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9 Endoscopic andLaparoscopic Techniques ofMinimally Invasive Components Separation
119
On initial encounter all major comorbidities
must be addressed by means of a multidisciplinary approach before proceeding to the
operating room. Emphasis is placed on assessing
cardiopulmonary and endocrine systems as they
pose the greatest risk for intraoperative morbidity
and mortality. Diabetic patients are to have their
HbA1C levels managed below 7.4 with established goals for postoperative glycemic control.
Morbidly obese individuals must achieve a target
body mass index (BMI) of less than 40 with any
patient of a BMI greater than 35 consulted by
either a registered dietician or nutritionist to
begin a comprehensive weight loss program.
Patients with a positive smoking history must
demonstrate cessation for at least 4weeks prior
to surgical intervention and may benet from
consultation with substance abuse counselors.
Nicotine levels are conrmed with serum cotinine levels in the preoperative area the day of surgery to proceed only in those testing negative for
nicotine derivatives.
It is important to discuss with the patient
likely outcomes and possible complications of
surgery in order to establish a reasonable series
of expectations postoperatively. Despite the minimally invasive nature of these procedures,
patients may still experience signicant amounts
of pain requiring inpatient management. Possible
complications including seroma, hematoma,
deep or supercial abscesses, bowel injury, and
their respective management options must be
presented. In the event of complex revisional procedures, the possibility for conversion to open
surgery is typically higher and warrants additional discussion. Additionally, patients with
active infection should be treated with properly
selected antimicrobial therapy with resolution of
the infection before surgery. Preoperative antibiotics should be properly selected and dosed
according to hospital protocol [15, 16]. We recommend routine administration of subcutaneous
heparin for DVT prophylaxis in our patient population, beginning prior to the induction of anesthesia and administered throughout the typical
duration of the procedure [17, 18]. A VTE
surgical risk model such as the Caprini score
method can be used to tailor VTE prophylaxis to
the specic patient. Sequential compression
devices (SCD) or foot pumps should be used
when available.
Operating Room Setup andPatient
Positioning
Patients are positioned supine with both arms
tucked to their sides. After induction of anesthesia, Foley catheter is routinely placed. The operating room table is exed with the legs extend
down at a minimum of 30° to afford the surgeon
and assistant greater instrument range of motion
(Fig.9.1). Failure to sufciently ex the operating table will result in surgeon’s hand collision
with the patient’s body while dissecting and
suturing the defects.
eTEP Access
The enhanced-view totally extraperitoneal
(eTEP) access approach was previously described
for laparoscopic inguinal hernia repair by Dr.
Jorge Daes [19]. This approach introduced the
notion that the extraperitoneal space is limitless
once the conuence of arcuate line and semilunar
line are taken down. We have adopted this
Fig. 9.1 Positioning of the patient for laparoscopic
CS. Patient is in Trendelenburg position with hips
extended. Bed exion is best avoided
120
technique for repair of ventral and incisional herniae [4, 14, 19]. The eTEP access approach relies
on dissection in the naturally occurring retromuscular spaces. Typically, dissection is initiated in
one of the retrorectus spaces and then crosses
over to the contralateral side, thus joining the two
spaces into one large operative region. The key
advantages of this approach are:
• The rapid creation of an extraperitoneal
domain.
• The technique may enable an entirely extra-
peritoneal approach.
• If the intra-abdominal cavity is entered, safe
adhesiolysis can be performed.
• Improved tolerance of pneumoperitoneum.
• Dynamic port setup that can be adjusted based
on the location of the defect.
Prior to incision, we suggest appreciating and
marking out relevant anatomy at skin level. This
includes the xiphoid process, bilateral subcostal
margins, symphysis pubis, linea alba, and semilunar lines. Preoperative CT scan and physical
exam are used to facilitate the marking of these
landmarks. Positioning of the surgeon, monitor,
and trocars is dependent on the location of the
hernia defect and decision where to crossover.
Monitors are placed at the head of the bed with
trocar sites on the lower abdomen when addressing an upper midline hernia defect and inverted in
instances of lower midline hernia defects.
