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S. P. Carmichael II and J. S. Roth
Lastly, previously placed mesh is often encountered in the re-operative abdomen.
Its removal should be based upon surgical judgment in the absence of data supporting universal excision. Placement of new prosthesis in a well-vascularized plane is
our guiding principle, which often necessitates excision of prior graft though transabdominal approach [27].
References
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lar mesh repair of complex incisional hernia: predictors of wound events and recurrence. J Am
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8. Alexandre JH.The story of EHS-GREPA 1979-2014. Hernia. 2015;19:349–54.
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men and of subsequent respiratory disorders. Chirurgie. 1973;99:547–63.
10. Rives J, Pire JC, Flament JB, Convers G.Treatment of large eventrations (apropos of 133
cases). Minerva Chir. 1977;32:749–56.
11. Stoppa R, Ralaimiaramanana F, Henry X, Verhaeghe P.Evolution of large ventral incisional
hernia repair. The French contribution to a difcult problem. Hernia. 1999;3(1):1–3.
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1989;13:545–54.
13. Nguyen V, Shestak KC.Separation of anatomic components method of abdominal wall recon-
struction—clinical outcome analysis and an update of surgical modications using the technique. Clin Plast Surg. 2006;33:247–57.
14. Culbertson EJ, Xing L, Wen Y, Franz MG.Reversibility of abdominal wall atrophy and brosis
after primary or mesh herniorrhaphy. Ann Surg. 2013;257:142–9.
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tion and collagenous ingrowth in a rabbit model of open incisional hernia repair. Hernia.
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outcomes of an enhanced recovery protocol for open repair of ventral hernia. Surg Endosc.
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PMID: 29270803.
19. Fischer JP, Wink JD, Nelson JA, Kovach SJ III.Among 1,706 cases of abdominal wall recon-
struction, what factors inuence the occurrence of major operative complications? Surgery.
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16 Technique: Posterior Rectus Sheath Release
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20. Plymale MA, Ragulojan R, Davenport DL, Roth JS.Ventral and incisional hernia: the cost of
comorbidities and complications. Surg Endosc. 2017;31:341–51.
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27. Johnson KC, Miller MT, Plymale MA, Levy S, Davenport DL, Roth JS. Abdominal wall
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repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann
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Ventral Abdominal Hernia Repair:
Technique—External Oblique Release
MarkW.Clemens andCharlesE.Butler
Introduction
Traditionally, laparotomy closures, large tumor ablations, congenital anomalies,
and trauma led to unacceptable rates of ventral hernia and abdominal wall morbidity. Primary fascial coaptation and mesh reinforcement of hernia defects have been
demonstrated to signicantly reduce both short- and long-term hernia recurrence
rates in prospective series. However, wide abdominal defects can present a challenge where fascial approximation is not possible under physiologic tension. In
1990, Ramirez and colleagues introduced the technique of components separation
and brought about one of the greater paradigm shifts forward in abdominal wall
reconstruction [1]. Components separation exploits the anatomic planes of the
abdomen to create musculofascial advancement aps which assists in fascial closure. Long-term outcomes support components separation for maintaining the
strength and integrity of the abdominal wall while preserving innervated muscle
function without tension [2–4]. This chapter focuses on planning, techniques, and
outcomes of components separation.
