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150
D. Earle
Technique
The decision about whether or not to perform an
ECS is made preoperatively, based on patient goals,
history, abdominal wall contour, midline location,
and the distance between rectus muscles.
Patient Position
The patient is positioned supine, with the arms
tucked at the sides. Occasionally, we will simply
swing the arm boards to the patient’s side, then
swing it back out for the open portion of the procedure. This is more helpful with obese patients.
All appropriate precautions should be taken to
avoid inadvertent injury to the upper extremity.
Access and Muscle Separation
We usually perform the ECS as the fi rst part of the
procedure to reduce the time the laparotomy incision is open. If there is a transverse/oblique incision, or ostomy on one side, we will do the side
without incisions fi rst. The initial 2–4 cm incision
is made transversely, near the costal margin, near
the tip of the 11th rib. This is more lateral than
you would anticipate, and we often tilt the table
away from us to improve exposure and ergonomics. The monopolar pencil with a protected electrode is used to divide the subcutaneous fascia,
and three “S” shaped retractors are used. The
external oblique muscle fi bers (not aponeurosis)
are then positively identifi ed, and bluntly separated until the most posterior fi bers are sliding
free from the underlying internal oblique. The
internal oblique fascia will appear white, although
it is quite thin (Fig 15.1a, b ). While it is possible
to start on the external oblique aponeurosis, this
area carries a higher risk to divide all the way
through common junction of the oblique muscles,
and is more diffi cult to use as an effective port site
because it is near the insertion of the external
oblique, which is divided as part of the release.
We also start on the muscle belly when performing open external oblique release.
Once the space between the oblique muscles
has been accessed, one of the “S” shaped retrac-
tors is placed under the external oblique to lift it
off the internal oblique. A round balloon dissector
(Covidien; North Haven, CT; USA) is introduced
and pushed blindly toward the ipsilateral groin
along a trajectory that takes it 2–3 cm medial of
the anterior superior iliac spine. It is important to
note that while the balloon is being pushed toward
the inguinal ligament, the tip should be angled
anteriorly to avoid going through the internal
oblique. Once the tip of the balloon is near the
inguinal ligament, it is infl ated and defl ated 3–4
times, beginning distally and moving proximally.
While there is no specifi c amount of air introduced, or number of pumps of the infl ator, there is
both visual inspection and palpation of the size of
the balloon as it is being distended. If there is any
doubt, under distention is better than over distention, which can tear the muscle fi bers of the internal oblique (Fig. 15.2a, b ). The balloon is then
removed, the introducer reinserted, and after elevating the external oblique with an “S” retractor,
is redirected above the costal margin. I initially
use the uninfl ated balloon in a back-and-forth
motion above the costal margin before infl ation,
and infl ate the balloon less than inferiorly.
Usually, only one to two infl ation sequences are
required here (Fig. 15.3a, b ).
Port Placement
After separating the oblique muscles with balloon
dissector, I place a 12 mm blunt-tipped AirSeal™
port (Surgiquest; Orange, CT; USA) through the
incision, and insuffl ate to 12 mmHg with CO 2 .
I used to use a round balloon-tipped port
(Covidien; North Haven, CT; USA), but the balloon often impeded the view of the external
oblique insertion, and is easily damaged by energy
sources. With the AirSeal™ port and insuffl ation
system , impedance of the external oblique insertion, smoke evacuation, or loss of insuffl ation
with a gas leak are rare. Once the space is insuffl ated, visual inspection confi rms whether the
correct plane was dissected, and whether or not
there has been any injury to the muscle belly of
the internal oblique. We then place two 5 mm
ports under direct visualization—one medial, and
inferior to the anterior superior iliac spine, and
15 Endoscopic Anterior Component Separation
a
151
Xiphoid
Wide scar
Costal margin
Umbilicus
Bulge
b
Initial incision
(2-4cm)
Pubic symphysis
Fig. 15.1 The location of the initial incision is near the
tip of the 11th rib, and its size will be dependent on the
amount of subcutaneous fat (2–4 cm). The blunt tipped
clamp will spread the external oblique fi bers and allow
visualization of the whitish fascia over the internal
oblique. The “S” retractor can be used to start the dissection between the obliques and lift the external oblique to
allow introduction of the dissection balloon. ( a ) Access is
illustrated in the left upper quadrant . ( b ) Photo depicts
access in the right upper quadrant
152
Fig. 15.2 Lift the external
oblique anteriorly and insert
the balloon dissector toward
the inguinal ligament,
passing just medial to the
anterior superior iliac spine
(ASIS). It is important to
keep the tip pressure
anteriorly and lateral to avoid
inadvertent penetration
through the internal oblique
or common junction. The tip
should be inserted all the way
to, but not through the
inguinal ligament. The
balloon is then serially
infl ated and defl ated
beginning distally and
moving proximally to the
area under the initial
insertion site. Then remove
the dissector and reassemble.