Upper Midline Defect
When dealing with upper midline defects we prefer to perform the crossover below the level of the
umbilicus, developing preperitoneal and retromuscular spaces that have not been previously violated. Figure9.2 demonstrates the port position for
upper midline defects. The rst incision is made
2cm below a horizontal line drawn through umbilicus just medial to the right linea semilunaris. The
anterior rectus sheath is identied and incised
sharply. Single site balloon dissector is used to
develop the right retrorectus space in cephalad and
caudal directions. It is critical to avoid over-ina-
Z. Sanford et al.
Fig. 9.2 Port positioning for upper midline defects. The
balloon dissector is placed in Port #1. Ports #1 and #2 in
red circles are working ports. Port #3 in yellow is the camera port
tion which may rupture the linea semilunaris and
consequently injure the rectus abdominis muscle.
In addition, special care should be given to appreciating the inferior epigastric vessels that travel
parallel and medial to linea semilunaris in the
vicinity of the #1 port. Once the space of Retzius
is developed, ports #2 and #3 are placed under
direct vision in the lower abdomen. The site of port
#3 can also be used to pass the balloon spacemaker in a cephalad direction to develop the left
retrorectus space. Thus, even before any initiation
of sharp dissection the retromuscular space surrounding the hernia defect is completely dissected
bluntly with the balloon space-maker.
A 30° scope is placed through port #3 after
which we proceed with division of the medial
contributions of the posterior rectus sheath to the
linea alba bilaterally from caudal to cephalad
direction. In the middle we try to preserve the
preperitoneal contributions to the posterior layer
which are made up of the falciform and umbilical
ligaments. In such a fashion the division of posterior rectus sheath and preservation of falciform
9 Endoscopic andLaparoscopic Techniques ofMinimally Invasive Components Separation
Fig. 9.3 View of the
retrorectus space. After
crossing over and
dissection, the
retrorectus spaces on
both sides are combined
into one large retrorectus
space. This falciform
ligament can be seen
below
ligament and umbilical ligaments allows us to
join the right and the left retrorectus spaces
together with midline preperitoneal space
(Fig.9.3).
Following the dissection in these planes we
then anticipate to encounter the neck of the hernia sac. In true incisional herniae, the layers surrounding the neck of the sack can be thoroughly
fused together and difcult to differentiate. A
recent preoperative CT scan, therefore, is an
invaluable aid in identication of the hernia and
its contents. An attempt may be made in some
cases to reduce the entirety of the sac by separating it from its distal attachments, however this is
not often attempted. We frequently give consider-
Fig. 9.4 Sharp opening of the peritoneal layer proximal
to the neck of the hernia sac, allowing for reduction of
visceral contents under direct visualization and limited
adhesiolysis
ation to sharply opening the peritoneal layer just
proximal to the neck of the sac to reduce visceral
contents under direct visualization and perform
limited adhesiolysis (Fig.9.4). Any defects in the
posterior layer can be xed with 3-0 suture. Once
the hernia contents are reduced, retromuscular
dissection commences with release of the medial
aspect of the posterior rectus sheath and concludes just below the level of the xiphoid
process.
the dissection in the upper portion of left retrorectus space. Figure9.5 demonstrates the typical
port position that we chose to use for this
approach. Balloon dissector is used at port position #1 to develop the left retrorectus space, followed by direct visualization for placement of
port #2 into the developed space with an optional
port #3. Blunt dissection in the left retrorectus
space is performed in a caudal direction and the
pubis is identied. As the upper midline has not
previously been violated above the level of umbi-
Lower Midline Defects
licus, the medial aspect of the left posterior rectus
sheath is incised and the preperitoneal space
For a right-handed surgeon, we found that lower
midline defects are easier to address by initiating
entered just supercial to falciform ligament
(Fig. 9.6). The right posterior rectus sheath is
121
122
Fig. 9.5 Port placement for a right-handed surgeon
addressing a lower midline defects. We initiate the dissection in the upper portion of left retrorectus space. Balloon
dissector is used at port position #1 to develop the left
retrorectus space, followed by direct visualization for
placement of port #2 into the developed space with an
optional port #3. Port #4 is used as a camera port
Fig. 9.6 Medial aspect of the left posterior rectus sheath
is incised and the preperitoneal space entered just supercial to falciform ligament
identied and its medial aspect incised and
released in a cephalad to caudal direction followed by blunt dissection in the right retrorectus
space (Fig. 9.7). Port #4 is then placed under
direct vision through the upper aspect of right
rectus abdominis muscle which is then used as
the camera port. The retrorectus dissection is carried out in the caudal direction completing bilateral release of the posterior rectus sheathes.
