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76 Section III • Open Repairs
2. Preoperative Considerations
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Preoperative Imaging
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Preoperative Optimization
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I recommend routine abdominal/pelvic computed tomography (CT) imaging. CT delin-
eates all abdominal wall defects, assessment of the integrity of the remaining abdominal
wall musculature, allows for detection of previous synthetic meshes and/or occult infection, and facilitates perioperative planning. I also mandate a screening colonoscopy in
appropriate patients before undertaking major abdominal wall reconstructions.
Nutritional evaluation and counseling for obese patients is paramount, and weight loss
surgery should be considered.
Smoking cessation is mandatory
Cardiac and pulmonary status should be assessed and optimized.
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Choosing the Type of Mesh
Chapter 5 • Open Retromuscular Ventral Hernia Repair 77
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3. Operative Steps
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Planning Incision
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Use a large, synthetic mesh with or without an antiadhesive barrier. I prefer a large (30 ×
30 cm) macroporous, reduced-weight polypropylene mesh.
Composite synthetic mesh with an antiadhesive barrier may need to be used if visceral
exposure through fenestrations in the posterior layer is possible/likely.
Biologic or biodegradable mesh should be considered in all contaminated and potentially
contaminated fields. Synthetic mesh should be avoided in patients with a previous history
of mesh infection, especially methicillin-resistant Staphyloccus aureus (MRSA). In addition,
biologic meshes should be considered in patients with multiple comorbidities (morbid
obesity, diabetes, systemic steroids or other form of immunosuppression, etc) and resultant
increased risks of wound/mesh infections.
A generous midline laparotomy is required.
Elliptical incisions are used to incorporate previous scars, skin ulcerations, and/or defects.
For most, and especially morbidly obese, patients with large midline hernias, I recommend
excision of the umbilicus to minimize postoperative wound morbidity.
Use an inverse “T” incision, if panniculectomy is contemplated.
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Lysis of Adhesions, Removal of Old Mesh
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Complete lysis of all visceral adhesions to the anterior abdominal and pelvic walls is per-
formed. This is particularly important in cases where dissection lateral to the linea semilunaris is undertaken. Inter-loop adhesions are typically ignored.
If possible, complete excision of all previously placed mesh is performed.
78 Section III • Open Repairs
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Incision of the Posterior Rectus Sheath (Rives-Stoppa-Wantz Technique)
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To dissect the retromuscular space to the linea semilunaris, the posterior rectus sheath is
incised sharply about 0.5 cm from its edge (Fig. 5-2, A). This typically is initiated at the
level of the umbilicus. The retromuscular plane is then developed using a combination of
blunt dissection and electrocautery. The lateral extent of this dissection is the linea semi-
lunaris, confirmed by visualizing the junction between the posterior and anterior rectus
sheaths (Fig. 5-2, B). Careful identification of the intercostal nerves and vessels is critical
to maintaining an innervated functional abdominal wall (Fig. 5-2, C).
Chapter 5 • Open Retromuscular Ventral Hernia Repair 79
B1
Incision of posterior
rectus sheath
A1
Linea semilunaris
(anterior and posterior
rectus sheath junction)
Anterior rectus sheath
Dissection of
retromuscular space
A2
Figure 5-2.
B2
C
80 Section III • Open Repairs
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Exposure of Cooper’s ligaments/pubis is shown in Figure 5-3. Inferiorly, the space or
Exposure of the subxiphoid space is shown in Figure 5-4. The retromuscular plane can be
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Lateralization of the Dissection Plane Beyond the Linea Semilunaris
Traditional Rives-Stoppa-Wantz dissection is carried out to the lateral edge of the rec-
Three techniques for lateral extension of the retromuscular plane have been described.
Retzius is entered to expose the pubis symphysis and both Cooper’s ligaments. This dissection is blunt in what is typically a bloodless plane. Since this area is below the arcuate line,
posterior layer includes peritoneum and transversalis fascia only. Because both of these layers are very thin, fenestrations are not uncommon and should be repaired. Care should be
taken to identify and preserve inferior epigastric vessels that course along the deep surface
of the rectus muscles. The urinary bladder may be filled with saline to facilitate its identification and dissection. This is particularly prudent in patients with a previous history of
pelvic surgery.
extended cephalad to the costal margin and to the retroxiphoid/retrosternal areas.
tus sheath. However, such dissection is insufficient for some patients undergoing major
abdominal wall reconstructions for three main reasons: (1) insufficient medial advancement of the posterior rectus sheath, (2) decreased potential for medialization of the rectus
muscles, and (3) insufficient space for large prosthetic reinforcement.