17
Indications/Contraindications
Indications for abdominal wall reconstruction are multifactorial and include hernia tumor ablation, congenital anomalies, and trauma. Proposed risk factors for
the development of hernias included tobacco use and a strong family history of
hernia, which suggests a genetic predisposition [5]. Studies have suggested that
M. W. Clemens (*) · C. E. Butler
Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas,
Houston, TX, USA
e-mail: mwclemens@mdanderson.org; cbutler@mdanderson.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_17
217
218
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M. W. Clemens and C. E. Butler
mechanical strain on load-bearing tissues can induce secondary changes in tissue
broblast function that in turn can result in failure of abdominal wall repairs. The
general indications for performing a components separation of the abdominal
wall include a deciency of the abdominal wall fascia, which would require a
bridged repair without fascial release [6]. Components separation is a fascial
release of the external oblique fascial with creation of musculofascial advancement aps [7]. This creates an autologous ap option for fascial coaptation which
is benecial particularly in the presence of mesh reinforcement. Relative contraindications include lateral abdominal wall hernias patients with ostomies directly
in line with a planned components separation. In these situations, a unilateral
components separation performed on the contralateral hemi-abdomen may be
sufcient to achieve fascial coaptation. It is not possible to perform components
separation in patients that have lost the anatomy required for such a fascial
release such as complete loss of abdominal tissue which can be seen in pancreatic stulas or necrotizing soft tissue infections and the anterior abdominal fascia. Radiated tissue is not an absolute contraindication but does have higher rates
of wound dehiscence, infection, necrosis, and delayed wound healing [8].
Patients with multiple previous abdominal wall surgeries or unclear reconstructive surgical history and anatomy should be approached cautiously [9]. Violation
of the rectus complex such as with an ostomy through the rectus abdominis muscle, elevation of a transverse rectus abdominis muscle (TRAM) ap or vertical
rectus abdominis muscle ap (VRAM) ap does not preclude the use of components separation [10].
Preoperative Planning
Physical examination should be performed to assess the patient’s general condition,
the abdominal wall integrity, the extent and location of any abdominal wall abnormalities, and the presence of scars that could become an obstacle to raising reliable
tissue aps. Routine laboratory tests and a nutritional workup are advised. Correct
diagnosis of abdominal wall defects is critical to proper management. Preoperative
computed tomography (CT) to examine the defect characteristics, abdominal wall
anatomy, and vascularity is helpful for surgical planning [11]. CT scans allow for
visualization of intra-abdominal organs, and the abdominal wall, three-dimensional
data sets, and multiplanar reformation capabilities. CT scans may assist in detecting
uid collections, bowel obstruction, incarceration, strangulation, and traumatic wall
hernias. Magnetic resonance (MR) imaging also permits the detection of soft tissue
defects and abdominal wall hernias though this modality does not usually offer
further sensitivity and therefore may be cost prohibitive. Thromboprophylaxis
should be administered based upon a patient’s particular risk for a thrombotic as
evaluated by the Caprini risk assessment tool. Prospective randomized controlled
data is unavailable regarding routine antibiotic prophylaxis. Most centers including
ours regularly prescribe prophylactic antibiotics intraoperatively for all patients.
Bowel preps may be benecial in patients with anticipated violation of the gastrointestinal tract.
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
219
Surgery
Preoperative/Markings
Patients should be marked in the preoperative holding area, and it is benecial to
evaluate patients in a recombinant and supine position for complete evaluation of
abdominal wall defects. The anatomy of the abdominal wall is covered in depth in
previous chapters; however the pertinent landmarks are recounted here. Markings
may delineate anatomical boundaries such as the pelvis, midline, and costal margin
as well as the fascial extent of any intra-abdominal defects. Once the patient is
transported to the operative room, they are placed supine on the operative table,
sedated, and intubated. Intraoperative intravenous antibiotics are initiated. The
abdomen is widely draped and prepped to expose the patient’s anks and from the
pelvis to the mid-sternal area. Patients should receive sequential compression
devices and or compression hoses for deep vein thrombosis prophylaxis. Patients
requiring greater exposure should have room temperatures maintained above 75°F
to minimize postoperative infections.