There is no specifi c amount
that the balloon should be
distended; however,
under-infl ation is generally
less risky than over-infl ation.
( a ) Placing the balloon
dissector on the left side . ( b )
Placing the balloon dissector
on right side
D. Earle
a
Insertion of
balloon dissector
ASIS
Balloon dissector
with balloon up
Pubic symphysis
b
one in between, at the same lateral margin as
the 12 mm port. The superior and inferior ports
are for the scope, and the middle port is used for
the instruments used to divide the external oblique
insertion (Fig. 15.4a, b ).
Fig. 15.3 After beginning the superior dissection over
the costal margin with the index fi nger, the balloon dissector is then reinserted superiorly, also over the costal margin, again keeping the pressure on the tip anterior and
slightly lateral. It generally only takes one to two infl ation-
Troubleshooting
If the initial inspection reveals an injury to the
internal oblique muscle, an assessment must be
made about the severity. If just the fascia is torn,
defl ation sequences with less distention than inferiorly.
Generally, under-infl ation is less risky than over-infl ation.
( a ) Placing balloon dissector on left side . ( b ) Placing the
balloon dissector on right side . ( c ) Infl ating the balloon
dissector on the right side
15 Endoscopic Anterior Component Separation
a
Pubic symphysis
153
Insertion of
balloon dissector
ASIS
Balloon dissector
with balloon up
154
D. Earle
a
10mm port (scope)
5mm port (scissors
/energy source)
5mm port (scope)
ASIS
Area of space between
internal and external
oblique muscles
Pubic symphysis
b
Fig. 15.4 The ports are all placed laterally, with the superior
and inferior ports being used for the scope and the middle
port used for the dissection and cutting instruments. With no
specimen extraction, all 5 mm ports could be used. We use a
10–12 mm port superiorly to take advantage of a unique
AirSeal™ insuffl ation system or blunt, balloon tipped port.
but the muscle belly is largely intact, nothing
needs to be done. If there is signifi cant disruption of the muscle belly, it should be repaired
with long acting absorbable suture, and consideration for covering the defect with a prosthetic
in this space, or as part of the hernia repair
As smaller ports with these features become available, the
size could be scaled down. ( a ) Left sided port set-up. ( b )
Right sided port set-up. Note the slight medial placement of
the inferior port. This allows for less interference of the fi eld
of view by the instrument in the working port. An angled
rigid or fl exible tip scope can also help avoid this
should be undertaken. If there is an injury to the
external oblique, nothing needs to be done as
this muscle is being divided anyway. If there is
an injury to the common junction medially,
either during the balloon dissection or during the
division of the external oblique, this must be
15 Endoscopic Anterior Component Separation
155
repaired. We repair these with long acting
absorbable, barbed suture material. Placement of
a prosthetic of any type should be done if there
is doubt that the suture repair was adequate. The
prosthetic can be placed in this space, or as part
of the hernia repair if an intra-peritoneal mesh is
being used. It is also possible to place the balloon dissector too superfi cially and dissect the
subcutaneous space rather than the space
between the oblique muscles. This requires nothing be done other than acknowledging the correct plane, and reinserting the balloon between
the oblique muscles while holding the space
open with an “S” shaped retractor, thus insuring
the balloon enters the correct plane.
External Oblique and Subcutaneous Fascial Division
Once the muscles have been separated, the space
insuffl ated with CO 2 , and the ports have been
placed, you will see the initial view of the space
between the oblique muscles (Fig. 15.5 ). Now
it’s time to divide the external oblique insertion.
