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335
28. Endoscopic Component Separation
The Technique of Endoscopic Component
Separation
A cutdown incision is performed off the tip of the eleventh rib. It is
critical that this incision is made lateral to the linea semilunaris to avoid
placing the balloon in the rectus sheath. This port should be placed lateral
enough to allow space between the linea semilunaris and the trocar,
enabling complete cephalad dissection. In my opinion, this is the most
important step in the operation, and the anatomy must be clearly
identi fi ed. Therefore, in obese patients, I extend this incision to the
appropriate size to permit clear identi fi cation of the fi bers of the external
oblique. The subcutaneous tissue and Scarpa fascia are bluntly separated,
and the external oblique is grasped with Kocher clamps.
If a midline open incision has been performed, the lateral edge of the
rectus muscle may be palpated through the incision and may help to
better determine the location for the initial 10-mm endoscopic incision.
Depending on how far lateral you have performed your cutdown, the
external oblique can be only fascia or fascia and muscle. It is important
to con fi rm this anatomy, to avoid cutting too deep into the internal
oblique. The external oblique fi bers are split and bluntly separated. An S
retractor gently creates the plane underneath the external oblique and
above the internal oblique heading in a caudal direction.
A standard preperitoneal inguinal hernia balloon dissector is placed
underneath the external oblique and passed inferiorly toward the pubic
tubercle. This balloon should be guided laterally to avoid injuring the
linea semilunaris. If prior transverse incisions are encountered, the
balloon might not be able to traverse the scar tissue and should be aborted
and the intermuscular space created under direct vision.
The balloon is insuf fl ated under direct vision, and the orientation of
the external oblique fi bers (“hands in pockets”), internal oblique fi bers
(“hands on the hips”), and the linea semilunaris are identi fi ed.
The shape of the standard preperitoneal inguinal hernia balloon
dissector usually does not permit cephalad dissection of the external
oblique off the costal margin. Therefore, the balloon is removed, and a
fi nger is placed in the intermuscular space, and the dissection is bluntly
carried out over the costal margin using a sweeping motion. If this space
is not created at this point, the dissection planes can be confusing
laparoscopically and may result in a technical error. Remember the
external oblique inserts 5–7 cm above the costal margin and should be
cleared off the costal margin to permit the muscles to slide medially.
336
M.J. Rosen
A balloon-tipped trocar is secured in the space to prevent air leakage.
One should avoid the use of a triangular-shaped structural balloon at this
point because it can result in obliteration of the dissection space.
Insuf fl ation pressures of 10–12 mmHg are used.
The inferior space can be bluntly created with a 30°, 10-mm
laparoscope to complete the dissection of the intermuscular space to the
posterior axillary line and inguinal ligament.
The second port is placed in the posterior axillary line. This port is
placed as far laterally as possible to provide the appropriate angle to
release the external oblique, 2 cm lateral to the linea semilunaris.
Using scissors with cautery, in the posterior axillary port, and the
camera in the cutdown port, the external oblique is incised from the
cephalad as much as possible to the inguinal ligament/pubic tubercle.
Great care should be taken to complete the release lateral to the linea
semilunaris.
Extra release can be achieved by continuing the dissection super fi cially
through Scarpa fascia. The majority of the blood supply runs super fi cial
to this layer and will not be disturbed.
The third port is placed through the released external oblique in the
lower abdomen. This port is placed medial to the original cutdown port
in the line that the external oblique will be transected when going over
the costal margin. This orientation is important because the cephalad
portion of the dissection can be challenging as it is performed in a reverse
camera orientation.
The camera is then placed in the lower abdominal trocar, and the
scissors are placed in the lateral port, and the cephalad dissection is
completed separating the external oblique off the costal margin. The
external oblique is carefully separated off the costal margin to provide a
clear plane and trajectory when transecting the external oblique. This
avoids releasing the linea semilunaris or dissecting underneath the costal
margin.
Once the dissection of the external oblique is completed, the camera
is positioned in the lateral port, and the LigaSure™ ultrasonic dissector
is placed in the inferior port. Since the external oblique is fairly muscular
at the cephalad portion, I prefer to use LigaSure™, as simple cautery can
result in troublesome bleeding.
The external oblique is transected several centimeters above the
costal margin. The exact cephalad extent of the transection of the external
oblique is variable, but it should be at least 5 cm above the superior extent
of the hernia defect and, likely, at least 3–4 cm above the costal margin.
337
28. Endoscopic Component Separation
A bilateral component separation is preferred in most patients to
provide symmetric distribution of tension on the closure.
The next steps depend on whether the endoscopic component
separation is being performed in conjunction with an open mesh
placement or as an entirely minimally invasive repair.
Open Mesh Placement
Midline laparotomy is performed (if not performed before the
endoscopic component separation), and bowel work is completed as
necessary.
Retrorectus Placement
My preferred space for mesh placement is in the posterior rectus
space. By using this technique, skin fl aps are not necessary for wide
mesh overlap. Drains are routinely placed above the mesh and below the
rectus muscle. Although some authors describe continuing the dissection
through the linea semilunaris into the lateral abdominal plane during a
retrorectus repair, this should be avoided if a component separation has
been performed. If the external oblique is released and then the transversus
abdominis is intentionally or unintentionally released, the lateral
abdominal wall is only supported by the internal oblique, which likely
will result in at least a bulge if not a hernia.
