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18 Technique: Transversus Abdominis Release
245
postoperatively. Abdominal compliance usually improves within 12–24h postoperatively, and pulmonary physiology returns to baseline allowing for safe extubation [18].
All patients are kept NPO on postoperative day 1, and diet is advanced according
to the patient’s status and the enhanced recovery pathway schedule (Fig. 18.1).
Alvimopan is given twice a day and is stopped after the rst bowel movement.
Patient-controlled analgesia is maintained for the rst 1–2days with adjunctive use
of oral acetaminophen and gabapentin. Drains are usually kept in place until the
3
output is <30–50cm
per day. Most patients will wear an abdominal binder at least
during the rst week.
Outcomes
As experience with TAR is expanding, a wealth of outcome data is now available in
the literature. In a nonrandomized study published in 2012 [19], 55 cases of TAR
were compared to 56 traditional anterior component separation cases looking for
differences in wound morbidity and repair durability. Hernia characteristics were
similar between groups, but the mean operative time was signicantly reduced in
the TAR group (228min vs 285min). Midline reapproximation was equally feasible
in both groups. Wound complications were signicantly reduced when TAR was the
procedure of choice (25.4% vs 48.2%, p 0.01), and this signicance remained even
after adjusting for differences in demographics between groups. There appeared to
be a trend for lower hernia recurrence rate in the TAR group (3.6% vs 14.3%), but
this was not statistically signicant (p 0.09). This study was able to demonstrate one
of the benets TAR, since it allows preservation of the abdominal wall blood supply
by avoiding creation of the skin aps that are typically needed in the traditional
anterior component separation.
The largest experience with TAR to date was published in 2016, when 428 con-
secutive repairs using synthetic mesh were reported [14]. The complex hernia population that was addressed by TAR in this study included a large proportion of obese
patients (68%) with a mean BMI of 34.4kg/m
quently present with comorbidities, DM (21%), COPD (12%), and active smoking
status (7%), and usually had several previous abdominal surgeries (mean 3.9, range
1–19). The majority of patients in this study had a clean wound, but clean-contaminated and contaminated scenarios were also included (28% and 8%, respectively).
Although the mean postoperative stay in this study was 6.1days, this has been
successfully reduced to 4days after implementation of the aforementioned enhanced
recovery pathway for ventral hernia. Surgical site events were present in 18.7% of
cases, and although overall surgical site infection incidence was 9.1%, it was only
6.7% for clean cases. Multivariate analysis revealed age, hernia width, and wound
class III to be predictors for surgical site infection. No mesh explantation was
required. The most common systemic complication after TAR was UTI (6.8%), followed by DVT/PE (6.3%) and pneumonia (1.2%).
After a mean follow-up of 31.5months, the recurrence rate was 3.7%, most of
which can be attributed to central mesh failure with polyester or to herniations
2
(range 20–65). Patients would fre-
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L. A. Martin-del-Campo and Y. W. Novitsky
outside the edges of the prosthetic reinforcement (subxiphoid, suprapubic, lateral).
Among those who recurred, repair was obtained either laparoscopically (IPOM) or
with an onlay technique. The favorable wound morbidity observed in this study
probably highlights the benets of using rapidly integrated macroporous polypropylene mesh in a retromuscular space that provides bilaminar fascial coverage.
A particular challenging repair is often needed in kidney transplant recipients, in
whom defect size, location, presence of an allograft, and multiple comorbidities and
immunosuppression are all signicant obstacles for a repair. We recently reported
the safety and efcacy of TAR in this special population; 11 kidney transplant recipients who underwent incisional hernia repair using this technique were analyzed,
most of whom had a previous attempted repair (73%) [7]. There were two cases of
supercial surgical site infection that resolved with antibiotics. One patient developed skin necrosis that required debridement. After a mean follow-up of 12months,
only one patient developed a lateral recurrence, which during revisional surgery was
found to be bulging and not a true hernia. Although a biologic mesh was used in two
cases, this study again demonstrated how the use of a macroporous synthetic mesh
in a sublay position can be safe and effective for such unique (immunosuppressed)
patient population.
