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286
Fig. 20.20 SCOLA—
Alternative access from the
suprapubic area. Threelow-port incision for a
patient with a recurrent
umbilical hernia, an
epigastric hernia, and a
diastasis (shown as
marked)
Fig. 20.21 SCOLA—
Measurement of the defect
and diastasis, after the rise
of the entire SC ap and
defect closure (Prolene
sutures)
F. M. M. de Oliveira et al.
(Figs. 20.22, 20.23, and 20.24). If done, this incision runs bilaterally from the
xiphoid process to the subumbilical area, thus exposing the bellies of both rectus
muscles, and the two medial segments of the anterior layer of the rectus sheath are
sutured together using continuous, nonabsorbable loop sutures (Fig.20.25). Inward
plication of the rectus abdominis diastasis is effected, and a new linea alba is formed
once suturing is complete. With that, both rectus muscles are restored to their position at the midline adjacent to the reconstructed linea alba.
Mesh Placement
Next step is the placement of a polypropylene mesh. Medium-weight macroporous
meshes are preferred due to the proximity to the skin. The mesh is tailored to size.
Only then is the mesh sutured to the anterior layer of the dissected rectus sheath
20 Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques
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Fig. 20.22 SCOLA—
Intra-op picture with the
three trocars in place and
entire subcutaneous
dissected/raised from the
fascia
Fig. 20.23 SCOLA—
Midline plication
287
Fig. 20.24 SCOLA—
Final aspect after midline
plication and defect closure
288
Fig. 20.25 ELAR—New
formed linea alba after
suturing the medial
portions of the two rectus
sheaths at the midline [15]
Fig. 20.26 SCOLA—
Final aspect after
laparoscopic mesh xation
with running sutures
F. M. M. de Oliveira et al.
Fig. 20.27 SCOLA—
Robotic suturing of the
mesh
20 Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques
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289
using continuous nonabsorbable suturing material (Figs.20.26 and 20.27). Drains
are placed, the subcutaneous tissue is sutured, and the skin is closed in a regular
fashion. Patients are advised to use an abdominal binder for 6weeks after the operation [16].
Conclusion
MIS for ventral hernias have been changing for the last few years, with a clear
trend to reproduce traditional open techniques and avoiding IPOM meshes. As
what happens with the open techniques, there is no one gold standard, but each
different approach described in this chapter has its own indications and contrain-
dications. The role of the surgeons is to analyze and decide the best technique for
each patient.
References
1. Halm JA, de Wall LL, Steyerberg EW, Jeekel J, Lange JF.Intraperitoneal polypropylene mesh
hernia repair complicates subsequent abdominal surgery. World J Surg. 2007;31(2):423–9.
2. Patel PP, Love MW, Ewing JA, Warren JA, Cobb WS, Carbonell A. Risks of subsequent
abdominal operations after laparoscopic ventral hernia repair. Surg Endosc. 2017;31(2):823–8.
3. Earle D, Roth JS, Saber A, etal. SAGES guidelines for laparoscopic ventral hernia repair. Surg
Endosc. 2016;30(8):3163–83.
4. Sanchez-Manuel FJ, Lozano-Garcia J, Seco-Gil JL.Antibiotic prophylaxis for hernia repair.
Cochrane Database Syst Rev. 2012;(2):CD003769.
5. Hull RD, Brant RF, Pineo GF, Stein PD, Raskob GE, Valentine KA.Preoperative vs postopera-
tive initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism
in patients undergoing elective hip replacement. Arch Intern Med. 1999;159(2):137–41.
6. Venturi ML, Davison SP, Caprini JA.Prevention of venous thromboembolism in the plastic
surgery patient: current guidelines and recommendations. Aesthet Surg J. 2009;29(5):421–8.
7. Daes J.The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg
Endosc. 2012;26(4):1187–9.
8. Belyansky I, Radu VG, Balasubra-manian R, Zahiri HR, Weltz AS.A novel approach using the
enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia
repair. Surg Endosc. 2018;32(3):1525–32. Houston, Texas.
9. Ghali S, Turza KC, Baumann DP, Butler CE.Minimally invasive component separation results
in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg. 2012;214(6):981–9.
