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Alexander & Scott
for most hernias and for larger hernias and those requiring extensive lysis of adhesions, patients may require several days of hospitalization. Pain can initially be intense
from the transfascial sutures, requiring intravenous (IV) narcotics for the first 24 hours.
Oral medications and IV antiinflammatories may also be used. Other adjuncts include
muscle relaxants such as cyclobenzaprine or diazepam to relieve muscle spasms
related to suture sites.
Diet may be advanced as tolerated in most cases, depending on the surgeon’s preference and the extent of adhesiolysis; a clear liquid diet may be started immediately
after surgery for most cases. Routine postoperative care includes early ambulation,
subcutaneous low-molecular-weight heparin, sequential compression devices, and
incentive spirometry. An abdominal binder is placed postoperatively, and the patient
is advised to wear it for 3 to 14 days, which may decrease the size and duration of
seromas.
20
Patients are discharged when tolerating a regular diet, and pain is
controlled on oral medications. Pain medications may need to be continued for up
to several weeks postoperatively, because improvement is often a slow but steady
process. Patients are encouraged to resume normal activity after surgery, but advised
not to lift heavy objects (>9.07 kg [20 lbs]) or engage in strenuous activities for 4 to
6 weeks.
COMPLICATIONS
Bleeding
Intraoperative bleeding most often is seen with insertion of the trocars, adhesiolysis, or
mesh fixation and is usually controlled with simple measures. Trocar bleeding usually
resolves with tamponade from the trocar itself. However, if it continues after removal, a
suture placement or electrocautery may be necessary.
During adhesiolysis, in an attempt to avoid thermal injury to the surrounding viscera,
bleeding may occur from the cut omentum or adhesive bands. A suction irrigator may
be necessary to identify bleeding locations, especially if substantial raw omental surfaces are present. If no bowel is close, points of bleeding can be controlled carefully
using a thermal energy device such as electrocautery or ultrasonic shears. However, it
may be necessary to apply clips or use suture ligation if the source of bleeding is close
to visceral structures. Similarly, if the bleeding source is on the bowel or mesentery,
suture ligation may be the most prudent means of achieving hemostasis.
During mesh fixation, an attempt should be made to identify the epigastric vessels
to avoid injury during passage of transfascial fixation sutures or placement of tacks. If
these vessels are injured, the bleeding is often controlled by simply tying the suture.
They may also be ligated by placing additional simple or figure-of-eight transfascial
sutures. Before completion of the procedure, the abdomen should be inspected to
ensure that adequate hemostasis has been achieved.
Intestinal Injury
The management of a recognized injury was discussed earlier. The reported incidence
of an incidental enterotomy is between 1% and 3%, which is higher than that reported
for open ventral hernia repairs.
preventing, recognizing, and treating this potentially lethal complication. An unrecognized enterotomy has been reported to occur in 0.33% of repairs.
8
It is therefore paramount that surgeons are vigilant in
9
Leblanc reported
that the mortality of an uncomplicated ventral hernia was reported as 0.05%; this
increased to 1.7% with a recognized enterotomy and to 7.7% with an unrecognized
injury. Presentation may include increasing pain, abdominal distention, or signs of
sepsis such as tachycardia, fever, hypotension, or decreased urine output. Diagnostic
Laparoscopic Ventral Hernia Repair
studies may be indicated, depending on the clinical scenario, but the surgeon should
not hesitate to take the patient directly to the operating room if a bowel injury is suspected. At exploration, if contamination is found, a laparotomy may be necessary to
repair the injury, wash out the abdomen, and remove the mesh; a primary abdominal
closure or an alternative method, such as absorbable or biological mesh placement,
may be performed.
Seromas
Because the hernia sac is left in place and drains are not traditionally used during a
laparoscopic hernia repair, most patients develop a seroma postoperatively. In the
early postoperative period, fluid fills the space between the mesh and the skin and
slowly becomes resorbed as scar tissue forms and obliterates this cavity. As a preventative measure, most surgeons place an abdominal binder to compress the hernia sac
area starting immediately postoperatively and continuing for at least 2 weeks. This
strategy may decrease the size and duration of seromas, but most patients still
have one. Most seromas are asymptomatic and resolve spontaneously. A study by
Susmallian and colleagues
21
followed 20 consecutive patients with routine ultrasound
examinations over a 90-day period. Although seromas formed in 100% of patients,
only 35% were detectable on physical examination. This study documented that the
peak in seroma volume was at 7 days and that 80% of the seromas resolved by
90 days. Other studies have reported an incidence of 0.7% to 12% for persistent or
symptomatic seromas.
