose to large fluid shifts. As
a result, patients undergoing complex abdominal wall reconstructions often remain intubated overnight. In addition, those patients with poor pulmonary reserve and/or significant
increase in plateau airway pressures are kept paralyzed for 24 to 48 hours postoperatively.
92 Section III • Open Repairs
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Pain Management
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The drains are kept in place until the output is <20 mL per day.
When a biologic graft is used, the drains are left in place for at least 2 weeks, regardless of
the output.
Antibiotics are continued for up to 24 hours, unless otherwise indicated.
Aggressive deep vein thrombosis prophylaxis is mandatory. I do not use systemic antico-
agulation and/or caval filters, unless specifically indicated. Ambulation is avoided until the
second postoperative day.
Abdominal binders are used in the early postoperative period. Beyond the first week, their
use is liberalized at the patient’s discretion.
Epidural catheters are strongly recommended. Epidural catheters are maintained until
patients are tolerating a diet and have full return of bowel function. In addition, sched-
uled (not prn) intravenous diazepam (Valium) is given for muscle relaxation and spasm
prevention.
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Diet
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5. Outcomes
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Routine nasogastric tube decompression is reserved for patients with intestinal resections,
significant intestinal manipulations, and prolonged adhesiolysis. Diet advancement is very
conservative in order to avoid early postoperative bloating, retching, and vomiting, which
may lead to pulmonary complications, as well as disruption of the repair. As a result, diets
are not advanced until return of bowel function occurs.
Retromuscular (Rives-Stoppa-Wantz) repair has been shown to result in an effective repair
of most ventral hernias. Recurrence rates of 3% to 6% at mid- to long-term follow-ups
have been reported. In fact, in 2004, given its superior track record, this approach was
proclaimed to be the gold standard for open ventral hernia repair by the American Hernia
Society.
Chapter 5 • Open Retromuscular Ventral Hernia Repair 93
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6. Pearls and Pitfalls
1. Anatomy
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The posterior component separation and retromuscular repair has the following advan-
tages: (1) it is relatively easy to adopt, (2) it is applicable in a broad range of patients, (3)
the creation of skin flaps is avoided, and (4) the risk of lateral laxity/bulging is low.An additional advantage is that sublay mesh placement allows for giant prosthetic reinforcement
of the visceral sac and for proper mesh placement and sufficient mesh overlap for repair of
hernias in difficult locations including the subxiphoid, suprapubic, flank, and parastomal
areas.
It may also be the best space for a biologic graft positioning to maximize the environment
for graft integration and regeneration via superior blood supply.
Neurovascular bundles supplying rectus muscles run in between transversus abdominis
and internal oblique muscles and traverse posterior rectus sheath near the linea semilunaris, entering rectus muscle at its lateral edge. Care should be taken to identify and preserve
these nerve bundles during the retrorectus dissection to prevent denervation of the rectus
muscles
The transversus abdominis muscle is the “corset” of the abdomen and is the muscle mostly
responsible for intraabdominal pressure. It extends more medially than both internal
and external obliques. These anatomic features allow for TAR in posterior component
separation.
2. Preoperative Considerations
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Smoking cessation is mandatory. Abdominal wall reconstructions in smokers carry a high
risk of wound morbidity and repair failures.
Abdominal imaging (CT) should be performed routinely.
Both synthetic and biologic meshes can be used in complex repairs even if component
release has been performed. Mesh choices should be based on the multitude of patient
factors and surgeon preferences and is more completely covered in Chapter 19.
94 Section III • Open Repairs
3. Intraoperative Considerations
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4. Technical Considerations
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Complete lysis of visceral adhesions to the abdominal wall is performed to facilitate fascial
advancement and to avoid subsequent intestinal injuries during component release.
Removal of ALL previous meshes is essential to allow optimum prosthetic integration and
reduce postoperative infectious complications.
In many patients, retromuscular dissection to the extent of the lateral edge of both rectus
sheaths may be sufficient.
Release of the posterior rectus sheath (posterior component separation) could be achieved
with or without transversus abdominis muscle release. Posterior component separations
should NOT be combined with any type of the anterior release. Traditional retrorectus dissection, on the other hand, could be an excellent adjunct to the anterior (external oblique)
release to allow for sublay mesh placement.
Fenestrations in the transversalis fascia should be repaired.
If posterior rectus sheaths cannot be re-approximated, omentum, remnants of the hernia
sac, or an absorbable mesh can be used to “bridge” the gap.
Complete exclusion of the abdominal viscera is essential to both avoid intestinal hernia-
tions/strangulations through defects in the posterior layer of reconstruction and to avoid
intestinal exposure to uncoated synthetic meshes.
The mesh should be sized to provide significant reinforcement of the whole visceral sac.
Typically, at least a 30 × 30 cm synthetic or a 20 × 20 cm biologic mesh is used.
Mesh fixation is performed with a wide lateral overlap. Full-thickness transabdominal
sutures are used to fixate the mesh and to provide physiologic tension across the entire
abdominal wall. “Tension-free” repair of the abdominal wall is not adequate if preservation
of the abdominal wall function is intended.
Chapter 5 • Open Retromuscular Ventral Hernia Repair 95
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5. Postoperative Care
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Selected References
Carbonell AM, Cobb WS, Chen SM: Posterior components separation during retromuscular hernia repair, Hernia 12(4):359–362, 2008.
Conze J, Prescher A, Klinge U, et al: Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the “fatty triangle”
Hernia 8(3):255–259, 2004.
Hammond DL, Ackerman L, Holdsworth R, Elzey B: Effects of spinal nerve ligation on immunohistochemically identified neurons in the
L4 and L5 dorsal root ganglia of the rat, J Comp Neurol 475(4):575–589, 2004.
Iqbal CW, Pham TH, Joseph A, et al: Long-term outcome of 254 complex incisional hernia repairs using the modified Rives-Stoppa
technique, World J Surg 31(12):2398–2404, 2007.
Novitsky YW, Porter JR, Rucho ZC, et al: Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias,
J Am Coll Surg 203(3):283–289, 2006.
Rives J, Pire JC, Flament JB, et al: [Treatment of large eventrations. New therapeutic indications apropos of 322 cases], Chirurgie
111(3):215–225, 1985.
Rosen MJ, Fatima J, Sarr MG: Repair of abdominal wall hernias with restoration of abdominal wall function. J Gastrointest Surg
14(1):175–185.
Stoppa RE: The treatment of complicated groin and incisional hernias, World J Surg 13(5):545–554, 1989.
Wirhed R: Athletic Ability & the Anatomy of Motion, 1984, Wolfe Medical Publications Ltd.
Fixated biologic mesh should be taut without bucking/wrinkling.
Follow pulmonary plateau pressures to minimize risks of postoperative abdominal hyper-
tension and respiratory failures. In cases of significant (>5 mmHg) intraoperative plateau
pressures elevation, fascial bridging, postoperative mechanical ventilation, and/or paralytics may be employed.
Aggressive pain management, including epidural and intravenous antispasmodic agents, is
mandatory.
Advance diet slowly.
Keep drains until output is <20 mL per day, especially when a biologic mesh used.