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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 11 • Endoscopic Component Separation 189
Ventral hernia
(wound breakdown
and exposed mesh)
Linea alba
Pubic tubercle
Inguinal ligament
Linea semilunaris
Fascia of external oblique
Figure 11-2.
3
3
ASIS
Muscular component
of external oblique
Rectus muscles
2
1
2 cm
1
2
Posterior axillary line
Costal margin
Eleventh rib tip
Abducted arm
External oblique fibers
grasped with Kocher clamps
S retractor creating plane
between external and internal oblique
Linea semiluanris
Caudal direction
Linea semilunaris
Internal oblique
Transversus abdominis
Split fibers of
external oblique
Costal margin
Cut-down incision off tip of
eleventh rib
Figure 11-3.
Fascia of
internal oblique
190 Section IV • Component Separation
s
s
A standard bilateral inguinal hernia balloon dissector is placed underneath the exter-
nal oblique and passed inferiorly to the pubic tubercle (Fig. 11-4). This balloon should
be guided laterally to avoid injuring the linea semilunaris. If prior transverse incisions
are encountered, the balloon might not be able to traverse the scar tissue and should be
aborted and the intermuscular space created under direct vision.
The balloon is insufflated under direct vision, and the orientation of the external oblique
fibers (“hands in pockets”), internal oblique fibers (“hands on the hips”), and the linea
semilunaris are identified (Fig. 11-5).
External oblique
External oblique fibers:
Chapter 11 • Endoscopic Component Separation 191
Camera tube inside
balloon dissector shaft
Linea semiluanris
Caudal direction
to pubic tubercle
Standard bilateral inguinal
external and internal oblique
Figure 11-4.
Linea semilunaris
(x-sec cut)
Internal oblique
Transversus abdominis
hernia balloon dissector,
creating space between
Hand pump
Transversus abdominis
Figure 11-5.
“hands in pockets” orientation
Insufflated balloon
Linea semilunaris
Internal oblique fibers:
“hands in the hips” orientation
192 Section IV • Component Separation
s
s
s
s
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s
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The shape of the standard bilateral inguinal hernia balloon dissector does not permit
cephalad dissection of the external oblique off the costal margin. Therefore, the balloon is
removed, and a finger is placed in the intermuscular space, and the dissection is bluntly
carried out over the costal margin using a sweeping motion (Fig. 11-6). If this space is
not created at this point, the dissection planes can be confusing laparoscopically and may
result in a technical error. Remember the external oblique inserts 5 to 7 cm above the costal
margin and should be cleared off the costal margin to permit the muscles to slide medially.
A balloon tipped trocar is secured in the space to prevent air leakage. One should avoid the
use of a triangular shaped structural balloon at this point because it can result in obliteration of the dissection space. Insufflation pressures of 10 to 12 mm Hg are used.
The inferior space can be bluntly created with a 30-degree, 10-mm laparoscope to com-
plete the dissection of the intermuscular space to the posterior axillary line and inguinal
ligament.
The second port is placed in the posterior axillary line. This port is placed as far laterally
as possible to provide the appropriate angle to release the external oblique, 2 cm lateral to
the linea semilunaris.
Using scissors with cautery, in the posterior axillary port, and the camera in the cut-down
port, the external oblique is incised from as cephalad as possible, to the inguinal ligament/
pubic tubercle (Fig. 11-7). Great care should be taken to complete the release lateral to the
linea semilunaris.
Extra release can be achieved by continuing the dissection superficially through Scarpa fas-
cia. The majority of the blood supply runs superficial to this layer and won’t be disturbed.
The third port is placed through the released external oblique in the lower abdomen. This
port is placed medial to the original cut-down port in the line that the external oblique will
be transected when going over the costal margin. This orientation is important because the
cephalad portion of the dissection can be challenging as it is performed in a reverse camera
orientation.
Chapter 11 • Endoscopic Component Separation 193
Pubic tubercle
External oblique muscle
Costal margin
Internal oblique muscle
Costal margin
Figure 11-6.
Blunt dissection sweeping
external oblique
off costal margin
Inguinal ligament
Scarpa fascia
Scissors
with cautery
External oblique
Internal oblique
Transversus
abdominis
Pubic tubercle
Rectus
muscles
Linea semilunaris
Inguinal ligament
Figure 11-7.
Transection of external oblique
194 Section IV • Component Separation
s
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The camera is then placed in the lower abdominal trocar and the scissors are placed in
the lateral port, and the cephalad dissection is completed separating the external oblique
off the costal margin (Fig. 11-8). The external oblique is carefully separated off the costal
margin to provide a clear plane and trajectory when transecting the external oblique. This
avoids releasing the linea semilunaris or dissecting underneath the costal margin.