5,9,22
The higher percentage reported in some studies is likely
because many surgeons do not consider a seroma as a complication unless an intervention such as aspiration is required. Most experts recommend the avoidance of
aspiration, because even using sterile conditions poses a risk of contamination of
an otherwise sterile fluid collection in contact with the mesh prosthetic. Instead, patients are reassured that most collections resolve, and a CT scan may be obtained
if there is any concern over a recurrence. Aspiration may be considered in patients
with significant symptoms of pain or pressure or with persistent seromas after
3 months of observation, but in practice this is rarely needed.
1107
Persistent Pain
Even although a large incision is not used, LVHR may be associated with significant
abdominal pain, which is usually muscular in nature and related to mesh fixation using
transfascial sutures and tacks. As mentioned earlier, patients may require analgesics
or muscle relaxants for the first few weeks postoperatively. Significant pain persisting
beyond the first 6 to 12 weeks is rare, with several studies indicating an incidence of
1% to 2%.
23–25
The pain is usually located at 1 of the suture sites, may be relatively
intense, and is exacerbated with physical activity. In this case, conservative treatment
is indicated and is likely be successful. If further treatment is needed, injection therapy
may be useful using local anesthetics.
5,26
Cobb and colleagues5recommended injecting the site with 25 to 30 mL of 0.25% bupivacaine with 1:200,000 epinephrine and 1%
lidocaine using a 22-gauge needle. Although rarely required, exploratory laparoscopy
with removal of tacks or transfascial sutures has been described with success. Other
potential causes of persistent pain include a seroma or hernia recurrence; CT scan
imaging may be indicated if the diagnosis is not clinically evident.
Wound and Mesh Infections
Most wound complications after LVHR are seromas, and infections are rare. In a metaanalysis (N 5 4582 LVHRs) published by Pierce and colleagues,
25
the overall wound
complications were reported as 3.8% to 5.3%, which did not include seromas. These
1108
Alexander & Scott
investigators reported an incidence of wound infections in only 1.3% to 2.3% of patients, and mesh infections in only 0.9% to 1.3% of patients. This incidence includes
data from the study by Heniford and colleagues
22
(N 5 819 LVHRs), which reported an
overall infection rate of 1.8%, including both wound and mesh infections.
Because trocar sites are usually located remotely in relation to the mesh, infections
at these locations may be treated with packing and antibiotics, with minimal risks of
involvement of the mesh. For the mesh to become infected is a rare event. CT imaging
may show gas and fluid collections, with extensive inflammatory changes. Such circumstances usually require open abdominal exploration, with identification of any
concomitant intra-abdominal complications, washout and drainage, and mesh removal. In select cases, some investigators have described management of limited
mesh infections with percutaneous or open drainage and prolonged antibiotics with
salvage of the mesh.
Recurrence
27–29
However, most infected meshes require excision.
Recurrence rates associated with LVHR have been acceptably low. Several studies
have shown better results for laparoscopic repairs compared with open repairs. In
the meta-analysis by Pierce and colleagues,
scopic (N 5 619) versus open (N 5 758) cases was 3.1% and 12.1%, respectively. In a
meta-analysis by Forbes and colleagues
25
the recurrence rates for paired laparo-
30
comparing 8 randomized controlled trials
evaluating laparoscopic versus open repair, the recurrence rates were similar at
3.4% and 3.6%, respectively.
Several factors have been shown to increase the risk of recurrence. As would be
expected, recurrent hernias, larger defects, and morbid obesity are associated with
an increased risk of recurrence.
and colleagues
5
reported an overall recurrence rate of 4.7%. Patients with a body
22
In a retrospective review of 270 LVHRs, Cobb
mass index (BMI), calculated as weight in kilograms divided by the square of height
in meters, of less than 40 (N 5 225) had a recurrence rate of 3.5% to 4.5%, compared
with 9.4% in patients with a BMI greater than 40 (N 5 52). Patients with previous hernia
repairs (N 5 257) had a recurrence rate of 7.3% compared with 2.2% for initial repairs
(N 5 138). Technical factors known to correlate with decreased recurrence include
adequate exposure of the defect with the mesh in contact with the fascia, appropriate
overlap, and adequate fixation.
Most experts advocate the use of transfascial sutures as a critical step in preventing
recurrence. Some investigators have reported low recurrence rates using tacks
12,31–33
only.
