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467
42. Open Versus Endoscopic Component Separation
Open Ventral Hernia Repair with Endoscopic
Component Separation
This technique includes the usual dissection for the open ventral
hernia repair combined with the endoscopic approach for the
component separation technique to avoid the open dissection of the
abdominal wall fl aps. The reinforcement of the repair is performed
usually intraperitoneally with synthetic (with adhesion barrier) or
biological mesh. The fascia is approximated at the midline with a
running #1 PDS (polydioxanone) suture.
Indications for CST
(a) Limited contaminated or clean contaminated fi elds.
(b) History of recurrence after several previous repairs.
(c) Large hernia defects including loss of domain.
(d) When restoration of physiology of abdominal wall is imperative
(patient with hernia and neo-bladder).
(e) Cosmetic restoration.
(f) Hernia with tension when attempting closure of fascia.
There are a number of surgeon-, hernia type, and patient-dependent
factors that will eventually contribute to the surgical techniques chosen
to complete any given hernia operation. Some of the intraoperative
decisions regarding choosing a component release may be in fl uenced by
the following hernia and patient characteristics:
Extension of Hernia Sac Laterally to the Semilunaris
Line and Complex Surgery that Involves the Lateral
Abdominal Wall
The fi brosis and/or scar tissue from previous surgery makes the
endoscopic CST approach more dif fi cult. The CST in these patients is
usually performed by open technique (Fig. 42.3 ).
468
E. Parra-Davila et al.
Need for Wound Revision
If the dissection requires a vast removal of soft tissue, the endoscopic
approach may not provide an advantage. This dissection will expose
most of the area needed to perform an open CST.
Need for Mesh Explantation
To be able to remove an onlay mesh, a vast subcutaneous fl ap
dissection is required, making an open CST a better choice (Fig. 42.4 ). If
the mesh was placed as an underlay, the CST can be performed
endoscopically or open depending on the surgeon’s preference since the
subcutaneous space has not been violated.
Presence of Ostomy
Most surgeons do not perform a bilateral CST in the presence of an
ostomy (Fig. 42.5 ). The unilateral approach for the CST can be performed
open or endoscopically, including mesh reinforcement.
Fig. 42.3. Multiple and extensive abdominal wall surgeries.
469
42. Open Versus Endoscopic Component Separation
Fig. 42.4. Removal of infected onlay mesh.
Fig. 42.5. Multiple parastomal hernia repairs.
Need for Panniculectomy
This technique requires bilateral abdominal wall fl aps that will expose
the aponeurosis of the external oblique for open CST (Fig. 42.6 ).
470
E. Parra-Davila et al.
Presence of Abdominal Contamination
In the setting of limited and controlled contamination, the endoscopic
approach provides the release of the fascia in a clean space not in
continuity with the midline incision. This potentially decreases the
incidence of postoperative wound infections.
Intraoperative Assessment of Tension
During the operation, if an open midline incision is made fi rst, an
assessment of tension and abdominal wall compliance can be done by
placing clamps on rectus muscle medial fascia and pulling them to the
midline. Although this is a very imprecise measure, this may help determine
the best approach for component separation: open or endoscopic.
In summary, the Achilles tendon of the open CST is the wound
infection, hematoma, seroma, and abdominal wall fl ap necrosis that are
reported in 12–67% of cases [ 8– 11, 13– 19 ] . Other reports in the literature
show an overall complication rates that were similar for endoscopic CST
(32%) and open CST (35%). Comparison between endoscopic CST and
open CST showed comparable hernia recurrence rates (endoscopic CST
17% and open CST 21%) [ 20 ] .
Fig. 42.6. Medically necessary panniculectomy.
471
42. Open Versus Endoscopic Component Separation
We believe that medialization of the rectus muscle is imperative
for improving abdominal wall function. The CST with muscle
advancement increases the abdominal wall circumference to enlarge
the intraperitoneal space for those patients af fl icted with large ventral
hernias and loss of domain. The placement of mesh for reinforcement
of the repair decreases the recurrence rate of the CST, and the rectus
medialization decreases the risk of mesh eventration. This technique
is not indicated for the small “average” ventral hernia when the fascia
can be easily approximated or in patients with multiple small (<2 cm)
“Swiss cheese” hernias. In our experience with open CST, we have
accomplished more advancement of the abdominal wall when
compared to the endoscopic CST. For this reason, we use the
endoscopic CST for selected cases of midsize (<10 cm), usually
midline primary or fi rst recurrent hernias. Please refer to Fig. 42.7 for
a decision-making fl owchart.
-History of multiple hernia repair
-Large Hernia Defect
-Need for Cosmetic Restoration
-Hernia with tension when attempting closure of fascial defect
Laparoscopic vs Open CST
Laparoscopic Ventral
Hernia Repair or Open
Ventral Hernia Repair
with Mesh
Need for CST
Yes
Laparoscopic CST
Open CST
Hernia defect <10 cm.
Hernia defect >10 cm.