Surgical Technique
Critically important to a hernia repair is the reestablishment of the abdominal
domain integrity with complete fascial coaptation. All attempts should be made to
avoid a bridged mesh repair because there is a clear association with higher recurrence rates compared with when the fascia can be reapproximated over a mesh
repair. Understanding all of the approaches for abdominal wall reconstruction and
particularly myofascial advancement aps is critically important to determine the
least invasive procedure to provide a long-lasting repair with an excellent functional
outcome for the patient. Ramirez and colleagues’ description of the surgical technique of components separation facilitates medicalization of the rectus musculofascia and thus midline abdominal closure by releasing the external oblique
aponeuroses and posterior rectus sheath bilaterally [1] (Fig.17.1). Although components separation will often allow for midline fascial reapproximation, which is the
optimal situation, occasionally this will not be possible, particularly for larger hernias; and the myofascial edges will need to be bridged with mesh. Data have shown
that defect size reduction, especially if less than 150cm
recurrence rates. There are several other theoretic advantages to reapproximating
the linea alba. If one considers the linea alba as the tendinous insertion of the rectus
and oblique muscles and borrows from the concepts of tendon repair, then it seems
logical that the physiological tension of the abdominal wall should be restored during ventral incisional hernia repair. Although every attempt to reestablish the midline is advisable, accomplishing that goal is not always feasible, and not all patients
can tolerate the intraperitoneal compression required (which can result in intraperitoneal hypertension, pulmonary compromise, or abdominal compartment syndrome). Once the mesh is inserted peripherally, the midline fascia will be
reapproximated, and the mesh and its inset will bear the majority of the tension.
2
, will lead to the lowest
220
Inguinal ligament
Skin graft/scar
Healthy edges of
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M. W. Clemens and C. E. Butler
Open Components Separation
Myofascial advancement techniques, or components separation, take advantage of the
laminar nature of the abdominal wall and the ability to release one muscular or fascial
layer to enable medial advancement of another [12, 13]. If the lateral abdominal compartment must be released, release can be done by open or minimally invasive components separation. A minimally invasive components separation can be performed in
various ways, but all of the techniques (to a certain degree) maintain the blood supply
to the skin from the underlying rectus abdominis muscles [14]. In contrast, an open
components separation is performed by raising large subcutaneous aps to expose the
external oblique fascia (Fig.17.1). The cutaneous perforators emerging from the anterior rectus sheath are ligated and divided to facilitate exposure of the linea semilunaris
remnants
Internal oblique fibers
Costal margin
anterior rectus fascia
Bilateral division of
external oblique fascia
Fig. 17.1 Open component separation. Subcutaneous aps are elevated off the anterior rectus
sheath to expose the external oblique aponeurosis. The external oblique aponeurosis is released
from the inguinal ligament inferiorly to above the costal margin superiorly. This allows exposure
of the internal oblique muscle bers once the external aponeurosis is incised (Adapted with permission from Rosen MJ.Atlas of Abdominal Wall Reconstruction, Elsevier 2011)
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
221
in its entirety [15]. These aps are carried laterally past the linea semilunaris. This
subcutaneous dissection itself can provide some medial advancement of the abdominal wall skin. An anatomically precise external oblique aponeurotomy is made 1–2cm
lateral to the linea semilunaris on the lateral aspect of the external oblique aponeurosis
from several centimeters above the costal margin to the pubis. It is important to conrm that the incision is not carried through the linea semilunaris, as this would result
in a full-thickness defect of the lateral abdominal wall, which is very challenging to
repair. The external oblique aponeurosis is then bluntly separated in the avascular
plane away from the internal oblique aponeurosis to the midaxillary line, allowing the
internal oblique and transversus abdominis muscles with the rectus abdominis muscle
or fascia to advance medially as a unit. These techniques, when performed bilaterally,
can yield up to 20cm of mobilization in the mid-abdomen.
Once the mesh inset and fascial closure are performed, the subcutaneous skin aps
are advanced and closed at the midline. To reduce subcutaneous dead space, interrupted quilting sutures should be placed between the Scarpa fascia and musculofascial
repair. This technique also decreases shear stress, which is thought to contribute to
postoperative seroma formation, and decrease the total drain output, allowing the surgeon to place fewer drains and leave them in for a shorter period. After paramedian
skin perfusion is critically assessed, a vertical panniculectomy may be performed so
that the skin is reapproximated in the midline without redundancy.