They advocate this technique to decrease the risk of persistent pain
that has been associated with transfascial suture fixation. However, other expert surgeons have reported high recurrences early in their career with the use of only
22,24
tacks.
Therefore, most experts advise transfascial fixation.
SUMMARY
LVHR has established itself as a well-accepted option in the treatment of hernias.
Clear benefits have been established regarding the superiority of LVHR in terms of
fewer wound infections compared with open repairs. Meticulous technique and
appropriate patient selection are critical to obtain the reported results.
REFERENCES
1. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias
using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc
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Laparoscopic Ventral Hernia Repair
2. Colavita PD, Tsirline VB, Belyansky I, et al. Prospective, long-term comparison of
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4. Franklin ME, Trevino JM, Portillo G, et al. The use of porcine small intestinal sub-
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1941–6.
5. Cobb WS, Kercher KW, Matthews BD, et al. Laparoscopic ventral hernia repair: a
single center experience. Hernia 2006;10:236–42.
6. Tsereteli Z, Pryor BA, Heniford BT, et al. Laparoscopic ventral hernia repair in
morbidly obese patients. Hernia 2008;12:233–8.
7. Newcomb WL, Polhil JL, Chen AY, et al. Staged hernia repair preceded by gastric
bypass for the treatment of morbidly obese patients with complex ventral hernias.
Hernia 2008;12:465–9.
8. LeBlanc KA, Elieson MJ, Corder JM III. Enterotomy and mortality rates of laparo-
scopic incisional and ventral hernia repair: a review of the literature. JSLS 2007;
11:408–14.
9. LeBlanc KA. Laparoscopic incisional and ventral hernia repair; complications–
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10. Berger D, Bientzle M, Mu¨ller A. Postoperative complications after laparoscopic
incisional hernia repair. Surg Endosc 2002;16:1720–3.
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nia repair in 407 patients. J Am Coll Surg 2000;190:645–50.
12. Carbajo MA, Martp del Olmo JC, Blanco JI, et al. Laparoscopic approach to inci-
sional hernia. Surg Endosc 2003;17:118–22.
13. Wassenaar EB, Schoenmaeckers EJ, Raymakers JT, et al. Recurrences after
laparoscopic repair of ventral and incisional hernia: lessons learned from 505
repairs. Surg Endosc 2009;23(4):825–32.
14. Ferrari GC, Miranda A, Sansonna F, et al. Laparoscopic repair of incisional
hernias located on the abdominal borders. Surg Laparosc Endosc Percutan
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15. Eisenberg D, Popescu WM, Duffy AJ, et al. Laparoscopic treatment of subxiphoid
incisional hernias in cardiac transplant patients. JSLS 2008;12:262–6.
16. Losanoff JE, Basson MD, Laker S, et al. Subxiphoid incisional hernias after
median sternotomy. Hernia 2007;11:473–9.
17. Edwards C, Geiger T, Bartow K, et al. Laparoscopic transperitoneal repair of flank
hernias: a retrospective review of 27 patients. Surg Endosc 2009;23:2692–6.
18. Carbonell AM, Kercher KW, Matthews BD, et al. The laparoscopic repair of supra-
pubic ventral hernias. Surg Endosc 2005;19:174–7.
19. Palanivelu C, Rangarajan M, Parthasarathi R, et al. Laparoscopic repair of supra-
pubic incisional hernias: suturing and intraperitoneal composite mesh onlay.
Hernia 2008;12:251–6.
20. Chowbey RK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair.
J Laparoendosc Adv Surg Tech A 2000;10:79–84.
21. Susmallian S, Gewurtz G, Ezri T, et al. Seroma after laparoscopic repair of hernia
with PTFE patch: is it really a complication? Hernia 2001;5:139–41.
22. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias:
nine years’ experience with 850 consecutive hernias. Ann Surg 2003;238:
391–9.
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23. Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of incisional hernias.
Surg Endosc 2002;16:345–8.
24. LeBlanc KA, Whitaker JM, Bellanger DE, et al. Laparoscopic incisional and
ventral hernioplasty: lessons learned from 200 patients. Hernia 2003;7:118–24.
25. Pierce RA, Spitler JA, Frisella MM, et al. Pooled data analysis of laparoscopic vs.
open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007;
21:378–86.
26. Carbonell AM, Harold KL, Mahmutovic A, et al. Local injection for the treatment of
suture site pain after laparoscopic ventral hernia repair. Am Surg 2003;69:
688–92.