-Presence of limited abdominal contamination
-Concomitant Visceral procedures
-Mesh explantation when mesh is explanted laparscopically
-Hernia with current ostomy (unilateral CST)
Small to mid size hernia under tension to close defect
-Complex Lateral Abdominal wall surgery
-Loss of Domain to accomplish closure of defect vs decreasing the size of defect before mesh placement
-Need for Panniculectomy or extensive skin mobilization
-Mesh explantation when previous mesh placed as onlay
-Hernia with current ostomy (unifateral CST)
No
Fig. 42.7. A decision-making fl owchart for the need for CST.
472
E. Parra-Davila et al.
References
1. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized
controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;
240:578–85.
2. Millikan KW. Incisional hernia repair. Surg Clin North Am. 2003;83:1223–34.
3. Sauerland S, Schmedt CG, Lein S, et al. Primary incisional hernia repair with or
without polypropylene mesh: a report on 384 patients with 5-year follow-up.
Langenbecks Arch Surg. 2005;390:408–12.
4. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with
mesh repair for incisional hernia. N Engl J Med. 2000;343:392–8.
5. Lomanto D, Iyer SG, Shabbir A, et al. Laparoscopic versus open ventral hernia mesh
repair: a prospective study. Surg Endosc. 2006;20:1030–5.
6. Novitsky YW, Porter JR, Rucho ZC, et al. Open preperitoneal retrofascial mesh repair
for multiply recurrent ventral incisional hernias. J Am Coll Surg. 2006;203:283–9.
7. Larson GM. Ventral hernia repair by the laparoscopic approach. Surg Clin North Am.
2000;80:1329–40.
8. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of
abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;
86:519–26.
9. de Vries Reilingh TS, van Goor H, Rosman C, et al. “Components separation
technique” for the repair of large abdominal wall hernias. J Am Coll Surg. 2003;
196:32–7.
10. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components
technique for the reconstruction of massive midline abdominal wall defects: anatomy,
surgical technique, applications, and limitations revisited. Plast Reconstr Surg.
2000;105:731–9.
11. DiBello Jr JN, Moore Jr JH. Sliding myofascial fl ap of the rectus abdominus muscles
for the closure of recurrent ventral hernias. Plast Reconstr Surg. 1996;98:464–9.
12. Rosen MJ, Williams C, Jin J, McGee MF, Schomisch S, Marks J, Ponsky J.
Laparoscopic versus open-component separation: a comparative analysis in a porcine
model. Am J Surg. 2007;194:385–9.
13. Girotto JA, Mascus K, Redett R, et al. Closure of chronic abdominal wall defects: a
long-term evaluation of the components separation method. Ann Plast Surg.
1999;42:385–94.
14. Cohen M, Morales Jr R, Fildes J, et al. Staged reconstruction after gunshot wounds to
the abdomen. Plast Reconstr Surg. 2001;108:83–92.
15. Jernigan TW, Fabian TC, Croce MA, et al. Staged management of giant abdominal
wall defects: acute and long-term results. Ann Surg. 2003;238:349–55.
16. Kuzbari R, Worseg AP, Tairych G, et al. Sliding door technique for the repair of
midline incisional hernias. Plast Reconstr Surg. 1998;101:1235–42.
17. Lowe III JB, Lowe JB, Baty JD, et al. Risks associated with “components separation” for
closure of complex abdominal wall defects. Plast Reconstr Surg. 2003;111:1276–83.
473
42. Open Versus Endoscopic Component Separation
18. Sukkar SM, Dumanian GA, Szczerba SM, et al. Challenging abdominal wall defects.
Am J Surg. 2001;181:115–21.
19. Ennis LS, Young JS, Gampper TJ, et al. The “open-book” variation of component
separation for repair of massive midline abdominal wall hernia. Am Surg. 2003;
69:733–42.
20. Tong WMY, Hope W, Overby DW, Hultman CS. Comparison of outcome after mesh-
only repair, laparoscopic component separation, and open component separation. Ann
Plast Surg. 2011;66:551–6.
475
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_43,
© Springer Science+Business Media New York 2013
43. Absorbable Fixation Materials:
A Critical Appraisal
Kevin El-Hayek and Matthew Kroh
Hernia repair is one of the most common procedures performed
around the world, with an estimated 1,000,000 such repairs being
performed per year in the United States alone [ 1– 4 ] . The most common
types include repairs of inguinal, ventral or incisional, and hiatal hernias.
Standard herniorrhaphy prior to the 1950s primarily involved direct
tissue re-approximation; however, this technique was associated with
reported recurrence rates of 25–54% [ 5– 9 ] . Subsequent development of
prosthetic mesh implantation decreased recurrence rates signi fi cantly;
however, a trade-off of more mesh-related complications has ensued.
These complications include infection, visceral adhesions, fi stulae, and
obstructions among others [ 10, 11 ] . In response to these complications,
more sophisticated mesh products have been designed to provide a
durable repair with adequate tissue ingrowth while maintaining a less
in fl ammatory barrier against the intra-abdominal viscera.