Once the dissection of the external oblique is completed, the camera is positioned in the
lateral port and the LigaSure™ ultrasonic dissector is placed in the inferior port (Fig.
11-9). Since the external oblique is fairly muscular at the cephalad portion, I prefer to use
LigaSure™, as simple cautery can result in troublesome bleeding.
Chapter 11 • Endoscopic Component Separation 195
Camera moved to
lower abdominal trocar
Released external
oblique muscle
Linea semilunaris
Costal margin
External
oblique
muscle
Scissors in lateral port
Figure 11-8.
LigaSure/Ultrasonic dissector
Released external
oblique muscle
Linea semilunaris
Costal margin
External
oblique
muscle
(cut line)
3-4 cm
Figure 11-9.
Camera moved to
lateral port
196 Section IV • Component Separation
s
s
s
s
Mesh Placement
s
The external oblique is transected several centimeters above the costal margin (Fig. 11-10).
The exact cephalad extent of the transection of the external oblique is variable, but it
should be at least 5 cm above the superior extent of the hernia defect, and likely, at least 3
to 4 cm above the costal margin.
A bilateral component separation is preferred in most patients to provide symmetric distri-
bution of tension on the closure.
Midline laparotomy is performed, and bowel work is completed as necessary.
In general, mesh should be placed under appropriate physiologic tension, using transfas-
cial fixation sutures to aid in medialization of the rectus muscles. These sutures allow the
forces of the abdominal closure to be redistributed to lateral abdominal wall. If the mesh is
placed in a completely tension-free manner, and the fascia is reapproximated in the midline, the mesh will buckle, and this likely leads to seroma formation, poor integration, and
mesh sepsis.
s
Retrorectus Placement
s
s
Intraperitoneal Placement
s
My preferred space for mesh placement is in the posterior rectus space. By using this tech-
nique as described in Chapter 5 skin flaps are not necessary for wide mesh overlap. Drains
are routinely placed above the mesh and below the rectus muscle. Although some authors
describe continuing the dissection through the linea semilunaris into the lateral abdominal
plane during a retrorectus repair, this should be avoided if a component separation has
been performed. If the external oblique is released and then the transversus abdominis is
intentionally or unintentionally released, the lateral abdominal wall is only supported by
the internal oblique, which likely will result in at least a bulge if not a hernia. Therefore,
if the rectus muscle seems too narrow to place a wide enough piece of mesh, the surgeon
has several alternative options. A standard open component separation can be performed,
allowing large skin flaps and easier mesh placement
Placing a large piece of mesh in the intraperitoneal position without a skin flap is techni-
cally challenging. Alternatively, laparoscopic visualization can be used to fixate the mesh.
In this approach, the abdominal portion of the procedure can be completed in an open
fashion. Before closing the midline incision, the mesh can be placed intraperitoneally
and secured with several transfascial fixation sutures (Fig. 11-11). Several laparoscopic
ports can be placed in the lateral abdominal wall under direct visualization. The midline
Chapter 11 • Endoscopic Component Separation 197
Complete release of external
Linea semilunaris
Linea alba
Internal oblique muscle
oblique muscle
Costal margin
Figure 11-10.
Figure 11-11.
198 Section IV • Component Separation
incision is then closed to allow for insufflation of the peritoneal cavity. The mesh can then
be secured using various laparoscopic fixation devices, including tackers or transfascial
sutures (Figs. 11-12 and 11-13).
4. Postoperative Care
s
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s
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Not all defects can be closed with a component separation. If excessive tension is necessary
It should be noted that the full effect of a component separation is typically not seen until
Epidural catheters are maintained until patients are tolerating a diet and have full return of
Diets are not advanced until patients have return of bowel function. While early postop-
Drains are maintained until outputs are <30 mL/drain/day.
Antibiotics are only continued for up to 24 hours unless otherwise indicated.
to reapproximate the midline fascia, a bridging type repair is indicated. Careful monitoring
of hemodynamic physiology and changes in airway pressure are undertaken. All patients
undergoing complex abdominal wall reconstructions remain intubated overnight if there
is a rise of greater than 5 mm Hg in plateau airway pressures after fascial closure.
24 to 48 hours later, and defects can often be closed under moderate tension and allow the
abdominal wall to completely expand.
bowel function.
erative feeding has shown promise in other fields of surgery, early postoperative retching
and vomiting can lead to disruption of the surgical repair in complex abdominal wall
reconstruction. Routine nasogastric tube decompression is avoided.