Minimally Invasive Abdominal Wall
Reconstruction
In patients with defects less than 10–12 cm, without a complex scar
requiring revision, and in who a standard laparoscopic ventral hernia
repair with mesh is not deemed suf fi cient an entirely minimally invasive
reconstruction can be performed. In this repair, the endoscopic component
separation is preformed fi rst to avoid leaking from the ports. After
completing the bilateral components separation, the ports for the
intraperitoneal hernia repair are then placed into the abdominal cavity.
The posterior surface of the entire anterior abdominal wall is freed of
338
M.J. Rosen
adhesions. The hernia defect is measured internally using spinal needles
in conjunction with a 15-cm ruler in a rostrocaudal and medial-lateral
orientation.
Next, the fascial defect is reapproximated. We do not typically excise
the hernia sac or remove the peritoneum from the fascia, but this is an
option. A small stab wound in the skin is made just above the hernia, and
a suture passer is placed with a #1 polypropylene suture through the skin
and through the fascial edge of the hernia defect. This is retrieved with a
laparoscopic grasper, the suture passer is then removed and passed
through the same skin incision to the contralateral side of the hernia
defect, and the suture is retrieved. A series of these interrupted sutures
are placed throughout the length of the hernia defect to allow a secure
musculofascial approximation. The insuf fl ation pressure is decreased,
and the sutures are tied with the knots below the skin on the fascia. Given
the fact that these sutures are typically placed under a fair amount of
tension, the repair may become disrupted. Therefore, we feel it is
important to size the mesh based on the original measurements of the
defect with at least 4 cm of overlap. An appropriately sized piece of
prosthesis is placed intraperitoneally and secured with transfascial
sutures. A laparoscopic tacker is then used to secure the mesh to the
abdominal wall. Placing additional transfascial sutures can off-weight
the forces on the midline closure to the lateral abdominal wall with the
mesh.
Complications
The absence of skin fl aps signi fi cantly reduces wound morbidity. We
have experienced one case of a postoperative hematoma at the external
oblique muscular release above the costal margin. At that location, the
external oblique is quite muscular and should be controlled with the
LigaSure to prevent this complication.
Similar to open component separation, it is important to avoid
transecting the linea semilunaris. If one divides this structure, there is a
full thickness defect in the lateral abdominal wall that will result in a
hernia that may be dif fi cult to repair. Maintaining the transection line at
least 2 cm lateral to the linea semilunaris can avoid this problem. Patients
with massive hernias (>20 cm) or loss of domain should typically be
approached with other reconstructive measures, as an endoscopic
component separation often is not adequate.
339
28. Endoscopic Component Separation
Suggested Readings
Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal
wall reconstruction. Am J Surg. 2010;199(3):342–6. discussion 346–7.
Rosen MJ, Fatima J, Sarr MG. Repair of abdominal wall hernias with restoration of
abdominal wall function. J Gastrointest Surg. 2010a;14(1):175–85.
Rosen MJ, Jin J, McGee M, Marks J, Ponsky J. Laparoscopic component separation in the
single stage treatment of infected abdominal wall prosthetic removal. Hernia.
2007a;11(5):435–40.
Rosen MJ, Reynolds HL, Champagne B, Delaney CP. A novel approach for the simultaneous
repair of large midline incisional and parastomal hernias with biological mesh and
retrorectus reconstruction. Am J Surg. 2010b;199(3):416–20. discussion 420–1.
Rosen MJ, Williams C, Jin J, McGee M, Marks J, Ponsky J. Laparoscopic versus open
component separation: a comparative analysis in a porcine model. Am J Surg.
2007b;194(3):385–9.
341
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_29,
© Springer Science+Business Media New York 2013
29. Technique: Laparoscopic
Ventral/Incisional Hernia Repair
Archana Ramaswamy
Ventral hernias may be primary or incisional. Primary central hernias
may be classi fi ed as umbilical, paraumbilical, lumbar, epigastric, and
spigelian. Incisional hernias have incidence rates greater than 15% and
are likely related to incision size, as well as closure technique [ 1 ] ,
postoperative complications such as infection and patient factors
including diabetes, smoking, and immunosuppressant use. Patients seek
repair most commonly for discomfort, decreased abdominal wall
function, and less commonly for bowel obstruction or bowel ischemia. It
is estimated that 300,000 ventral hernias are repaired in Europe and
400,000 in the USA each year [ 2 ] .