A major limitation of open components separation is the wound morbidity asso-
ciated with the large skin aps necessary to access the lateral abdominal wall. To
avoid this morbidity, several reports have described innovative minimally invasive
approaches to components separation. These approaches are designed to gain direct
access to the lateral abdominal wall without creating large skin aps, creating dead
space, or interrupting the primary blood supply to the central abdominal skin by
ligation of the rectus abdominis perforator vessels.
Laparoscopic Components Separation
Laparoscopically, components separation is performed through a 1cm incision below
the tip of the 11th rib overlying the external oblique muscle (Fig.17.2) [16, 17]. The
external oblique muscle is split in the direction of its bers, and a standard bilateral
inguinal hernia balloon dissector is placed between the external and internal oblique
muscles and directed toward the pubis. Three laparoscopic trocars are placed in the
space created, and the dissection is carried from the pubis to several centimeters above
the costal margin. The linea semilunaris is carefully identied, and the external
oblique aponeurosis is incised from beneath the external oblique muscle at least 2cm
lateral to the linea semilunaris [18]. The muscle is released from the pubis to several
centimeters above the costal margin. This procedure is performed bilaterally.
Periumbilical Perforator-Sparing Technique
A periumbilical perforator-sparing technique of components separation may be performed to preserve the blood supply to the anterior abdominal wall skin near the
222
Hand pump
to public tubercl
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External oblique
Camera tube inside
balloon dissector shaft
(x-sec cut)
Linea semiluanris
M. W. Clemens and C. E. Butler
Linea semilunaris
Internal oblique
Transversus abdominis
Caudal direction
e
Standard bilateral inguinal
hernia balloon dissector,
creating space between
external and internal oblique
Fig. 17.2 Endoscopic component separation. Access to the external oblique aponeurosis is
achieved through a small incision at the costal margin through which a balloon dissector is placed.
The external oblique aponeurosis is then divided from the pubis to above the costal margin. This
minimally invasive approach preserves the attachments of the subcutaneous tissue (including myocutaneous perforators) to the anterior rectus sheath throughout its course. Credit: (Adapted with
permission from Rosen MJ.Atlas of Abdominal Wall Reconstruction, Elsevier 2011)
midline and is based primarily on perforator vessels from the deep inferior epigastric
vessels. Cadaver dissections and radiographic studies have conrmed that the majority of these vessels are located within 3cm of the umbilicus. With preservation of
these vessels, ischemic complications involving the subcutaneous aps are signicantly reduced. To avoid injury to the periumbilical perforator vessels, a line is
marked no less than 3cm cephalad and 3cm caudal to the umbilicus. The periumbilical perforator tunnels are begun at the epigastric and suprapubic regions. Subcutaneous
tunnels are created using lighted retractors to identify the external oblique fascia. The
superior and inferior tunnels are connected using cautery and retractors while maintaining the subcutaneous attachments of the periumbilical region. The linea
17 Ventral Abdominal Hernia Repair: Technique—External Oblique Release
223
semilunaris is identied by palpation, and the external oblique is incised 2cm lateral
to this junction. The aponeurotomy is extended several centimeters above the costal
margin and to the pubis. The external oblique muscle is separated from the internal
oblique muscle in an avascular plane toward the posterior axillary line. The periumbilical perforator-sparing approach has several limitations. One of the benets of
minimally invasive components separation is to reduce subcutaneous dead space.
The periumbilical perforator-sparing technique creates considerable dead space and
sacrices more perforator vessels to the skin than other minimally invasive techniques [19]. When skin mobilization is necessary, adequate advancement occasionally can be difcult to achieve because the midline skin is still invested in the
periumbilical region. Additionally, the placement of a wide piece of mesh as an
underlay can be difcult given the large subcutaneous paddle that is still attached.