Repairing incisional hernias in patients with underlying inammatory bowel dis-
ease can be problematic, since extensive surgical history and impaired healing are
almost universal in this group of patients. Our retrospective analysis of 32 patients
with IBS that underwent TAR for incisional hernias [20] found that 34% of patients
developed a surgical site event, while 18.4% had a surgical site infection.
Nevertheless, there were no intestinal complications, and after a mean follow-up of
approximately 3years, there were only three recurrences. Therefore, TAR displayed
a favorable wound morbidity and durability prole in this series of complex hernias
in difcult patients.
Experience with TAR has been replicated in other centers across the USA, where
a series of 37 consecutive patients was recently published [21]. Similarly, patients
often had defects with several previous abdominal procedures as well as attempted
repairs. Almost 90% of the patients in this series had a clean wound, and the majority of these repairs was done using synthetic mesh (81.1%). Surgical site infection
occurred in 5.4% of patients, and there was only one recurrence after a mean followup of 21months. Similar results have been published in the UK [
22], where a series
of 12 patients has found anecdotical wound morbidity and no recurrences have been
observed. Introduction of TAR has ignited changing practice patterns of hernia in
many centers around the world. In Mexico, Espinosa de los Monteros etal. have
progressively transitioned from anterior component separation to TAR for many of
their complex ventral hernia repairs [23]. Similarly, promising reports from Russia
[24] and Romania [25] suggest that the technique can be reproducible.
In order to address the concerns surrounding the potential impact that releasing
the transversus abdominis would have in the abdominal wall physiology, we performed a CT-based analysis of the preoperative and postoperative morphology of
the abdominal wall in 25 patients who underwent TAR and 25 who had a laparoscopic ventral hernia repair without defect closure (bridged repair) [26]. Development
18 Technique: Transversus Abdominis Release
247
of compensatory hypertrophy of the rectus abdominis and both external and internal
obliques was observed only in the TAR group, reinforcing the importance of reconstruction of the linea alba. It is probably the combination of a functional midline
restoration and the compensatory hypertrophy that has allowed for signicant
improvements in postoperative abdominal wall function, as demonstrated by dynamometric evaluation and quality-of-life indicators [27].
Conclusions
The transversus abdominis release technique has found an increasing role in
addressing complex ventral hernia. TAR allows reconstruction of the linea alba
and creation of a large sublay plane for prosthetic reinforcement without raising
lipocutaneous aps or injury to the neurovascular bundles.
Ever since its rst description, data from the USA and many other countries
have shown it to be a versatile, safe, and durable repair. Deep understanding of
the surgical anatomy related to the abdominal wall and this procedure are paramount to prevent injury and offer a durable repair. Outcomes for elective cases
can be maximized by adhering to perioperative optimization and managing
patients according to our enhanced recovery pathway for ventral hernia.
References
1. Rives J, Pire JC, Flament JB, Convers G.Treatment of large eventrations (apropos of 133
cases). Minerva Chir. 1977;32:749–56.
2. Stoppa R, Louis D, Henry X, Verhaeghe P.Postoperative eventrations. Apropos of a series of
247 surgically treated patients. Chirurgie. 1985;111:303–5.
3. Wantz GE. Giant prosthetic reinforcement of the visceral sac. Surg Gynecol Obstet.
1989;169:408–17.
4. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominalwall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86:519–26.
5. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ.Transversus abdominis muscle release: a
novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204:709–16.
6. Majumder A, Miller HJ, Sandoval V, Fayezizadeh M, Wen Y, Novitsky YW.Objective assessment of myofascial medialization after posterior component separation via transversus abdominis muscle release. J Am Coll Surg. 2016;223:S57.