290
10. Tandon A, Pathak S, Lyons NJ, Nunes QM, Daniels IR, Smart NJ.Meta-analysis of clo-
sure of the fascial defect during laparoscopic incisional and ventral hernia repair. Br J Surg.
2016;103(12):1598–607.
11. Belyansky I, Zahiri HR, Park A.Laparoscopic transversus abdominis release, a novel minimally
invasive approach to complex abdominal wall reconstruction. Surg Innov. 2016;23(2):134–41.
12. Reinpold W, Schröder M, Schröder A, Berger C, Nehls J, Stoltenberg W, Köckerling
F.Minimally invasive sublay mesh repair of incisional and primary abdominal wall hernias
using the MILOS technique. Eur Surg. 2017;49:59–64.
13. Bittner R, Schwarz J.Endoscopic mini/less open sublay operation for treatment of primary and
secondary ventral hernias of the abdominal wall. Eur Surg. 2017;49:65–70.
14. Schwarz J, Reinpold W, Bittner R.Endoscopic mini/less open sublay technique (EMILOS)—a
new technique for ventral hernia repair. Langenbeck's Arch Surg. 2017;402:173–80.
15. Köckerling F, Botsinis MD, Rohde, Reinpold W.Endoscopic-assisted linea alba reconstruction
plus mesh augmentation for treatment of umbilical and/or epigastric hernias and rectus abdominis diastasis– early results. Front Surg. 2016;3:27. https://doi.org/10.3389/fsurg.2016.00027.
16. Köckerling F, Botsinis MD, Rohde C, Reinpold W, Schug-Pass C.Endoscopic-assisted linea
alba reconstruction. New technique for treatment of symptomatic umbilical, trocar, and/or
epigastric hernias with concomitant rectus abdominis diastasis. Eur Surg. 2017;49:71–5.
F. M. M. de Oliveira et al.
Component Separation: Outcomes
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andComplications
MauriceY.Nahabedian
Introduction
The primary goal of abdominal wall reconstruction in the setting of a midline ventral hernia is to achieve primary fascial closure and maintain abdominal function.
The transverse diameter of the abdominal wall defect is a critical factor that often
determines the reconstructive approach. For midline defects less than 5cm in diameter, midline fascial closure is often possible without undue tension and can be
performed with or without mesh reinforcement; however, mesh reinforcement is
typically used and recommended. For defects that range from 5 to 10cm in diameter, additional maneuvers such as relaxing incision of the external oblique fascia are
often necessary and usually require mesh reinforcement. However, for defects that
exceed 10cm in diameter, more aggressive maneuvers are often required to achieve
midline closure.
The introduction of the anterior component separation operation has facilitated
our ability to close complex defects of the anterior abdominal wall. This classic
operation was rst described by Ramirez etal. in 1990 and has revolutionized hernia repair [1]. Prior to component separation, midline approximation of complex
ventral hernias was difcult and often not possible. The premise for this operation
is to separate the muscle groups that constituted the anterior abdominal wall to
facilitate the midline excursion of the rectus abdominis muscle. This can be performed unilaterally and bilaterally depending on the width of the hernia defect.
Early studies demonstrated that the mobility of the unilateral rectus abdominis myofascial complex was approximately 4cm above the umbilicus, 8cm at the level of
the umbilicus, and 3cm below the level of the umbilicus [
this approach is that it is considered a functional repair because the muscle groups
are mobilized without compromising the vascularity or innervation.
2]. The primary benet of
21
M. Y. Nahabedian
Virginia Commonwealth University - Inova Branch Falls Church, McLean, VA, USA
© 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_21
291
292
M. Y. Nahabedian
With the evolution of hernia repair techniques, the use of mesh to further support
the repair has demonstrated success. The benets of using a surgical mesh have
been demonstrated in the classic study by Luijendijk who found that primary fascial
closure with and without mesh reinforcement resulted in a recurrence rate of 24%
and 43%, respectively, at 3-year follow-up [3]. Ten-year follow-up of the same
cohort demonstrated a recurrence rate of 32% and 63%, respectively [4]. Although
the initial description of component separation by Ramirez did not utilize mesh,
current techniques of component separation are usually performed using a mesh for
reinforcement. This mesh can be biologic, synthetic, or resorbable and can be placed
in various layers that include onlay, underlay, retrorectus, as well as fascial interposition/bridge. The anterior component separation can also be performed as a minimally invasive technique or laparoscopically. Another recently described method is
the “sandwich” technique whereby a classic component separation is performed
followed by bilaminar mesh reinforcement as an underlay/retrorectus and onlay [5].