Z. Sanford et al.
Fig. 9.7 The right posterior rectus sheath is identied
and its medial aspect incised then released in a cephalad to
caudal direction followed by blunt dissection in the right
retrorectus space
When encountering the hernia sac we try to
sharply dissect the distal attachments, thus mobi-
lizing it downward. Alternatively, the sac can be
sharply entered and laparoscopic adhesiolysis
performed as needed.
Transversus Abdominis Release
For more complex defects that require large mesh
placement, the transversus abdominis release
(TAR) procedure is added [20, 21]. We have found
that incorporation of the TAR is benecial in
cases with wide (>10cm) defects, narrow (<5cm)
retrorectus spaces, or when dealing with a poorly
compliant abdominal wall. Any defects in the pos-
terior layer are closed with 2-0 absorbable suture.
The abdominal wall defect is primarily closed
using 0 barbed suture in running fashion, while
pneumoperitoneum is dropped to 8mmHg.
For defects wider than 10cm, primary fascial
closure can rarely be achieved under physiologic
tension unless additional CS in the form of l-TAR
is added to the procedure. The edge of the cut
posterior rectus sheath (PRS) on one side is
retracted medially and a thin, almost transparent
layer of connective tissue that covers the transversus bers is identied as the posterior lamina
of the internal oblique muscle and incised with
hook electrocautery, thus exposing the transversus abdominis muscle bers (Fig.9.8). Care must
be taken to stay medial to the perforating nerves
and vessels at the linea semilunaris to maintain
functional segmental innervation to the rectus
9 Endoscopic andLaparoscopic Techniques ofMinimally Invasive Components Separation
123
(Fig. 9.9). Hook cautery is used to elevate and
transect the exposed transversus bers, revealing
the glistening transversalis fascia underneath.
This is continued from cephalad to caudad until
the transversalis fascia is seen as a glistening line
extending the entire craniocaudal length of the
abdominal wall. Blunt dissection is now used to
develop the plane just deeper to the transversus
muscle bers and supercial to the transversalis
fascia resulting in a retromuscular preperitoneal
plane, thereby achieving the TAR (Fig. 9.10).
The plane can be extended in the lateral direction
as far as the mid axillary line. A unilateral TAR
can achieve as much as 7cm of medial fascial
mobilization at the level of the umbilicus.
Bilateral TAR can be performed as needed.
Cut portion of posterior lamina of Internal oblique
Exposed Transversus Abdominis fibers
Fig. 9.8 The cut edge of PRS is retracted medially
revealing the posterior lamina of the internal oblique muscle, a thin layer of connective tissue covering. Once identied and incised with hook electrocautery the transversus
abdominis muscle bers can be appreciated
Closure
Posterior Layer
The edges of the PRS are sutured together in the
midline with 2-0 absorbable or barbed suture
starting near the xiphoid process running caudally. Starting at the dome of the bladder the surgeon and assistant switch positions and suture is
run cranially, meeting in the middle where the
two sutures are tied together.
Anterior Layer
Pneumoperitoneum is dropped to 8–10 mmHg.
The defect being closed is at the top of the monitor and is sutured “upside down” with backhanded needle driving. A 0 barbed suture is used
for this closure due to technical ease of use
afforded in this situation. If a large subcutaneous
sac is present, one or more bites of the sac are
included in the suture line for plication in order to
reduce the likelihood of developing a postoperative seroma (Fig.9.11). With the previously performed posterior CS, the defect edges should
come together in a reasonably tension-free fashion. The defect is closed with V-lock suture, completed with four or ve throws run in a backwards
fashion.
