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Complications of Inguinal Hernia Surgery
121
ring to avoid mesh contact with the vas deferens at this point. Otherwise, cutting an oval
orifice in the mesh is better than simply splitting it. Avoidance of plugs at the internal ring is
also recommended to avoid contact between the mesh and the vas deferens. This complication
can occur also in laparoscopic repairs. Meshes made with more supple materials, like PTFE
or polyvinylidene, that result in fewer adhesions between the vas deferens and the mesh could
be a good alternative. Pathologic mechanisms were not confirmed by experimental work on
dogs that compared clinical and pathologic findings in standard herniorrhaphy with
hernioplasty. No differences were found in testicular volume, temperature, blood flow, or
diameter of the vas deferens one year after surgery, suggesting that in most cases contact with
the mesh causes no alteration of the vas deferens [Uzzo et al., 1999].
Intestinal Lesions
Intestinal lesions are rare after open repair of inguinal and femoral hernias and typically
occur when opening sacs containing sliding large intestine. Recent evidence disregarding high
ligation and resection of the sac as maneuvers having no effect on the quality of the repair
underlies the trend toward reducing sacs without opening them as a way to avoid injury to the
sliding intestine and its blood supply, and making difficult and potentially dangerous
reperitonealization maneuvers unnecessary. If colonic perforation occurs during hernia
operation it is usually possible to perform a two-layered suture repair.
When suture-ligating the neck of an indirect hernia sac, an intestinal segment can be
accidentally transfixed by the suture, resulting in postoperative intestinal obstruction, or
abscess or fistula formation [Condon and Nyhus, 1989].
Intestinal lesions can occur during laparoscopic operations due to trocar placement or
damage caused by surgical instruments or prostheses, especially in intraabdominal
approaches. Greater experience with laparoscopic technique and the use of totally
extraperitoneal approaches aid in minimizing such complications.
Bladder Lesions
The location of the bladder, behind and medial to the posterior wall of the inguinal canal,
puts it at risk when sliding into an inguinal (most frequently a direct hernia) or femoral
hernia. If injury is detected during the operation, the bladder should be repaired in two layers
and a urinary catheter placed, with complete recovery expected in most cases.
Recurrence
Recurrence rate is the principal measure of successful hernia repair. The use of prosthetic
materials has resulted in greatly reduced recurrence rates, with both open and laparoscopic
hernioplasty techniques having very similar recurrence rates, typically below 5%.
Early recurrence is usually associated with defective technique: failure to find a sac,
placement of too small a mesh, defective mesh fixation, etc. In a large observational study
from Denmark reoperation rate for recurrence was found to be 2.4% following Lichtenstein
Manuel Hidalgo, Josè L. Porrero, Manuel Ortiz et al.
122
repair; 36% after other types of mesh repair; 6.2% when no mesh was used; and 3.3%
following laparoscopic repair [Neumayer et al., 2004].
Some patients develop femoral hernias 7 to 10 months after inguinal hernia repair, most
commonly men, with a mean age of 60 years. The cause of this increased incidence of
femoral hernia is not well understood, though it is believed that they represent hernias that
were undiagnosed at the time of inguinal repair [Mikkelsen, 2004]. Femoral hernias occur
without regard to the type of inguinal repair (anatomical or mesh) though it has been
postulated that the Lichtenstein technique results in less traction on the inguinal ligament than
with other repair methods, such as the Shouldice repair method. To avoid this complication,
systematic exploration of the femoral orifice should be carried out in the course of inguinal
hernia repairs [Chan and Chang, 2008].
The low recurrence rates attained with current techniques are the result of abandonment
of high-tension anatomical repair methods and the introduction of tension-free techniques that
can be mastered by most surgeons [Kehlet and Bay-Nielsen, 2008].
