7. Creation of Subcutaneous Tunnels

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Chapter 9 • Periumbilical Perforator Sparing Components Separation 149

Figure 9-5.

150 Section IV • Component Separation

7. Creation of Subcutaneous Tunnels

The PUPS components separation is now begun with creation of subcutaneous tunnels

that will allow exposure of the anterior aspect of the external oblique fascia bilaterally (Fig.

9-6 and Fig. 9-7).

At the epigastric and suprapubic levels, using ﬁber optic lighted retraction, the skin and

subcutaneous tissues are dissected off the anterior rectus sheath extending just lateral to the linea semilunaris. The epigastric tunnel typically exposes the costal margin and extends inferiorly from the xiphoid to a level 2 to 4 cm superior to the umbilicus (Fig. 9-8, A). The suprapubic tunnel typically exposes the inguinal ligament and extends superiorly from the pubic tubercle to a level 6 to 8 cm inferior to the umbilicus (Fig. 9-8, B).

The intact subcutaneous tissue between the epigastric and suprapubic tunnels remains

attached to the underlying anterior rectus sheath, thus preserving the periumbilical perforators of the deep inferior epigastric vessels.

Left subcostal tunnel

rectus sheath

fibers

Chapter 9 • Periumbilical Perforator Sparing Components Separation 151

Medial fascial edge

Umbilicus intact

Left suprapubic flap creation

Left subcostal flap creation

Linea semilunaris

Intact periumbilical perforator branches

Figure 9-6.

Left suprapubic tunnel

Perforators

intact

Lateral connection of subcutaneous tunnel

External oblique muscle

Linea semilunaris

Umbilicus

intact

Figure 9-7.

152 Section IV • Component Separation

8. Connecting the Subcutaneous Tunnels

9. Division of the Aponeurosis of the External Oblique Muscle

The epigastric and suprapubic subcutaneous tunnels can be connected before or during

the division of the external oblique muscle.

Using a deep ﬁber optic lighted retractor or a headlight and deep Deaver retractor, these

tunnels are connected from the top down and from the bottom up using cautery dissection. In this way, they can be joined together lateral to the linea semilunaris while avoiding injury to the periumbilical perforators (Fig. 9-8, C).

Exposure for division of the external oblique muscle fascia is through the epigastric and

suprapubic tunnels. The rectus abdominis can be manually retracted medially and the aponeurosis of the external oblique muscle is divided with cautery in a longitudinal orientation approximately 2 cm lateral to the linea semilunaris (Fig. 9-8, C) (Fig. 9-9). Note that at this distance from the linea semilunaris, the external oblique is comprised of thin fascia inferiorly and thicker muscle superiorly.

The external oblique division can continue superiorly approximately 5 to 6 cm over the

costal margin onto the thoracic ribcage and can extend inferiorly to the external inguinal ring if necessary (Fig. 9-9). Fiber optic lighted retraction allows maintenance of an optical cavity lateral to the linea semilunaris such that the periumbilical perforators are preserved during fascial incision.

Once the external oblique muscle is completely divided, it is then separated from the

underlying internal oblique muscle in an avascular plane laterally toward the ﬂank (Fig.

9-8, D).

Using the PUPS approach, the longitudinal division of the external oblique muscle and

its separation from the internal oblique muscle allows medial advancement of the rectus abdominis in continuity with the internal oblique and transversus abdominis muscles towards the midline.

Chapter 9 • Periumbilical Perforator Sparing Components Separation 153

A B

C D

Figure 9-8.

External oblique muscle

Dissection above costal margin

Internal oblique muscle

Medial

advancement

of rectus

abdominis

External oblique

muscle release

Figure 9-9.

Dissection to and through external inguinal ring

Inguinal ligament

Preserved iliohypogastric and ilioinguinal nerve

154 Section IV • Component Separation

10. Reassessment of Fascial Approximation

11. Division of Posterior Rectus Fascia

Once the external oblique PUPS components separation release has been performed bilat-

erally, midline fascial approximation is reattempted. If successful, then mesh implantation can be performed. If unsuccessful, a posterior rectus release can be performed to increase the amount of rectus abdominis muscle advancement medially.

If the posterior release is needed, the medial rectus abdominis edge can be retracted ante-

riorly and laterally with Kocher clamps, and the posterior rectus sheath can be incised longitudinally with cautery approximately 2 cm from the midline. From superior to inferior, this release can extend from under the costal margin to the arcuate line of Douglas where the posterior rectus sheath terminates (Figs. 9-10 and 9-11). Division of the posterior rectus sheath in this fashion typically yields another 1to 2 cm of release per side. Fascial approximation at the midline is again assessed.

Chapter 9 • Periumbilical Perforator Sparing Components Separation 155

Figure 9-10.

Preserved intercostal

vessels communicating

with lateral row of

inferior epigastric vessels

Posterior rectus sheath

dissected to linea semilunaris

Posterior rectus fascia incised 2 cm from medial border

Rectus

muscle

reflected

Figure 9-11.

Preserved intercostal

nerves

Inferior epigastric vessels

156 Section IV • Component Separation

12. Mesh Placement

Once the PUPS components separation has been completed, mesh placement is performed.

The mesh is typically placed as an underlay in a retro-rectus or intraperitoneal location, whether a synthetic mesh or a biologic matrix is chosen, because the periumbilical perforators have been preserved (Fig. 9-12).

In placing the mesh as an underlay, the subcutaneous tunnels are used for placement of

horizontal mattress transfascial sutures laterally to secure the mesh, thereby avoiding the periumbilical perforator vessels. The lateral sutures can be passed through the laterally displaced cut edge of the external oblique if the mesh underlay is wide enough. Otherwise, sutures can be placed through the medial cut edge of the external oblique at the linea semilunaris just lateral to the perforators (as noted in Fig 9-13 and 9-14). However, placement of sutures through the internal oblique and transversus abdominis muscles in the lateral subcutaneous tunnel can be performed to secure the underlay mesh as well. The mesh can be sutured with permanent or long-lasting absorbable sutures.

Before fascial closure, a drain should be placed anterior to the mesh to minimize the inci-

dence of subfascial ﬂuid accumulation (see Figs. 9-12 and 9-13, A). This ﬂuid could other- wise be a source of postoperative discomfort or infection, and it can be a barrier preventing apposition of the mesh to the rectus muscle, thereby preventing early ﬁbroblast and vascular ingrowth and incorporation.

A “double lay” mesh placement, combining both an underlay and onlay mesh, can be per-

formed in cases of biologic matrix implantation in an attempt to minimize the chance of hernia recurrence (Fig. 9-14). A 4- to 6-cm wide segment of mesh is cut from the lateral side of the original piece. The underlay component is sutured in with at least a 5- to 7-cm underlayment; a drain is placed anterior to the underlay mesh, and the fascia is closed primarily over the drain. The onlay mesh piece is “pie-crusted” before implantation to avoid seroma entrapment between the anterior rectus sheath and the onlay mesh. The onlay portion of the double lay matrix may need to be “hour-glassed” at the level of the periumbilical perforators in order to preserve them. The onlay mesh can be sutured along its perimeter with a running long-lasting absorbable or permanent suture.