With the scope in the upper (12 mm) port and the
scissors in the middle (5 mm) port, any remaining
fi bro-areolar connective tissue not separated by
the balloon is divided to complete the separation.
A small opening is then made directly perpendicular to the port and lateral to the common
junction. You should see yellow, subcutaneous
fat (Fig.
15.6a ). If you see muscle fi bers, you are
in the wrong plane, and need to reassess the anatomy. This may require restarting more laterally.
This can be done by extending the initial incision,
and rotating the table away from the surgeon.
Once the initial incision is made, and subcutaneous fat is seen, the jaws of the scissors can be
opened, and one blade inserted above the fascia.
The shaft can then be slightly rotated downward,
and this will help avoid cutting into the subcutaneous tissue too deeply, which has a risk of
excess bleeding. This incision is then carried
down to just above the inguinal ligament. When
dividing the external oblique insertion, it is
important to stay parallel and lateral to the common junction of the oblique muscle complex and
the lateral border of the rectus muscle. This can
be diffi cult with the small working space, oblique
instrument angles that change as you move along,
and a visual horizon that may rotate (Fig.
15.6b ).
Once the insertion has been divided along the
majority of its length, the subcutaneous fascia is
divided, which gives the majority of the medial
mobilization that can easily be seen as the fascia
is released. An energy device is very helpful here
to control bleeding. When dividing the subcutaneous fascia, it is important to stay in a line perpendicular to the external oblique division, and
avoid straying too medial (Fig. 15.6c ). If this part
of the dissection deviates too medial, there can be
Fig. 15.5 Initial view of the
right side (looking distally)
after creating the space
between the oblique muscles.
Note the fascia of the internal
oblique has been stripped from
the muscle belly by the initial
insertion of the balloon
dissector or slight over
distension of the balloon.
Because there is no defect in
the muscle, no repair is
required. The common
junction is marked by the
white dashed line, and the
anterior superior iliac spine
(ASIS) is seen laterally
156
D. Earle
Fig. 15.6 ( a ) Initial division of external oblique ( Vi ew :
right side, looking distally). The scope is currently in the
most superior port. The initial incision ( arrow ) in the
external oblique is made medial to the common junction
( dashed line ) and perpendicular to the middle port through
which the scissors have been placed. Note the subcutaneous fat, confi rming complete division of the external
oblique aponeurosis. ( b ) Distal external oblique division.
( Vi ew : right side, looking distally) The incision ( arrow ) is
made medial and parallel to the common junction ( dashed
line ) all the way to, but not including the inguinal liga-
an injury to the hernia sac or bowel. Additionally,
if there is an ostomy present, subcutaneous
redundancy of the bowel is common, and the viscera are at increased risk of injury during this
portion of the procedure.
After the inferior portion of the external
oblique insertion and subcutaneous fascia has
been divided, the scope position is changed to the
inferior (5 mm) port. The superior portion is then
accomplished in the same way. Near the costal
margin, however, the external oblique insertion
will become more muscular, and is usually
divided with an energy source only. It will remain
this way the entire distance above the costal margin (Fig.
15.7 ).
ment. Note the narrowing where an old ostomy site was.
( c ) Subcutaneous tissue division. ( Vie w : right side, look-
ing distally) Staying parallel to the common junction, the
subcutaneous fascia is divided with an energy source. We
utilize an ultrasonic device, but many utilize a monopolar
device. The cut edges of the external oblique ( dashed line )
can be seen, and are much further apart after division of
the subcutaneous tissue. Note the aponeurotic portion of
Scarpa’s fascia ( arrow ) superfi cially. This is inconsis-
tently seen. The grasper can be used to estimate the
amount of separation
Limits of Dissection
The limits of the muscle separation are the inguinal ligament, the common junction of the oblique
muscle complex and rectus muscle, the superior
attachment of the external oblique about 5–7 cm
above the costal margin, and the lateral neurovascular bundles between the internal and external
oblique muscles. For more inferior defects, the
superior portion is less important and vice versa.
For smaller defects, the lateral separation is less
important. The limits of the external oblique division are typically just above the inguinal ligament to about 5–7 cm above the costal margin.