7. Petro CC, Orenstein SB, Criss CN, etal. Transversus abdominis muscle release for repair of
complex incisional hernias in kidney transplant recipients. Am J Surg. 2015;210:334–9.
8. Majumder A, Orenstein SB, Miller HJ, Novitsky YW.Stapled transabdominal ostomy reinforcement with retromuscular mesh (STORRM): technical details and early outcomes of a
novel approach for retromuscular repair of parastomal hernias. Am J Surg. 2018;215(1):82–7.
9. Martin-Del-Campo LA, Weltz AS, Belyansky I, Novitsky YW. Comparative analysis of
perioperative outcomes of robotic versus open transversus abdominis release. Surg Endosc.
2018;32(2):840–5.
10. Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ.Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia. 2015;19:285–91.
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L. A. Martin-del-Campo and Y. W. Novitsky
11. Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW.Benets of multimodal
enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg.
2016;222:1106–15.
12. Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Novitsky YW.Efcacy of transversus
abdominis plane block with liposomal bupivacaine during open abdominal wall reconstruction. Am J Surg. 2016;212:399–405.
13. Majumder A, Miller HJ, Patel P, Wu YV, Elliott HL, Novitsky YW.Evaluation of antibiotic
pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction. Surg
Endosc. 2017;31:2763–70.
14. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB.Outcomes
of posterior component separation with transversus abdominis muscle release and synthetic
mesh sublay reinforcement. Ann Surg. 2016;264:226–32.
15. Petro CC, Nahabet EH, Criss CN, etal. Central failures of lightweight monolament polyester
mesh causing hernia recurrence: a cautionary note. Hernia. 2015;19:155–9.
16. Fayezizadeh M, Majumder A, Belyansky I, Novitsky YW.Outcomes of retromuscular porcine
biologic mesh repairs using transversus abdominis release reconstruction. J Am Coll Surg.
2016;223:461–8.
17. Majumder A, Winder JS, Wen Y, Pauli EM, Belyansky I, Novitsky YW.Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs. Surgery.
2016;160:828–38.
18. Petro CC, Raigani S, Fayezizadeh M, etal. Permissible intraabdominal hypertension following
complex abdominal wall reconstruction. Plast Reconstr Surg. 2015;136:868–81.
19. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ.Posterior and open anterior components
separations: a comparative analysis. Am J Surg. 2012;203:318–22; discussion 22.
20. Wang J, Majumder A, Fayezizadeh M, Criss CN, Novitsky YW.Outcomes of retromuscular
approach for abdominal wall reconstruction in patients with inammatory bowel disease. Am
Surg. 2016;82:565–70.
21. Winder JS, Behar BJ, Juza RM, Potochny J, Pauli EM.Transversus abdominis release for
abdominal wall reconstruction: early experience with a novel technique. J Am Coll Surg.
2016;223:271–8.
22. Appleton ND, Anderson KD, Hancock K, Scott MH, Walsh CJ.Initial UK experience with
transversus abdominis muscle release for posterior components separation in abdominal wall
reconstruction of large or complex ventral hernias: a combined approach by general and plastic
surgeons. Ann R Coll Surg Engl. 2017;99:265–70.
23. Espinosa-de-los-Monteros A, Avendano-Peza H, Gomez-Arcive Z. Comment to comment
article “Posterior component separation with transversus abdominis release successfully
addresses recurrent ventral hernias following anterior component separation” Pauli EM, etal.
Hernia 2015; 19: 285–291. Tulloh B, de Beaux AC and to reply to comment article “Posterior
component separation with transversus abdominis release successfully addresses recurrent
ventral hernias following anterior component separation” Tulloh B etal. Hernia 2015; 19:687–
688. Pauli EM, Rosen MJ.Hernia. 2016;20:335–7.
24. Smarstsev VA, Gavrilov VA, Parshakov AA, Kuznetsova MV. Posterior separation hernioplasty TAR in treatment of postoperative ventral hernias W3 (Article in Rusian). Perm Med J.