This chapter will include a description of the various types of component separation
repairs with an emphasis on outcomes and complications.
Anatomy
A thorough knowledge of the anterior abdominal wall anatomy is critical in order to
perform the component separation technique. The primary components include the
skin, subcutaneous fat, anterior rectus sheath, paired rectus abdominis muscles,
paired external, internal, and transverse oblique muscles, external oblique fascia,
and the posterior rectus sheath. There are four paired muscles that provide function
to the anterior abdominal wall. The origin, insertion, vascularity, innervations, and
function are listed in Table21.1.
It is important to recognize that the vascularity and innervation to the abdominal
muscles are segmental. The rectus abdominis muscle is a type 3 and 4 muscle according to the Mathes and Nahai classication because it has two dominant pedicles (inferior and superior epigastric vessels as well as segmental vascularity via the intercostal
vessels). The intercostal arteries, veins, and nerves enter the rectus abdominis at the
junction of the lateral and central third and are spaced every 5–6cm along the length
of the muscle. Within the rectus abdominis muscle, the dominant inferior and superior
vessels can course via one, two, or three dominant pathways. The intercostal arteries,
veins, and nerves that supply the oblique musculature lay between the external and
transversus oblique muscles. The plane between the external and internal oblique
muscles is a loose areolar plane without blood vessels or nerves.
The midline conuence of the anterior and posterior rectus sheath is the linea
alba. Lateral to the rectus abdominis and medial to the oblique muscles is the linea
semilunaris which is the conuence of the external, internal, and transversus fascia.
The tendinous inscriptions along the rectus abdominis muscles are zones of conuence between the muscle and the anterior rectus sheath to prevent bowstringing. The
vascularity at the tendinous inscription can be altered and known as choke vessels
that are of lesser caliber than the primary source vessel.
21 Component Separation: Outcomes andComplications
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Table 21.1 The vascularity, innervation, origin, and insertion of the four paired abdominal muscles are provided
Muscle
Rectus
abdominis
External
oblique
Internal
oblique
Transversus
abdominis
Origin Insertion Vascularity Innervation
Pubic symphysis Costal
Lower 8 ribs Linea alba,
Thoracolumbar
fascia
Lower 6 ribs,
thoracolumbar
fascia
margin 5–7,
xyphoid
ASIS, pubic
crest
Linea alba,
pubic crest,
lower 3 ribs
Linea alba,
pubic crest
Deep and
superior
epigastric
Intercostal
and
subcostal
Intercostal
and
subcostal
Intercostal
and
subcostal
Thoracoacromial
nerves
Intercostal 7–11,
subcostal,
ilioinguinal
Intercostal 7–11,
subcostal,
ilioinguinal
Intercostal 7–11,
subcostal,
ilioinguinal
Function
Trunk exion
Trunk exion
and lateral
bending
Trunk exion
and lateral
bending
Abdominal
compression
293
The vascularity of the skin and fat of the anterior abdominal wall is another
important consideration. The arteries and veins that nourish the skin and subcutaneous layers of the abdomen include perforating branches of the superior and inferior
epigastric vessels as well as perforating branches from the intercostal and subcostal
systems. The supercial inferior epigastric vessels provide perfusion to the lower
anterior abdominal wall, while the deep epigastric, intercostal, and subcostal perforators provide perfusion to the mid- and lateral abdominal wall. The majority of
dominant perforators emanate from the periumbilical region and typically range in
diameter from 1 to 3mm. Previous work has demonstrated that a 1.5mm perforator
can adequately perfuse approximately 750 g of tissue (unpublished data). The
importance of these perforators is that they are preserved when performing a perforator sparing component separation or a minimally invasive component separation.