History of Laparoscopic Ventral Hernia Repair
Open suture ventral hernia repair was the standard of care for many
years. The long-term outcomes of this technique were questioned when
recurrence rates of 18–63% were published [ 3 ] . Open repair with mesh
was then demonstrated to have lower recurrence rates in a randomized
study of moderate size hernias (<6 cm) where recurrence rates were
statistically lower in the mesh group (43% vs. 23%) at 3 years [ 4 ] . As
mesh utilization for open ventral hernia repair was being adopted, various
locations were being utilized for mesh placement including inlay, onlay,
and underlay (retrorectus, extra- and intraperitoneal). The lowest
recurrence rates were noted with underlay placement [ 5 ] . In parallel with
these studies was the publication of the fi rst technical description of
laparoscopic ventral hernia repair [ 6 ] . The technique described in 1993
utilized PTFE mesh with fi xation with staples to the anterior abdominal
342
A. Ramaswamy
wall. There have been various mesh and fi xation options introduced since
then, but the basic technique has remained unchanged.
Patient Selection
As there is still limited penetration of laparoscopic ventral hernia
repair among general surgeons, complex cases should be reserved to those
past their learning curve. Though there is no de fi ned learning curve for
this procedure, the most severe complications are related to laparoscopic
adhesiolysis and bowel injury [ 7 ] . Operative time (including abdominal
access, adhesiolysis, and mesh placement) is increased when associated
with patient variables comprising the following: greater BMI, higher ASA
classi fi cation, prior ventral hernia repairs, suprapubic location, bowel
adhesion to the abdominal wall or hernia sac, larger hernia defect,
incarcerated hernia contents, and decreased postgraduate year of the
surgical assistant [ 8 ] . Though some of these are variables only identi fi able
intraoperatively, others can be assessed preoperatively to select operative
candidates. Appropriate case selection for the novice includes primary
hernias or fi rst-time incisional hernias of small to moderate size in normal-
weight healthy patients. Once a comfort level is reached with
straightforward cases, then, atypical locations, recurrent hernias, large
defects, and components separation may be added to the surgeon’s
armamentarium. Operative planning can be aided by CT scans to de fi ne
hernia size and potential issues with loss of domain. Patient comorbidities,
such as diabetes, immunosuppression, obesity, and smoking, may be
related to increased complications, complexity of surgery, and recurrence
[ 9– 12 ] . These factors should be addressed preoperatively when possible.
Operative Setup
The patient is placed supine, with alterations in positioning for
atypical locations. The arms are generally both tucked if the patient’s
girth allows it, to allow the surgeon enough mobility to perform
adhesiolysis and fi xation in the lower quadrants. A Foley catheter may be
placed if a lengthy procedure is envisioned, or if the hernia extends well
below the umbilicus. A monitor on each side of the table is necessary as
the surgeon/assistant will frequently need to work from both sides of the
patient for adhesiolysis and for mesh fi xation (Fig. 29.1 ).
343
29. Technique: Laparoscopic Ventral/Incisional Hernia Repair
Abdominal Access
Access methods have been described via closed techniques (Veress
needle and optical trocar) as well as open techniques. The basic concept
is to gain access away from the hernia defect, in an area which should
presumably have a paucity of adhesions (Fig. 29.2 ).
Adhesiolysis and Hernia Reduction
Adhesiolysis and hernia reduction may be straightforward or may
take up the majority of the operative time. Hernia size and number of
previous repairs may help predict an increased time for adhesiolysis
and aid operative planning [ 8 ] . Adhesiolysis is generally safer using
blunt and sharp dissection with avoidance of energy sources. Energy
sources may cause an injury which is not visible at the time of surgery
but may have a lateral thermal spread, which can result in a delayed leak.
A missed bowel injury is also possible when dissecting without the use
Fig. 29.1. Patient and monitor positioning.
344
A. Ramaswamy
of energy sources. The bowel should be examined after completion of
adhesiolysis. Though most serosal injuries are unlikely to be signi fi cant,
their closure is recommended to avoid the uncommon instances where it
may progress to a full-thickness injury. Management of bowel injury is
discussed elsewhere. Bleeding may occur during adhesiolysis and can
usually be managed by application of clips, or focal use of energy.
Complete adhesiolysis of the abdominal wall is generally performed
since hernias other than the palpable one are not infrequently identi fi ed.
At the least, 5 cm of abdominal wall needs to be cleared on either side of
the fascial defect to allow adequate overlap of mesh with healthy fascia.
Inferiorly, this may require mobilization of the bladder and identi fi cation
of Cooper’s ligament and superiorly, transection of the falciform
ligament. With umbilical hernias, it is important to remember that it is
often preperitoneal fat which is herniated, and an adequate laparoscopic
hernia repair cannot be completed without preperitoneal dissection and
reduction of these contents.
Reduction of chronically incarcerated contents may be challenging.
A hand-over-hand technique and use of external pressure may be helpful.
If no progress is being made, consideration should be given to making a
small incision over the hernia defect and performing adhesiolysis within
the sac to allow reduction, or to converting to a completely open approach
(Figs. 29.3 and 29.4 ).
Fig. 29.2. Recommended locations for port insertion.
345
29. Technique: Laparoscopic Ventral/Incisional Hernia Repair
Hernia Sizing and Mesh Selection
The hernia defect may be measured intracorporeally using a suture
held between two graspers. Alternatively, the defect can be measured
externally using small-gauge or spinal needles. The defect edges are
Fig. 29.3. Initial view of unreduced hernia.
Fig. 29.4. Hernia defect following hernia reduction.