In conjunction with increased technology of mesh products, fi xation
devices have evolved as well. Historically, the only options for mesh
fi xation were sutures of varying degrees of absorbability and permanence.
The in fl ux of laparoscopy in general surgery has ushered in new options
for fi xation, including tacking devices and sealants. Laparoscopic ventral
hernia repair is associated with lower recurrence rates, lower mesh
infection rates, fewer postoperative complications, and shorter hospital
stays [ 12– 14 ] . Though the majority of operative repairs, including
laparoscopy, are performed using permanent sutures or tacks, there is
currently an opportunity to limit the amount of foreign material by using
absorbable fi xation devices. The goal of this chapter is to review the
materials and methods involved in the use of absorbable fi xation for
inguinal and ventral hernias.
476
K. El-Hayek and M. Kroh
Principles of Mesh Fixation
The physical and physiologic changes that exist at the time of hernia
repair and subsequent to implantation ultimately dictate long-term ef fi cacy.
Discussion of fi xation devices is therefore dependent on a brief review of
their interactions with various mesh types. Mesh material is a critical
consideration when preparing to repair a hernia. Characteristics of mesh to
consider prior to implantation include material, pore size, and density [
15,
16 ] . Mesh material will dictate the degree of in fl ammatory response and
the ultimate scar plate that is deposited. This interaction will in large part
determine the strength of a repair. Pro-in fl ammatory materials such as
polypropylene and polyester generate excellent tissue ingrowth but are
also prone to adhesion formation when exposed to viscera [ 10 ] . The
structure of mesh will also guide tissue ingrowth and ultimately stability.
The porosity of the mesh weave will to varying degrees allow for native
tissue in fi ltration. Microporous mesh (<10–75 m m) such as ePTFE has the
advantage of causing less visceral adhesions; however, tissue ingrowth is
also decreased. Macroporous (>75 m m) mesh provides much better tissue
ingrowth; however, this mesh can lead to more dense adhesions [ 15, 16 ] .
Consideration of porosity is important when selecting fi xation devices as
mesh that is less porous will require greater fi xation than mesh that allows
for better tissue ingrowth. Finally, mesh density may dictate fi xation
material penetration, which in turn determines adequate security.
Once the mesh is chosen, how to secure the mesh becomes relevant.
The fi xation technique must provide adequate stability to ensure that the
mesh does not migrate. Migration and mesh shrinkage are two common
causes of hernia recurrence. During ventral hernia repair, data has shown
that greater fascial overlap, typically at least 3–5 cm, will decrease
recurrence rates [ 17 ] . If the fi xation material and method do not provide
adequate strength to maintain proper orientation, the mesh can pull away
due to normal body movements. The time and strength required of such
a fi xation device is variable based on anatomic location of mesh repair,
for example, inguinal versus abdominal wall, and the speci fi c to the type
of mesh used, based on material and porosity.
In addition to adequate strength, fi xation materials must provide
durability. Additionally, mesh fi xation involves limiting postoperative
complications such as foreign body reaction, infection, and pain. There
are many absorbable materials in use today which purport to have many
of these positive properties while limiting the negative properties of
mesh fi xation.
477
43. Absorbable Fixation Materials: A Critical Appraisal
Composition and Properties of Absorbable
Fixation Materials
Currently, permanent fi xation is commonly used for hernia repair.
Speci fi cally for abdominal wall repair with synthetic mesh, permanent
transfascial suture fi xation has shown excellent strength [ 18, 19 ] .
Transfascial fi xation with permanent suture remains the gold standard in
laparoscopic ventral hernia repair, but these are not without complication
[ 20 ] . When used to secure mesh laparoscopically, transfascial fi xation
sutures traverse all layers of the abdominal wall in a mass closure
technique. From a strength standpoint, this is ideal. In a porcine model of
mean tensile strength, transfascial sutures were found to be 2.5 times
stronger than tack placement in securing polypropylene mesh [ 19 ] .
However, this technique can also result in signi fi cant patient pain. Studies
have shown that placement of sutures using this technique for mesh
fi xation during ventral hernia repair can result in chronic and often
dif fi cult to manage pain [
21, 22 ] . Even after surgical suture removal,
pain may not be mitigated in these patients. Though still considered the
most durable long-term option for mesh fi xation, these unique
complications from permanent suture fi xation have prompted investigation
into other materials.
Absorbable Suture
Sutures are foreign bodies and as such, illicit reaction from adjacent
tissue. The development of absorbable suture was designed to limit this
reaction as most tissues, once approximated, will adhere to one another
without permanent fi xation. There are numerous types of absorbable
sutures. The main variants include material, braidedness, and absorption
pro fi le. These sutures range from beef or sheep submucosa to synthetic
material such as polyglactin and poliglecaprone. Their absorption
pro fi les vary from 40 to >200 days. The main mechanism for absorption
is via hydrolization and enzymatic degradation when the body
recognizes this foreign material [ 23 ] . Transfascial suture fi xation is
currently the most common form of mesh fi xation during open and
laparoscopic ventral hernia repair, and typically this is performed with
permanent suture.