Mesh Placement
Once both anterior and posterior fascial layers
are closed, the mesh is deployed in the
Fig. 9.9 When incising
the lateral edge of the
PRS sheath to expose
the transversus
abdominis, care must be
taken to prevent injury
to the neurovascular
bundles near the linea
semilunaris
Neurovascular bundles
124
Z. Sanford et al.
Fig. 9.10 The
transversalis fascia is
separated from the
transversus abdominis
by blunt dissection
achieving TAR
Fig. 9.11 Closure of
the anterior layer. A 0
barbed suture is used in
a back-handed fashion
with an “upside down”
view to take bites of the
edges of the defect while
including the sac (if a
large subcutaneous
portion is present) in
between to reduce the
chance of postoperative
seroma
Posterior Side of Rectus Abdominis
Cut portion of Transversus Abdominis Fibers
Transversalis fascia
retromuscular sublay position. The developed
retromuscular space is measured for appropriate
mesh size selection. Our preference is medium
weight macroporous polypropylene mesh which
is deployed through our 12mm trocar (Fig.9.12).
There is no need for antiadhesion barriers as
there now exists an autologous barrier between
the mesh and viscera, a signicant advantage of
the sublay position. Mesh placement in the retromuscular space has allowed for the discontinuation of aggressive penetrating xation techniques
with transfascial sutures, transitioning rst to
brin glue and, more recently, to complete cessation of mesh xation as our data illustrates penetrating xation is associated with higher incidence
of chronic pain without the added benet of low-
ered rates of recurrence. Pneumoperitoneum is
released under direct vision, assuring the mesh is
lying at and wrinkle-free between the posterior
and anterior layers.
Formerly, we once placed drains just supercial to the mesh in all repair cases. We are now
more selective with drain placement and do not
utilize it for most patients. To date, we have not
observed an increase in wound morbidity as a
result.
Transabdominal Approach
Alternatively, traditional laparoscopic transabdominal approach can be used. Standard
9 Endoscopic andLaparoscopic Techniques ofMinimally Invasive Components Separation
Fig. 9.12 Placement of
a medium weight
macroporous
polypropylene mesh
deployed through the
12mm trocar. There is
no need for antiadhesion
barriers as there now
exists an autologous
barrier between the
mesh and viscera
125
laparoscopic entry to the peritoneal cavity can be
achieved and adhesions taken down. The PRS is
then incised just lateral to the defect or the linea
alba. Dissection can proceed from there as we
described in l-TAR originally, prior to our adoption of the eTEP access approach [5].
Postoperative Management
After recovery from anesthesia, patients are
transferred from the PACU for admission to the
wards or alternatively discharged to home as
determined by the complexity of the surgery.
Those that underwent an eTEP access Rives
Stoppa repair (retrorectus mesh placement) are
typically discharged home the same day. Diet is
advanced as tolerated and patients are encouraged to ambulate as early and often as possible to
prevent postoperative ileus. The average length
of stay at our center following TAR via the eTEP
access approach is approximately 1–2 days.
Prolonged postoperative ileus, although uncommon, is the primary cause for length of hospital
stay.
Immediately following surgery, pain is controlled with patient-controlled analgesia (PCA)
devices, substituted the following morning to
oral analgesics. The minimally invasive approach
has allowed us to signicantly reduce dependence on PCA and associated large volumes of
narcotics for postoperative analgesia.
Patients are provided incentive spirometry
(IS) to assist in their pulmonary toilet and
instructed to use these devices ten times per
hour while awake to minimize any respiratory
complications from splinting. Sequential compression devices (SCD) are placed and subcutaneous unfractionated or low molecular weight
heparin is used for DVT prophylaxis until the
patient is ambulating. Abdominal binders are
offered to all patients for their psychological
benet and are advantageous in promoting early
ambulation [22, 23]. Drain(s), when used, are
left in place until their output is <30cc per day.
Patients are discharged from the hospital once
they are sufciently ambulating, tolerate oral
intake, have a return of bowel function, and tolerate pain control without the need for intravenous
medications. Typically, patients are seen 4 weeks
following surgery for their rst postoperative
clinic visit; however, visits are scheduled sooner
if they are discharged with a drain in place.