Etiology andIndications
The etiology of the ventral midline hernia is multifactorial. Factors that contribute
to the formation include suture pull-through, increased intra-abdominal pressure,
and patient comorbidities such as obesity, poorly controlled diabetes mellitus, malnutrition, tobacco use, as well as inadequate soft tissue support to withstand the
forces of hernia formation [6]. Physiologically, as the midline repair along the linea
alba becomes disrupted or attenuated, the contraction of the rectus abdominis and
oblique muscles causes widening of the midline defect resulting in a hernia. The
indications for performing component separation include a wide midline defect
where primary fascial closure is not possible, patients at high risk of recurrence, and
in patients that have had prior repair of a hernia >5cm [7, 8].
The use of preoperative abdominal computerized tomography to determine the
feasibility of anterior component separation has been studied [9, 10]. In a review of 54
patients that had CT imaging prior to component separation, it was demonstrated that
when the transverse diameter and defect area were greater than 19.8cm and 420cm2,
294
M. Y. Nahabedian
respectively, a bridged repair was likely, whereas when the transverse diameter and
defect area were less than 10.4cm and 184cm2, respectively, primary fascial closure
was readily achieved (P=0.0002 and 0.006, respectively) [9]. Pannus thickness and
circumference as well as the estimated intra-abdominal area and volume were similar
in both groups. Blair demonstrated that preoperative CT scan was useful for planning
and patient education [10]. Increasing defect width and abdominal wall thickness
were associated with an increased need for component separation.
The use of perfusion angiography using indocyanine green (ICG) is also useful
for perfusion assessment following component separation with or without panniculectomy. In a review of 17 patients following abdominal wall reconstruction, woundhealing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs. 1/5
(20%) of the ICG cohorts [11]. Figure21.1 illustrated the hypoperfusion following
panniculectomy with the relative perfusion gradients noted. Figure21.2 demonstrated the postoperative ischemic changes of the abdomen that directly correlated
with the perfusion scan.
Fig. 21.1 Color-enhanced
uorescent angiography
demonstrating an area of
hypoperfusion on the left
lower abdominal wall
Fig. 21.2 Postoperative
ischemic tissue that
correlates with the
intraoperative angiography
21 Component Separation: Outcomes andComplications
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295
Techniques
The technique of anterior component separation has been previously described in the
literature [12, 13]. The salient aspects of the operation will be reviewed. Prior to
performing the component separation, a thorough lysis of adhesions and all bowel
work is completed. Upon completion, the adipocutaneous skin aps are widely
undermined usually to the level of the anterior axillary line. Perforator preservation
is strongly recommended when undermining to preserve the vascularity of the adipocutaneous tissue and minimize the likelihood of soft tissue necrosis and delayed
healing [14–16] (Fig.21.3). The hernia defect, anterior rectus sheath, linea semilunaris, and external oblique fascia are in clear view. Component separation can be performed unilaterally or bilaterally. In the original description by Ramirez, the
separation of parts allowing mobilization of the anterior muscle groups occurs via
two routes [1]. The rst is by release of the posterior rectus sheath from the rectus
abdominis muscle preserving the inferior epigastric artery and vein coursing through
the muscle. The posterior sheath is incised throughout its length that permits 2–3cm
of mobilization of the rectus abdominis muscle toward the midline. The second and
more effective release point is the external oblique fascia and muscle. The external
oblique fascia and muscle is incised 1cm lateral to the linea semilunaris. The avascular plane between the external and internal oblique muscles is entered and undermined toward the anterior axillary line. Following this release the rectus abdominis
musculofascial complex is pulled medially to achieve primary fascial approximation.
When mobility is hindered superiorly or inferiorly, the origin of the rectus abdominis
muscle on the costal margin and pubic bone can be released to achieve additional
excursion. The use of a biologic or synthetic mesh is usually considered following
component separation to reinforce the repair and to reduce the likelihood of recurrence [3]. These mesh materials can be positioned in a variety of locations that
include underlay, retrorectus, onlay, and interposition [17]. The goal of anterior component separation is to achieve primary fascial closure. When not possible, bridging
Fig. 21.3 Perforator
sparing component
separation illustrating the
individual perforators
perfusing the
adipocutaneous tissue
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