They are the preperitoneal, posterior component separation with intramuscular dissection, and the posterior component separation with transversus abdominis release (TAR). A
description of each follows.
Preperitoneal: The preperitoneal plane may be entered immediately at the medial bor-
der of the rectus sheath. Kocher clamps are placed on the edge of the posterior rectus
fascia and peritoneum is incised. Alice clamps are then placed on the cut edge of the
peritoneum and the plane is developed laterally using blunt dissection. Medial traction
applied by the Alice clamps significantly facilitates the dissection. This technique has
significant limitations, as it does not provide for any fascial release/advancement. In
addition, peritoneal flap (especially its medial edge) is very tenuous in many patients
and may tear easily. Such fenestrations should be repaired primarily or buttressed by
underlying visceral fat and/or omentum. If complete exclusion of the peritoneal cavity
is not possible, this plane should be bridged or buttressed with an absorbable, a biodegradable or a biologic mesh.
The preperitoneal plane also can be entered from within the rectus sheath. Following
a traditional retromuscular dissection (described above), the posterior rectus sheath is
incised about 1 to 2 cm medial to the linea semilunaris. Once the plane is entered, the
dissection is carried out as described above.
Posterior component separation with intramuscular dissection (Fig. 5-5): Starting in the
periumbilical area, the lateral edge of the posterior rectus sheath is incised, dividing the
posterior aponeurotic sheath of the internal oblique muscle. This allows access to the
plane between the internal oblique and transversus abdominis muscles. The dissection
is carried out laterally using electrocautery. The main limitation of this technique is division of the neurovascular bundle to the abdominal musculature traversing this plane.
Figure 5-3.
Chapter 5 • Open Retromuscular Ventral Hernia Repair 81
Figure 5-4.
transversus abdominis muscle
Mesh between
internal oblique and
Figure 5-5.
Bilateral released edges of
posterior aponeurotic sheath of
internal oblique muscle
82 Section III • Open Repairs
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Posterior component separation with transversus abdominis release (TAR): Starting in
the upper third of the abdomen, about 0.5 cm medial to the anterior/posterior rectus
sheath junction (linea semilunaris), the posterior rectus sheath is incised to expose the
underlying transversus abdominis muscle (Fig. 5-6, A and B). The muscle is then divided
along its entire medial edge using electrocautery. The use of a right-angled dissector
significantly facilitates this release and minimizes injury to the underlying transversalis
fascia and peritoneum. Transection of the medial edge of the transversus abdominis
muscle allows for entrance to the space between the transversalis fascia and the lateral
Chapter 5 • Open Retromuscular Ventral Hernia Repair 83
Incision of
posterior
rectus sheath
Aponeurosis of
transversus abdominus
muscle
Exposed belly
of transversus
abdominis muscle
Transversalis fascia
Peritoneum
A1
Cephalad
Caudal
Linea semilunaris
Rectus muscle
reflected
A2
Figure 5-6.
Transversus abdominis release
B1
(TAR)
B2
84 Section III • Open Repairs
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edge of the divided transversus abdominis muscle (Fig. 5-7). The retromuscular space is
bluntly developed further laterally to as far as the lateral border of the psoas muscle to
allow for a reinforcement of a visceral sac with a large mesh (Fig. 5-8). Also, if needed,
this dissection may be extended superiorly above the costal margin and inferiorly to
expose both myopectineal orifices (Fig. 5-9).
The key component to the release is the division of the entire medial edge of the trans-
versus abdominis muscle. The main function of the transversus is to act as a “corset”
around the abdomen. The synergistic action of the transversus and the posterior fibers of
the internal oblique produce hoop tension through the thoracolumbar fascia. By dividing
the transversus abdominis, I am able to release the circumferential muscle tension and
not only provide for expansion of the abdominal cavity but also afford significant medial
advancement of the posterior rectus fascia (Fig. 5-10).
Chapter 5 • Open Retromuscular Ventral Hernia Repair 85
Peritoneum
A1
Figure 5-7.
Figure 5-8.
Developed
preperitoneal
plane
Division of
posterior
rectus sheath
A2
Figure 5-9.
Figure 5-10.