As with the muscle separation, these limits can
15 Endoscopic Anterior Component Separation
157
Fig. 15.7 Proximal division of external oblique. ( Vi ew : right
side, looking proximally). Although there is no common
junction of the oblique muscles above the costal margin
( dashed line ), the line of division of the external oblique and
subcutaneous tissue remains parallel to the common junction
( arrow ). Note the aponeurosis does not extend above the cos-
tal margin at this position, and the muscle belly of the exter-
be adjusted depending on the size and location of
the defect. This is the same for the limits of the
subcutaneous dissection.
Troubleshooting
If the initial incision through the perceived external oblique aponeurosis reveals muscle fi bers, the
wrong plane has been entered. You will need to
reassess the anatomy by critically analyzing the
direction of the muscle fi bers and fascia to confi rm that you are in the space between the internal
and external oblique muscles. If you are not in
the right plane, or can’t tell, then start over by
identifying the external oblique muscles fi bers,
not aponeurosis. This may require extending the
initial incision laterally. If you are in the right
plane, it’s possible that you are too far laterally
on the external oblique. If this is the case, it is
acceptable to continue by dividing these muscle
fi bers parallel to the common junction. You may
however be working too close to the ports, and
can thus carry the incision line slightly more
medial. If the muscle fi bers are oriented in the
craniocaudal plane, it is probably the rectus mus-
nal oblique can be seen near the costal margin. We utilize an
ultrasonic device, but an alternative energy source can be
used. It is also important to note the lateral placement of the
12 mm port in the right upper quadrant. If this is placed too
medially, it may impede instrument manipulation. Also, if a
balloon-tipped port is used here, care must be taken to avoid
contact with the balloon with the energy source
cle, and you will need to start over by positively
identifying the external oblique fi bers, which will
require lateral extension of the initial incision.
When dividing the subcutaneous tissue, it is
possible to enter the hernia sac. If this happens,
make sure to open the sac enough to assess for
evidence of a bowel injury, as any part of the GI
tract can be densely adherent to the sac from
adhesions. If this is not possible, the area must be
assessed during the hernia repair phase of the
operation. If planning on this, Consider marking
the area with a suture to positively identify the
area later. If there is an ostomy present, it is common for redundant bowel to be present in the
subcutaneous space, or for there it be a parastomal hernia containing adjacent loops of bowel.
A slower and more meticulous subcutaneous
dissection is warranted in this situation. If a
bowel injury occurs, appropriate action for repair
is in order.
Exiting the Space
Like any laparoscopic procedure, the ports are all
removed under direct vision, and the CO
2
is
allowed to escape. We do not place drains in this
space, except when management of the overlying
158
D. Earle
soft tissue envelope requires excision of excess
tissue and opens this space . The drains are then
placed in an open fashion. If drains are placed,
we prefer drains with metal spikes that are placed
from the inside, as we believe it creates a better
seal at the skin. The fascia of the external oblique
at the port sites obviously does not need to be
closed, and the skin is closed according to surgeon’s preference.
Completing the Hernia Repair
We then typically perform an open scar excision
and retro-rectus sublay with a variety of prosthetics and fi xation methods depending on the clinical situation and goals of the operation. I utilize
long-acting absorbable, barbed suture material
with a short stitch technique for both the posterior and anterior sheath closure. During the anterior sheath closure, the fascial edges are freed of
excess scar tissue, hernia sac, and fat. Care is
taken to avoid cutting too far back where the
anterior sheath is thin. We also take signifi cant
precautions to avoid suturing any muscle fi bers.
Limitations
Complications and Outcomes
Complications of ECS are few and infrequent,
but can be serious. This is particularly true of if
the common junction of the oblique muscle complex and rectus muscles are inadvertently divided.