27. Paton BL, Novitsky YW, Zerey M, et al. Management of infections of
polytetrafluoroethylene-based mesh. Surg Infect (Larchmt) 2007;8(3):337–41.
28. Trunzo JA, Ponsky JL, Jin J, et al. A novel approach for salvaging infected pros-
thetic mesh after ventral hernia repair. Hernia 2009;13:545–9.
29. Collage RD, Rosengart MR. Abdominal wall infections with in situ mesh. Surg
Infect (Larchmt) 2010;11(3):311–8.
30. Forbes SS, Eskicioglu C, McLeod RS, et al. Meta-analysis of randomized
controlled trials comparing open and laparoscopic ventral and incisional hernia
repair with mesh. Br J Surg 2009;96:851–8.
31. Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia
repair: results and critical review. Hernia 2004;8:138–42.
32. Baccari P, Nifosi J, Ghirardelli L, et al. Laparoscopic incisional and ventral hernia
repair without sutures: a single-center experience with 200 cases. J Laparoendosc
Adv Surg Tech A 2009;19(2):175–9.
33. Olmi S, Scaini A, Cesana GC, et al. Laparoscopic versus open incisional hernia
repair. Surg Endosc 2007;21:555–9.
Open Ventral Hernia Repair with Component Separation
b,
Eric M. Pauli, MDa, Michael J. Rosen, MD
KEYWORDS
Ventral herniaIncisional herniaAbdominal wall reconstruction
Retromuscular hernia repairTransversus abdominis release (TAR)
Rives-Stoppa technique
KEY POINTS
Incisional hernias are the most common complication after laparotomy and the most com-
mon indication for reoperation after laparotomy.
Recent advancements in mesh technology and technical refinements in the methods of
herniorraphy have dramatically changed the way open hernia surgery is conducted.
Abdominal wall reconstructive procedures, which typically include separation of the
abdominal wall layers and release of one or more myofascial planes, require a clear understanding of the anatomy of the abdominal wall.
The authors’ favored approach to open ventral hernia repair is a posterior component sep-
aration (retrorectus dissection with release of the transversus abdominis aponeurosis and
muscle) with sublay of appropriately selected mesh between layers of vascularized tissues and subsequent reconstruction of the linea alba.
Retromuscular hernia repairs have been shown in multiple studies to have a low recur-
rence rate (3%–6%) at long-term follow-up and have been accepted as the gold standard
technique for open ventral hernia repair by the American Hernia Society.
*
INTRODUCTION
Despite improved outcomes in many other areas of surgery, abdominal wall hernia
formation still complicates 11% to 50% of all laparotomies.
common complication following laparotomy and is the most common indication for
reoperation by a 3:1 margin over bowel obstruction.
7
With more than 2 million laparot-
1–6
It remains the most
omies performed in the United States annually, general surgeons are faced with
Disclosures: Eric Pauli is a speaker for Bard and Synthes. Michael Rosen is a speaker for Covidien,
Bard, and Lifecell. He receives research support from Lifecell, Davol, W.L. Gore, and Cook.
a
Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149,
Hershey, PA 17036, USA;
sity Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
* Corresponding author.
E-mail address: michael.rosen@uhhospitals.org
Surg Clin N Am 93 (2013) 1111–1133
http://dx.doi.org/10.1016/j.suc.2013.06.010 surgical.theclinics.com
0039-6109/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
b
Department of Surgery, Case Comprehensive Hernia Center, Univer-
1112
Pauli & Rosen
epidemic numbers of patients requiring ventral herniorraphy.8A reliable method with a
low recurrence rate is still clearly necessary for the estimated 200,000 patients undergoing ventral hernia repairs annually.
Traditional methods of hernia repair have unacceptably high recurrence rates.
Primary open suture repair of ventral hernias with simple fascial reapproximation
results in recurrence rates in excess of 50% in long-term follow-up.
years ago, the mesh herniorraphy was introduced.
mesh reinforced herniorraphy has undergone technical refinements since this time
and is still considered to be the gold standard repair.
implementation of this “gold standard,” the addition of mesh to open repairs still
results in long-term recurrence rates as high as 32%.
9
10,11
6,12–19
20
The principle of a tension-free
11,21
Despite the widespread
17–19
Moreover, the ideal method
Fifty-five
of mesh implantation is the subject of ongoing debate.
With the advent of laparoscopic ventral hernia repair in 1993, minimally invasive
techniques became the preferential method for many surgeons.