Minimally Invasive Components Separation (MICS)
Butler and colleagues modied the standard open Ramirez-style procedure that further reduces the subcutaneous dead space and maximize the blood supply to the
abdominal skin with rectus perforator preservation [20, 21]. The minimally invasive
components separation (MICS) technique is designed to avoid division of the musculocutaneous perforators overlying the rectus sheath and thus maintain perfusion to
the paramedian skin. After lysis of adhesions and identication of the fascial edges,
bilateral, 3cm wide, subcutaneous access tunnels are created over the anterior rectus
sheath from the midline to the linea semilunaris at the level of the costal margin
(Fig.17.3). Through these access tunnels, the external oblique aponeurosis is vertically incised 1.5cm lateral to the linea semilunaris. The tip of a metal Yankauer suction handle (Cardinal Health, Dublin, OH), without suction, is inserted through the
opening in the avascular plane between the internal and external oblique aponeuroses, separating them at their junction with the rectus sheath. The suction tip is
advanced inferiorly to the pubis and superiorly to above the costal margin. Dissection
is performed between internal and external oblique muscles with a sweeping motion
of the Yankauer suction handle. A narrow Deaver retractor is used to create a narrow
(2.5cm) subcutaneous tunnel overlying the planned line of external oblique aponeuroses release inferiorly and superiorly. The external oblique aponeuroses are then
released superiorly with electrocautery and inferiorly with scissors (Fig.17.4). Next,
lateral dissection between the internal and external oblique muscles is performed to
the midaxillary line. Minimal subcutaneous skin aps are then elevated over the anterior rectus sheath circumferentially to the medial row of rectus abdominis perforator
vessels, and a retrorectus or preperitoneal mesh inlay is generally used. If a preperitoneal inset is used, the preperitoneal fat is dissected from the posterior sheath circumferentially to allow the mesh to be inlaid directly against the posterior sheath or
rectus abdominis muscle (below the arcuate line). Mesh is inserted to the semilunar
line with #1 polypropylene sutures via the horizontal access tunnels and the cranial
and caudal aspect of the defect. Next, the myofascial edges are advanced and reapproximated over the mesh with sutures placed through the myofascia. Interrupted
resorbable 3-0 sutures can be placed to afx the posterior sheath to the mesh, thereby
obliterating dead space and reducing the potential for uid collection. Closed-suction
224
ab
lique
musculocutaneous perforators
c
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M. W. Clemens and C. E. Butler
Access tunels
Incision of external oblique
aponeurosis
Lateral tunnels
Xiphoid
Costal margin
External oblique muscle
External oblique
aponeurosis
release:
• superior direction
• Inferior direction
Umbilicus
Linea semilunaris
Dissected space
between external and
internal oblique muscles
Proposed line of incision
Subcutaneous
tunnel creation
Internal ob
muscle fibers
Intact medial and lateral row
Fig. 17.3 Minimally invasive component separation (MICS) technique. (a) Access to the external
oblique aponeurosis is achieved through a small tunnel from the midline to the supraumbilical
external oblique aponeurosis. Vertical tunnels are created dorsal and ventral to the planned release
site of the external oblique aponeurosis. Periumbilical perforators and the subcutaneous tissue
overlying the anterior rectus sheath are left undisturbed. (b) The external oblique aponeurosis is
then divided from the pubis to above the costal margin. The external oblique aponeurosis in the
upper abdomen is released with electrocautery as muscle is transected at, and superior to, the costal
margin. (c) Scissors are generally used to release the external oblique aponeurosis inferiorly. This
MICS approach preserves the attachments of the subcutaneous tissue (including myocutaneous
perforators) to the anterior rectus sheath throughout its course (Adapted with permission from
Rosen MJ.Atlas of Abdominal Wall Reconstruction, Elsevier 2011)
drainage catheters are placed in each components separation donor site area, in the
space between the rectus complex closure and mesh, and in the subcutaneous space.
The remaining undermined skin aps are sutured to the myofascia with vertical rows
of interrupted resorbable 3-0 quilting sutures to reduce dead space and potential
shear between the subcutaneous tissue and myofascia (Figs.17.5, 17.6, 17.7, 17.8,
17.9, 17.10, 17.11, 17.12, 17.13, 17.14, and 17.15).
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