The sublay mesh placed over the rectus sheath
will not cover the iatrogenic defect laterally, and
a postoperative fl ank hernia will develop. We
have had one case early on in our series where
this occurred, and a laparoscopic hernia repair
was successfully performed utilizing a barrier
coated, intra-peritoneal prosthetic. Additionally,
long-term seromas requiring operative drainage
procedures occur about 5% of the time in our
patients. Reoperation is performed if the seroma
has been persistent for more than 6 months, and
is accomplished with local/sedation or general
anesthesia. The old port sites are used, and the
seroma is drained and the majority of the lining
excised endoscopically. A drain is placed and
removed when the output is less than 30 cm 3 per
24 hours for at least two consecutive days. Shortterm seromas in the ECS site occur in about 30%
of our patients and are evenly distributed between
unilateral and bilateral.
Use of an endoscopic approach to external oblique
release is primarily for midline hernia defects only.
Its use is limited for hernias that extend beyond the
semilunar line, such as fl ank and subcostal hernias. If there is an associated parastomal or incisional hernia at an old stoma site, these can usually
be repaired transversely with long acting absorbable suture and covered with the sublay mesh. One
example where an open perforator sparing technique may be more appropriate is during a concomitant panniculectomy for a lower midline
hernia. A long, low transverse incision will expose
the lateral abdominal wall, and tunneling cephalad
to avoid the perforators will give ample operative
exposure to the external oblique for a release.
References
1. Young D. Repair of epigastric incisional hernia. Br
J Surg. 1961;48(211):514–6.
2. Ramirez OM, Ruas E, Dellon AL. “Components sep-
aration” method for closure of abdominal-wall
defects: an anatomic and clinical study. Plast Reconstr
Surg. 1990;86(3):519–26.
3. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel
WE. Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast
Reconstr Surg. 2000;105(2):720–30.
4. Rohrich RJ, Lowe JB, Hackney FL, Bowman JL,
Hobar PC. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg. 2000;105(1):202–16.
Open Anterior Component Separation with Perforator Preservation
Gregory A. Dumanian
Introduction
As surgeons, we can all agree that blood fl ow to
tissues is associated with healing, while ischemia
is associated with tissue loss and complications.
In regard to hernia repair, a technique called “perforator preservation” serves to maintain pulsatile
skin blood fl ow while still performing a components separation hernia repair by avoiding the
undermining of skin fl aps. This style of ventral
hernia repair is more than simply avoiding the
division of blood vessels to the skin; it also
requires an understanding of abdominal skin
blood fl ow, an appreciation of the forces at the
suture/tissue interface (STI), a means to achieve
primary fascial closure with mesh using concepts
of force distribution, and excision of redundant
midline skin. In the following chapter, a brief
introduction of laminar versus pulsatile blood
fl ow and the angiosome theory of perfusion will
be presented. The history of perforator preservation as an adjunct to the components separation
technique will be recounted. The value of compo-
Electronic supplementary material: The online version
of this chapter (doi:
contains supplementary material, which is available to
authorized users.
G. A. Dumanian , M.D. (*)
Northwestern Feinberg School of Medicine ,
Northwestern Memorial Hospital , Chicago , IL , USA
gdumania@nm.org
e-mail:
10.1007/978-3-319-27470-6_16 )
1 6
nents separation as a means to reduce suture pullthrough will then be introduced. The technique of
perforator preservation at the time of components
separation and use of a narrow mesh will be
presented in a video demonstrating this repair in
a 76 year old gentleman with heart disease, a one
pack per day current smoker, four previous
attempts at repair including prior mesh, and with
a 16 cm in transverse dimension hernia by CT.
Laminar Versus Pulsatile Blood Flow/Blood Flow of the Abdominal Wall
Vascular surgeons have extensive studies correlating the quality of tissue perfusion with the healing
of surgical incisions. In the early 1970s, lower
extremity blood fl ow was analyzed using a combination of pulse-volume recordings and blood
pressures [
on a toe or across the instep of the foot would
have a small incremental change in pressure due
to the stroke volume of blood introduced into the
aorta by the heart during systole. Normal blood
fl ow is pulsatile, correlating to each heartbeat.
Laminar fl ow, in contradistinction, does not experience the repeated episodic increases in pressure.
Laminar fl ow is associated with numerous conditions familiar to surgeons including prior scar,
radiation, proximal vascular obstruction, and
division of native vascularity. It has been shown
experimentally and clinically that primary healing
1 ]. A tiny blood pressure cuff placed
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_16
159© Springer International Publishing Switzerland 2016