2017;XXXIV:535–40.
25. Oprea V, Radu VG, Moga D.Transversus abdominis muscle release (TAR) for large incisional
hernia repair. Chirurgia (Bucur). 2016;111:535–40.
26. De Silva GS, Krpata DM, Hicks CW, etal. Comparative radiographic analysis of changes in
the abdominal wall musculature morphology after open posterior component separation or
bridging laparoscopic ventral hernia repair. J Am Coll Surg. 2014;218:353–7.
27. Criss CN, Petro CC, Krpata DM, etal. Functional abdominal wall reconstruction improves
core physiology and quality-of-life. Surgery. 2014;156:176–82.
Robotic Transversus Abdominis Release:
Tips andTricks
JeremyA.Warren andAlfredoM.Carbonell
Introduction
Robotic ventral hernia repair (rVHR) has experienced exponential growth in recent
years. The benets of three-dimensional, magnied visualization, articulating
instruments that allow complex intracorporeal dissection and suturing, and improved
surgeon ergonomics are appealing. Open retromuscular VHR as initially described
by Rives [1] is widely considered the standard for hernia repair, with placement of
mesh in a well-vascularized space behind the rectus muscle, isolated from the visceral cavity by closure of the posterior sheath. However, wound morbidity remains
a signicant deterrent to this approach, particularly in patients at higher risk for
these complications. The robotic platform enables this complex myofascial dissection to be performed in a minimally invasive fashion, thus maximizing the benets
and minimizing the complications associated with standard laparoscopic or open
repairs. Published literature to date on robotic transversus abdominis release (rTAR)
demonstrates a reduced length of stay compared to both laparoscopic and open
repair and some improvement in wound complications [2] [3, 4]. This is a complex
technique that requires detailed understanding of abdominal wall anatomy and how
to manipulate the various layers to ultimately mobilize the posterior layers and
release tension on the anterior fascia for closure of the linea alba.
19
J. A. Warren (*) · A. M. Carbonell
Department of Surgery, University of South Carolina School of Medicine Greenville,
Greenville, SC, USA
e-mail: jwarren1@ghs.org; ACarbonell@ghs.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_19
249
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J. A. Warren and A. M. Carbonell
Technique Overview
After entry into the abdominal cavity and establishing pneumoperitoneum, trocars
are placed along the right lateral abdominal wall. Adhesiolysis is completed and the
hernia reduced. Beginning on the contralateral side, the posterior rectus sheath is
incised just lateral to the linea alba along the entire length of the hernia defect. The
posterior rectus sheath is dissected away from the rectus muscle laterally to the
semilunar line. Above and below the hernia defect, the preperitoneal space along the
midline is taken down, leaving the linea alba intact. This allows additional incision
of the posterior rectus sheath above and below the defect and allows mesh overlap
superior and inferior to the defect.
The transversus abdominis release (TAR) is performed by incising the transversus abdominis (TA) muscle and aponeurosis within the lateral aspect of the posterior sheath to enter the preperitoneal plane, which is then developed laterally to
approximately the midaxillary line. New trocars are placed in the contralateral
abdominal wall into the preperitoneal space in mirror image to those placed initially. The hernia defect and dissected space are measured intracorporeally. Mesh is
cut to size and placed into the retromuscular space, xating it to the lateral abdominal wall below the nascent trocars. The robot is then undocked and redocked on the
opposite side. Identical retromuscular and transversus abdominis dissection is completed, bringing the initially placed trocars into the preperitoneal plane. The posterior sheath is then closed with a running absorbable self-xating suture for complete
closure of the visceral sac. Mesh is retrieved from the lateral abdominal wall and
deployed across the closed posterior sheath, afxing it to the opposite abdominal
wall. The hernia defect is closed with a running, absorbable self-xating suture to
complete the repair.