22
Intuitively, these
repairs had the advantage: they provided wide mesh overlap of the hernia defect
without significant soft tissue dissection. Short-term data suggested decreased
morbidity and a lower recurrence rate.
long term, where recurrence rates in well-selected populations still reach 14% to
24–27
17%.
As a consequence, one of the most pressing controversies of ventral hernia
repair is whether to approach the problem in an open or laparoscopic fashion.
23
Sadly, these data were not borne out in the
11
Parallel with the evolution of laparoscopic ventral hernia repair, novel methods of
abdominal component separation were being developed. In 1990, Ramirez and
colleagues
28
originally described techniques of medial fascial advancement to aid in
definitive reconstruction. In their components separation, Ramirez and colleagues
first released the posterior rectus sheath. In 30% of their patients, this was insufficient
to permit midline closure, and they therefore created large skin flaps to expose and
release the external oblique muscle. Recurrence rates after such component separation hernia repairs range from 10% to 22%, with mean follow-up periods of 9.5 months
to 4.5 years.
29–31
Modifications of these myofascial advancement flaps have been
developed to reduce the morbidity incurred by creating these skin flaps (and by
default reduce the recurrence rate). Such methods include periumbilical perforator
sparing (PUPS) methods, endoscopic release of the external oblique muscle, and,
more recently, posterior component separation methods that avoid any skin
undermining.
32–38
Posterior component separation methods are based on the Rives-Stoppa-Wantz
retrorectus repair, which used the 6-cm-wide to 8-cm-wide potential space between
the posterior rectus sheath and the rectus muscle to permit mesh positioning in a sublay fashion.
gold standard method for open ventral hernia repair by the American Hernia Society in
2004.
39–42
Given its superior track record, this approach was deemed to be the
11,38
Although durable, the Rives-Stoppa-Wantz technique does not permit
dissection beyond the lateral border of the posterior rectus sheath, making it insufficient to permit adequate mesh overlap and tension-free repair of larger abdominal
wall defects.
include preperitoneal dissection, intramuscular plane formation, and release of the
transversus abdominis muscle.
able to achieve recurrence rates as low as 3% to 6%.
38,42
Methods to extend this potential space have been described and
35,37,38,43
Using these methods, surgeons have been
35,36,38,43
In this article, we describe our current operative technique for open ventral hernia
repair using component separation. Although we describe methods of anterior
component separation, in our current practice, we primarily use posterior component
separation with transversus abdominis release to permit dissection beyond the
retrorectus space. This method adheres to the literature supported principles of a
28
Component Separation Hernia Repair
tension-free midline fascial closure with wide mesh overlap of mesh positioned in a
sublay position. Our experience with this method supports a low recurrence rate
and reduced wound morbidity.
PREOPERATIVE PLANNING
Physical Examination
Defect size, location of prior incisions or stomas, draining sinuses, exposed
mesh, skin issues (eg, thinning, ulceration, cellulitis) should all be ascertained
from physical examination.
Operative History
Review of old operative reports is mandatory to identify what types of repairs
have been previously attempted, what type of mesh was used (if any), and into
which plane it was placed.
Abdominal Wall Imaging
Computed tomography (CT) of the abdomen and pelvis remains the gold
standard preoperative imaging modality for ventral hernia repair. Typically no
contrast is required.
CT scans demonstrate the size and location of the hernia sac(s), identify synthetic
mesh as well as signs of mesh infection (fluid collections, inflammatory stranding,
sinus tracts), and provide information about the remaining abdominal musculature.
CT angiography can identify the periumbilical perforating vessels and may help
in deciding between classical or PUPS anterior component separation.
1113
Managing Medical Comorbidities
Comorbidities associated with higher rates of recurrence and complication
should be medically optimized; diabetic blood sugar control, cardiac risk factors,
obesity, malnutrition, pulmonary function, methicillin-resistant Staphylococcus
aureus (MRSA) colonization.
Smoking cessation is an absolute requirement. Supplemental oxygen use also
precludes surgery.
Obese patients, especially those with a body mass index higher than 45, should
undergo a medical bariatric evaluation to facilitate weight loss, improve exercise
tolerance, reduce protein malnutrition, and possibly steer the patient to surgical
weight loss surgery before herniorraphy is attempted.
Preoperative Counseling
A frank discussion with the patient about the likelihood of one or more complica-
tions is part of the informed consent process. Hernia recurrence, mesh infection
(and its potential consequences), abdominal compartment syndrome, and
requirement for postoperative ventilation are all reviewed.
