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Chapter 11 • Endoscopic Component Separation 199
Passer instrument
retrieving transfacial
Mesh
Intraperitoneal mesh placement
(dotted outline)
fixation suture
Figure 11-12.
Tack fixation of mesh
Midline closure
and reinsufflation
Transfascial sutures
Tack fixation of mesh
viewing of tack placement
Figure 11-13.
Laparoscopic
200 Section IV • Component Separation
5. Pearls/Pitfalls
s
s
s
s
s
s
s
s
Realize the limitations of this operation.
Medial advancement is difficult to achieve with defects at the xiphoid and suprapubic
region of the abdominal wall. These should be avoided early in one’s experience.
Large defects, >20 cm, and noncompliant fixed abdominal wall defects often cannot be
medialized to completely reconstruct the linea alba.
Realistic expectations for patients, families, and surgeons as to the severity of the opera-
tion, including risks, and the ability to reconstruct a normal abdominal wall are critical to
the success of this procedure.
Endoscopic component separation is ideal in circumstances where a stoma is present. If
the stoma is through the rectus muscle, a component separation can be performed endoscopically without undermining the skin around the stoma and risking peristomal skin
necrosis and a floating stoma.
Component separation should be performed bilaterally in most cases to redistribute the
tension symmetrically during closure.
Endoscopic component separation does not achieve the same release as an open compo-
nent separation. Typically 85% of the fascial release can be achieved without a skin flap.
If the exposure cannot be achieved laparoscopically for the cephalad part of the release of
the external oblique, the skin incision can be enlarged, and using lighted retractors, the
release can be completed using an open technique.
Chapter 11 • Endoscopic Component Separation 201
Selected References
Harth KC, Rosen MJ: Endoscopic versus open component separation in complex abdominal wall reconstruction, Am J Surg 199(3):
342–346, 2010 Mar:discussion 346–347.
Rosen MJ, Fatima J, Sarr MG: Repair of abdominal wall hernias with restoration of abdominal wall function, J Gastrointest Surg
14(1):175–185, 2010 Jan.
Rosen MJ, Jin J, McGee M, Marks J, Ponsky J: Laparoscopic component separation in the single stage treatment of infected abdominal
wall prosthetic removal, Hernia 11(5):435–440, 2007 Oct.
Rosen MJ, Reynolds HL, Champagne B, Delaney CP: A novel approach for the simultaneous repair of large midline incisional and para-
stomal hernias with biological mesh and retrorectus reconstruction, Am J Surg 199(3):416–420, 2010 Mar:discussion 420–421.
Rosen MJ, Williams C, Jin J, McGee M, Marks J, Ponsky J: Laparoscopic versus open component separation: A comparative analysis in a
porcine model, Am J Surg 194(3):385–389, 2007 Sep.
Panniculectomy and
1. Clinical Anatomy of the Anterior Abdominal Wall
C HAPT E R
12
Abdominal Wall
Reconstruction
Maurice Y. Nahabedian, MD, FACS
1. Relevant General Anatomy
s
2. Relevant Muscular Anatomy
s
s
s
When considering panniculectomy in the setting of abdominal hernia repair, the underly-
ing musculature, aponeurotic layers, and adipocutaneous structures are important. The
three components are interrelated and should be addressed systematically in order to optimize outcomes following panniculectomy.
The rectus abdominis and the internal, external, and transverse oblique musculature con-
tribute to the support and contour of the anterior abdominal wall (Fig. 12-1).
The perforating vasculature to the adipocutaneous component of the anterior abdomi-
nal wall emanates from the intramuscular vascular network (Fig. 12-2). The majority of
significant perforators arise from the deep inferior epigastric system. Other blood vessels
contributing to the perforating system include the superficial inferior epigastric artery,
superficial circumflex iliac artery, and the deep circumflex iliac artery. All of these perforators converge at the dermis, forming the subdermal plexus.
Prior abdominal operations associated with undermining can disrupt this perforating vas-
cular network. However, secondary perforators can evolve over time and may be preserved. In addition, as a compensatory mechanism, the remote vascularity will acclimate
to the new perfusion patterns and perfuse the undermined tissue.
204
External
Linea alba
oblique
muscle
Transversus
abdominis
muscle
Internal
oblique
muscle
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 205
Linea alba
Level
EO
IO
TA
TF
RA
above
arcuate
line
Rectus
abdominis
muscle
Figure 12-1.
Femoral artery
External iliac artery
Inguinal ligament
EO
IO
TA
TF
Inferior epigastric
RA = Rectus abdominus
EO = External oblique
IO = Internal oblique
TO = Transversus abdominis
TF = Transversalis fascia
Deep inferior
epigastric arteries
RA
vessels
Superficial inferior
epigastric artery
Level
below
arcuate
line
Superficial circumflex
iliac artery
Camper fascia
Scarpa
fascia
Figure 12-2.
Subdermal
plexus
Deep
circumflex
iliac artery
Deep inferior
epigastric arteries
206 Section V • Other Abdominal Wall Procedures
3. Relevant Aponeurotic Anatomy
s
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The aponeurotic layers of the anterior abdominal wall include the linea alba, anterior rec-
tus sheath, posterior rectus sheath, and the external oblique fascia (Fig. 12-3).