Patient Selection
The published literature to date is inadequate to clearly dene indications and contraindications for rTAR. However, many basic principles of laparoscopic ventral
hernia repair (LVHR) patient selection still apply. Patients at higher risk for wound
complications, including patients with diabetes, chronic obstructive pulmonary
disease, or obesity likely benet from this minimally invasive approach. Patients
with poor skin condition, such as wide scars from prior wound complications or
skin graft, are poor candidates for rTAR.Very large hernias, greater than 15cm,
should be approached cautiously, as larger defects are often difcult to close even
with open VHR.This largely depends on the judgment and experience of the surgeon and the patients’ abdominal wall compliance on physical exam. We have
successfully used the rTAR approach for closure of defects up to 20cm. Finally,
patients with smaller hernias do not need signicant myofascial release to reapproximate the defect. Defects less than 8cm are typically repaired with some variation of rVHR, either a preperitoneal mesh placement or a single-dock approach
that avoids TAR [3, 5–7].
19 Robotic Transversus Abdominis Release: Tips andTricks
251
Technique inDetail: Tips andTricks
Patient Positioning, Trocar Placement, andDocking
Patient is placed supine with the bed exed at the hip to open the angle between the
costal margin and iliac crest. Arms are left out, as tucked arms tend to impair the anterior reach of the robotic arms. For da Vinci
CA) users, it is helpful to turn the patients’ feet approximately 45° to allow the robotic
cart to be brought in from the patients left side more easily. This will likely vary
depending on operating room conguration, and certainly if the da Vinci
(Intuitive Surgical, Sunnyvale CA) platform is used. We prefer an optical trocar placement in the right subcostal, anterior axillary line location, with initial trocar placement
along the right lateral abdominal wall. Trocars are placed in the lateral abdominal
wall, with the camera trocar placed midway between the costal margin and iliac crest
near the midaxillary line. The working trocars are placed just off the costal margin
superiorly and iliac crest inferiorly near the anterior axillary line. All trocars are long
(180 mm), as this increases both the clearance from the patient and surgical table
when working anteriorly and increasing the reach of the instruments when completing
the contralateral dissection. When docking, the robotic arms should be brought downward parallel to the trocars in their resting position rather than distracting the trocars
vertically to meet the robotic arms. This keeps the tip of the trocars away from the
viscera to prevent bowel injury. Once docked, the instruments are “burped” up by
clutching the robotic arm and elevating the trocar along with the abdominal wall. This
maneuver allows the instruments to better reach the anterior abdominal wall.
The robotic cart is brought in on the patients’ left side for docking to the trocars
placed along the right side. We prefer to place the center column aligned with or just
below the inferior-most working trocar. This accomplishes two things: First, this
increases the space between the left arm and the robotic cart to allow placement of
the left-sided trocars once the initial retromuscular dissection and TAR are completed and for passage of the mesh. Second, the elbows of the robotic arms tend to
have greater clearance from each other in this position, resulting in fewer collisions.
The camera is oriented with a 30°—upward view.
(R)
Si system (Intuitive Surgical, Sunnyvale
(R)
Xi system
Positioning: Tips andTricks (Fig.19.1)
• Supine
• Arms out
• Bed exed
Trocar Placement: Tips andTricks (Fig.19.2)
• Long (180mm) trocars.
• Lateral: between anterior and midaxillary line.
• “Burp” trocars up by clutching robotic arm and elevating anteriorly.
Docking: Tips andTricks (Fig.19.3)
• Center column aligns with or below lowest trocar.
• Bring robotic arm downward to parallel, rather than trocar up to vertical for docking.