Future Directions
Controversies abound in the ventral hernia literature regarding the best anatomical approach,
ideal mesh material, and the best plane for prosthetic placement. Better deniton of indications,
contraindications and complication rates for each
approach and further renement of techniques
are avenues for future research that will continue
126
Z. Sanford et al.
to improve care for these complex patients with
major hernia disease.
On the subject of minimally invasive surgical
techniques, robotics deserves special mention.
Increasing case volumes and ergonomic challenges of laparoscopic surgery pose signicant
physical strain on surgeons, potentially leading to
chronic pain and earlier or more frequent burn
out for experienced surgeons [24]. Robotic
surgery allows for an increased degree of freedom with more elegant technical maneuvering
while offering improved ergonomics and comfort
to the operating surgeon. Nevertheless, many
questions remain unanswered on the subject of
robotic- assisted surgery, including its impact on
operative and postoperative costs [25]. Data on
comparative outcomes for ventral hernia repair is
scarce, with less than a handful of studies currently in the literature. This topic is better
addressed in a different chapter of this text.
Prospective large-scale trials are ideal for
providing the best quality evidence to compare
and contrast different approaches hernia repair.
MIS CS is but one eld within hernia repair that
is still in relative infancy and is as yet not widely
practiced. The eTEP access approach to laparoscopic CS may perhaps lend itself to rapid learning and technical adoption [14]. Although the
preliminary data are encouraging, more studies
are necessary, particularly on long-term outcomes as it joins the armamentarium of the hernia surgeon.
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Robotic Component Separation
ClaytonC.Petro andYuriW.Novitsky
10
Historical Context: TheEvolution
ofComponent Separation
Techniques
For large ventral hernias, primary fascial closure
and recreation of the linea alba can be difcult to
achieve without undue tension. Component separation techniques involve strategic division of fascial
and muscular layers of the abdominal wall that
relieve such tension and thereby allow for an
increased abdominal domain. In the 1980s, Jean
Rives and René Stoppa described division of the
posterior rectus sheath in their series of large incisional hernias. This retrorectus dissection provides
both medial fascial advancement and allows for
placement of a prosthetic reinforcement in the retrorectus space [1]. However, when bilateral release
of the posterior rectus sheathes is insufcient to
gain adequate medial advancement, further myofascial release is necessary. In 1990, Oscar Ramirez
described division of the external oblique fascia
from its insertion on the internal oblique aponeurosis in a cadaver study, coining the term “component
separation.” Importantly, he rst quantied the
C. C. Petro
Department of Surgery, Cleveland Clinic, Cleveland,
OH, USA
Y. W. Novitsky (*)
Department of Surgery, Columbia University Medical
Center, New York, NY, USA
e-mail: yn2339@cumc.columbia.edu
medial advancement gained by a bilateral posterior
rectus sheath release (Rives-Stoppa technique) as
6, 10, and 6 cm in the upper, middle, and lower
thirds of the abdominal wall, respectively.
Adjunctive bilateral division of the external oblique
myofascial layer allowed for additional advancement, crudely measured to be 10, 20, and 6cm [2].
This approach would become one of the most common ways to achieve sufcient facial medialization
for large ventral incisional hernias, and today some
still consider the term “component separation” to
specically regard division of the external oblique
myofascial layer.
While Ramirez’s technique grew in popularity,
limitations were noted. Access to the external
oblique aponeuroses’ insertion on the internal
oblique typically requires signicant undermining of skin and subcutaneous tissue anterior to the
rectus fascia. These soft tissue aps, reliant on
blood supply from anterior perforators of the epigastric vessels, can be at risk of devascularization
and subsequent wound morbidity has been
reported from 26 to 63% [3, 4]. Such wound morbidity could prove to be more signicant if a prosthetic enforcement is placed in the onlay
position—anterior to the fascia and just beneath
the soft tissue aps—leaving the prosthetic
directly exposed to and involved with any supercial surgical site morbidity. In order to minimize
soft tissue mobilization and devascularization,
modications to Ramirez’s external oblique
release were developed. The periumbilical “perfo-
© Springer International Publishing AG, part of Springer Nature 2018
K. A. LeBlanc (ed.), Laparoscopic and Robotic Incisional Hernia Repair,
https://doi.org/10.1007/978-3-319-90737-6_10
129