The anterior rectus sheath and linea alba are composed of collagen fibers arranged in an
interwoven lattice. The width and thickness of these structures vary along the surface of
the anterior abdominal wall. These measurements fluctuate at various regions of the anterior abdominal wall and are related to the distance from the umbilicus. With respect to
the linea alba, its width ranges from 11 to 21 mm between the xiphoid process and the
umbilicus and then decreases from 11 to 2 mm from the umbilicus to the pubic symphysis.
The thickness of the linea alba ranges from 900 to 1200 μm between the xiphoid and the
umbilicus and increases from 1700 to 2400 μm from the umbilicus to the pubic symphysis. With respect to the anterior rectus sheath, the thickness ranges from 370 to 500 μm
from the xiphoid to the umbilicus and then increases to 500 to 700 μm from the umbilicus
to the pubic symphysis. The posterior rectus sheath, on the other hand, is slightly thicker
than the anterior rectus sheath above the umbilicus, ranging from 450 to 600 μm, but then
it drops off precipitously from the umbilicus to the arcuate line to 250 to 100 μm.
Pectoralis major
muscle
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 207
Linea alba
External oblique
muscle and
aponeurosis
Rectus sheath
(anterior)
Figure 12-3.
Umbilicus
208 Section V • Other Abdominal Wall Procedures
s
Perforating vessels pierce the anterior rectus sheath and external oblique fascia as they
course through the adipose layer, until contributing to the subdermal plexus of vessels
(Figs. 12-4 and 12-5).
4. Relevant Adipocutaneous Anatomy
s
In the patient with an abdominal pannus, the overlying skin may be thickened and indu-
rated. Ulcerations may be present with associated infections.
s
The thickness of the pannus is variable and depends on body habitus and body mass index
(BMI). The adipose component may be edematous with very large fatty lobular tissue.
2. Preoperative Considerations
s
As with all operations, proper patient selection is important. A careful assessment of the
risks and benefits of panniculectomy must be made, and the patient must be informed
of the risks. These risk factors can increase the risk of postoperative morbidity and
complications.
1. Preoperative Imaging
s
2. Assessment of Risk Factors
s
Preoperative imaging is important when considering panniculectomy. Computed tomog-
raphy (CT) or magnetic resonance imaging (MRI) delineate the size of the hernia defect
and provide information regarding the thickness of the abdominal pannus (Fig. 12-6). The
abdominal musculature also is appreciated. MRI also permits visualization of the larger
arteries and veins that course through the pannus.
Systemic risk factors that require optimization include but are not limited to diabetes mel-
litus, obesity, hypertension, pulmonary disease, poor nutritional status, cardiac disease,
connective tissue disorders, abdominal aortic aneurisms, and immunosuppression. Local
risk factors include but are not limited to prior soft tissue or cutaneous infections, fistula,
indurated skin, lymphedema, and ulcerations.
Figure 12-4.
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 209
Perforating vessels
External oblique
fascia
Subdermal plexus
Figure 12-5.
Anterior
rectus sheath
Adipose layer
Figure 12-6.
210 Section V • Other Abdominal Wall Procedures
s
3. Prior Hernia Surgical History
s
s
In patients with an elevated BMI (>35), uncontrolled diabetes mellitus, and poor nutri-
tional status, the incidence of complications such as delayed healing, incisional dehiscence, soft tissue necrosis, infection, and prolonged drainage are likely to be increased.
The anticipated length of the operation may influence the timing of the panniculectomy,
immediate or delayed.
Prior studies have demonstrated an increased risk of infection in patients with an abdomi-
nal hernia. Although, many of these operations appear at first glance to be “clean” operations, they are, in fact, more susceptible to infection. Many of these infections manifest
in the skin and subcutaneous fat. The incidence of soft tissue infection is approximately
10-fold higher in patients with a hernia (16% vs. 1.5%). In patients with a prior abdominal
hernia repair, the risk of infection continues to increase (42% vs. 12%). Surgeons should
be cognizant of these statistics when considering panniculectomy.
In general, prior vertical midline incisions are preferred because a fleur-de-lis pattern can
be used. With this pattern, excess skin and fat can be excised in both the horizontal and
vertical planes. When the prior incisions are transverse in orientation, problems related to
blood supply can occur, especially when the incisions are located in the mid- and upper
abdominal areas. Low transverse abdominal incisions are usually fine because this is where
the transverse incisions are usually made for panniculectomy.
3. Operative Steps
s
1. Design Patterns for Panniculectomy
s
Preparing for panniculectomy is in many ways similar to preparing for abdominoplasty.
The principles and concepts for the two are similar. Design patterns for skin excision must
consider the vascularity of the skin. This will be related to the location of the prior incisions, the thickness of the soft tissues, and the degree of undermining. The degree of soft
tissue undermining must include an appreciation for the thickness of the pannus because
this can impact the perfusion of the adipocutaneous component.
There are several design patterns for abdominal panniculectomy. These include the hori-
zontal incision; vertical incision; and a horizontal and vertical incision, also known as a
fleur-de-lis pattern (Fig. 12-7). The specific pattern depends on the location of excess tissue and the location of prior incisions. Most patients with abdominal hernias will have a
prior vertical midline incision. Incorporating this into the excision pattern is useful and
does not usually result in additional scars.