We specifically address “unacceptable outcomes” with patients as part of our
determination of what mesh (synthetic or biologic) to use. Some patients will
accept the risk of synthetic mesh infection or draining sinus for a lower hernia
recurrence rate; others will not.
CLINICAL ANATOMY
A thorough understanding of the anatomy of the abdominal wall is mandatory when
performing ventral herniorraphy with component separation. This includes not only
1114
Pauli & Rosen
an understanding of the neurovascular supply to muscle, fat, and skin, but also knowledge of force vectors each of the muscular layers generates. Such knowledge results
in the best clinical outcomes by providing a well-vascularized, innervated, and
correctly oriented abdominal wall reconstruction.
Normally, 2 vertically oriented rectus abdominis muscles originate at the pubic
symphysis and insert on the costal cartilage of ribs 5 to 7. These muscles should lie
on either side of the intact, midline linea alba. On each side of the rectus, 3 flat
semihorizontally oriented muscles are found layered on one another: the external
oblique muscle, the internal oblique muscle, and the transversus abdominis muscle
(from superficial to deep). Disruption of the linea alba permits unopposed lateral pull
on the recti by the lateral musculature and contributes to increase in size of incisional
midline hernias.
At the lateral boarder of the rectus muscle, the aponeurosis of the lateral abdominal
muscles alternately separate or fuse to contribute to the rectus sheath. Here, the
external oblique aponeurosis and rectus sheath fuse to form the linea semilunaris.
Above the arcuate line, the internal oblique aponeurosis splits to contribute to both
the anterior and posterior rectus sheaths (Fig. 1). Below the arcuate line, the aponeurosis does not split but rather fuses with the external oblique fascia to form the anterior
rectus sheath alone (see Fig. 1). The transversus abdominis muscle’s medial aponeurosis merges with the posterior lamina of the internal oblique to form the posterior
sheath. For retrorectus repair, it is important to note that the transversus abdominis
does not contribute to the linea semilunaris. Its muscle belly extends medial to the
linea semilunaris, behind the rectus muscle, in the upper one-third of the abdomen
(Fig. 2).
Each rectus muscle receives blood supply from the inferior and superior epigastric
arteries as well as intercostal arterial branches that enter the muscle belly laterally.
These intercostal branches are also the main blood supply to the lateral musculature.
They travel with the thoracoabdominal nerves (branches of T7–T12) in the “neurovascular plane” located between the internal oblique and transversus abdominis muscles.
In addition to supplying the lateral abdominal musculature and skin, these branches
innervate the rectus muscle posteriorly and slightly medial to the linea semilunaris.
Both anterior and posterior component separations are able to preserve these intercostal neurovascular bundles due to their location deep to the internal oblique.
For anterior component separation, where lipocutaneous flaps are created, knowledge of the skin vascularity is also critical. For a classic component separation
(external oblique release), transection of the deep epigastric perforating vessels leaves
the central abdominal wall without its major blood supply. PUPS component separation preserves these vessels to reduce the risk of ischemia-related wound
complications.
CHOICE OF MESH
For patients with clean wounds, we prefer a large (30.5 30.5-cm) lightweight,
macroporous, polypropylene mesh. There is emerging evidence that use of
this mesh is also acceptable in patients with multiple comorbidities (diabetes,
obesity, prior mesh infection) or in clean-contaminated circumstances (fistula
takedown, enterotomy closure, small bowel resection, stoma formation or
relocation).
Use of synthetic mesh with an antiadhesive coating can be considered if the
viscera will be exposed to the mesh, but this is rarely necessary with either technique to be described.
Component Separation Hernia Repair
1115
Fig. 1. Normal anatomic positions of the abdominal wall musculature. Cross-sectional views
(left) show the division and fusion of the lateral muscle fascial sheaths at the linea
semilunaris both above and below the arcuate line. (From Rosen M, editor. Atlas of abdominal wall reconstruction. New York: Saunders; 2011; with permission.)
Biologic mesh is appropriately considered for patients with a higher risk of devel-
oping a postoperative surgical site infection (SSI). This includes potentially
contaminated or contaminated fields, patients with medical comorbidities (diabetes, obesity, immunosuppression, steroid use) or history of MRSA infection.
SURGICAL TECHNIQUE: POSTERIOR COMPONENT SEPARATION
Positioning and Marking
The patient is positioned in a supine position with arms abducted.
A Foley catheter and an orogastric tube are placed.
The abdomen is clipped of hair and is widely sterilized with a 2% chlorhexidine
gluconate and 70% isopropyl alcohol solution.