252
ac
a
b
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J. A. Warren and A. M. Carbonell
a
r
b
Fig. 19.1 Patient positioning tips and tricks. (a) Schematic of operating room setup. Bed is turned
approximately 45°, keeping the head near anesthesia; a anesthesia cart, r robotic cart. (b) Operating
room setup. (c) Schematic of bed position. (d) Bed and patient exed to open the space between
the iliac crest and costal margin
d
c
Fig. 19.2 Trocar placement tips and tricks. (a) Schematic of trocar placement. Trocars placed
laterally between the anterior and midaxillary lines. (b) Lateral trocar placement. (c) Trocars are
“burped” up to allow anterior reach of the robotic instruments (red lines)
19 Robotic Transversus Abdominis Release: Tips andTricks
253
a
b
c
Fig. 19.3 Docking tips and tricks. (a) Positioning of the robotic cart. The center column is aligned
at or below the lowest trocar. (b) Robot docked. (c) Schematic demonstrating docking technique.
Robotic arms should be brought down to parallel when docking to avoid bowel injury
Retromuscular Dissection
The posterior rectus sheath is incised about 5mm lateral to the linea alba, typically
near the midpoint of the hernia defect. This incision is made longitudinally, exposing
the rectus muscle, and extended to, but not yet beyond, the upper and lower limits of
the hernia defect. The instruments can then be placed into the retromuscular space,
bluntly separating the posterior sheath from the rectus muscle. It is important to
maintain the line of incision just off the linea alba and prevent tapering the incision
laterally, which would limit the width of posterior sheath available for closure. To
avoid this, simply slide the instrument within the posterior sheath medially to the
linea alba. The deection of the instrument will clearly delineate the midline, allowing accurate incision of the posterior sheath. Below the arcuate line, only a thin layer
of transversalis fascia attaches to the linea alba, which is taken down easily.
Blunt dissection is used to create the retromuscular space, with minimal need for
cautery in most cases. Retraction of the posterior sheath in a medial and dorsal/
posterior direction will ensure adequate tension—counter-tension to facilitate blunt
separation of the fascia from muscle. Inferiorly, below the arcuate line, it is helpful
to incise the transversalis fascia and remain in the preperitoneal plane. This ensures
the dissection will remain below the epigastric vessels and is easily continued laterally. The lateral extent of the dissection is the linea semilunaris, where the oblique
aponeuroses converge to create the anterior and posterior rectus sheath. This can be
identied primarily by visualizing the intercostal neurovascular bundles that penetrate the posterior rectus sheath laterally to innervate the rectus muscle. These run a
course in the interparietal plane between the internal oblique and transversus
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J. A. Warren and A. M. Carbonell
abdominis muscles and are the critical landmark for initiating the TAR.The semilunar line itself is seen as a thicker, more dense condensation of fascia and will typically reect the light of the camera more brightly than the surrounding tissue.
Additionally, when retracting medially and posteriorly on the posterior rectus sheath
at the semilunar line, vertical lines of tension are seen, and the rectus muscle can be
observed reecting downward.
Retromuscular Dissection: Tips andTricks (Fig.19.4)
• Identify rectus by visualization or cautery stimulation of muscle.
• Begin posterior sheath incision 5mm lateral to linea alba.
• Retraction is medial and posterior on the posterior sheath. Pneumoperitoneum
applies anterior retraction on the rectus for counter-tension.
• Blunt dissection.
• Pull instrument medially within the rectus sheath to consistently identify the
linea alba and maintain the proper line of posterior sheath incision.
• Linea semilunaris is identied by visualizing intercostal neurovascular bundles,
thick condensation of fascia, and a bright reection from the fascia.
a
b
c
Fig. 19.4 Retromuscular dissection tips and tricks. (a) Initial posterior sheath incision; solid line
linea alba, hd hernia defect. (b) Using the retracting hand to identify the linea alba and maintain
appropriate line of dissection; solid line linea alba, dashed line line of incision along posterior
sheath. (c) Extent of lateral retromuscular dissection; solid line cut posterior sheath, solid arrow
segmental neurovascular bundle, dashed arrow semilunar line, ra rectus abdominis
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