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 9
COMPONENTS SEPARATION TECHNIQUE
AND MODIFICATIONS TO IMPROVE OUTCOMES
Jennifer Sabino, Jamil A. Matthews and Devinder P. Singh
*
University of Maryland School of Medicine, Division of Plastic Surgery,
Baltimore, MD, US
ABSTRACT
The goal of abdominal wall reconstruction is to restore abdominal wall continuity
and provide functional structural support while attempting to deliver a reasonable
aesthetic outcome. Components separation technique accomplishes primary fascial
closure over the midline through bilateral fasciotomies lateral to the rectus abdominus
muscles allowing for additional medial fascial advancement. This technique can result in
10 cm or more of fascial advancement at the umbilicus to facilitate primary closure. The
widespread adoption of components separation has allowed reconstructive surgeons to
close larger abdominal wall defects in patients with significant medical comorbidities at
high risk of complications. However, as a result of the growing number of these difficult
cases, the incidence of poor outcomes such as wound healing complications and hernia
recurrence remains significant. Since the original description of components separation
by Ramirez and colleagues in 1990, several techniques have become available to improve
outcomes including perforator- sparing dissection, minimally invasive, and endoscopic
approaches. Adjunct therapies such as the use of synthetic and biologic mesh for
reinforcement, progressive tension sutures, concurrent panniculectomy, indocyanine
green angiography, and negative pressure incisional dressings have further decreased the
rate of complications. We review the anatomy and indications of components separation
and its modifications in order to optimize outcomes by carefully considering each
individual patient’s presentation and reconstructive goals.
Keywords: Components separation, hernia, complex abdominal wall reconstruction
*
Corresponding author: University of Maryland School of Medicine, Division of Plastic Surgery, Baltimore, MD
USA. DSingh@smail.umaryland.edu.
Jennifer Sabino, Jamil A. Matthews and Devinder P. Singh
126
INTRODUCTION
Advances in trauma management and operative techniques present surgeons with
increasingly complex abdominal wall reconstruction [Shapiro et al., 2000; Rodriguez et al.,
2007]. In 1990, Ramirez and colleagues described the “components separation” technique
(CST), also referred to as “separation of parts” or external oblique release, that utilizes
bilateral, innervated, bipedicled muscle flaps which are transposed medially to reconstruct
central abdominal defects [Ramirez et al., 1990; Shestak et al., 2000]. The important concept
of this technique is dual vascularity in the abdominal muscles and preservation of the
thoracolumbar intercostal nerves deep to the internal oblique layer which allows for rectus
abdominus muscle advancement toward the midline with minimal donor site morbidity. CST
performed in this manner allows for midline closure of massive, often multiply recurrent
ventral hernias and has become a first line option for many abdominal wall surgeons as a
result of favorable results compared to prosthetic repair [de Vries Reilingh et al., 2007].
Despite applying the best and most advanced techniques for abdominal wall
reconstruction the surgeon may still be faced with devastating postoperative complications.
The population has increased in medical complexity particularly as a result of the increased
incidence of obesity; as a result, midline incisional hernias have also dramatically increased in
frequency, size, and complexity. Postoperative complications such as superficial and deep
infection, wound dehiscence, and hernia recurrence lead to significant morbidity and
mortality in these complex procedures in already high risk patients [Peralta and Latifi, 2012].
Furthermore, hernia recurrence can lead to significant physical deficits with productivity loss,
post-traumatic stress disorders, and depression [Zarzaur et al., 2011].
Poor outcomes range from relatively minor complications such as superficial wound
infection, seroma, and hematoma, resulting in the need for local wound care or minor re-
operative intervention. These minor complications can contribute to more significant
morbidity such as deep infection and hernia recurrence. Hernia recurrence after complex
abdominal wall reconstruction can be as high as 50% [Luijendijk et al., 2000]. Postsurgical
complications can also include systemic problems from the physiologic burden of a
complicated procedure with long operative times such as abdominal compartment syndrome,
renal failure, and respiratory failure with inability to wean from mechanical ventilation. While
many complications may be related to patient comorbidities, surgical technique and
intraoperative decisions may also play a role in poor outcomes. In this chapter we will review
the anatomy and indications of components separation and its modifications in order to
optimize outcomes by carefully considering each individual patient’s presentation and
reconstructive goals.
ANATOMY
A thorough understanding of the anatomy of the abdominal wall is absolutely essential
when performing a proper open component separation operation. The rectus abdominus
muscles are paired in the midline and function to primarily flex the pelvis. The muscles are
vertically oriented, lie within the rectus sheath, and should normally be side by side in the
Components Separation Technique and Modifications to Improve Outcomes
127
midline. In between these two muscles is the tendinous linea alba which is functionally the
tendinous insertion of the fascial extensions of the six lateral abdominal wall muscles
(bilateral external oblique, internal oblique, and transverses abdominis). Lateral to the rectus
abdominus is the linea semilunaris. This represents an aponeurotic fusion of the lateral triad
of muscles prior to splitting and contributing to the rectus sheath.
It is the differential contribution of this lateral triad of muscles to the rectus sheath that is
the anatomic basis for the horizontal arcuate line. Superior to the transversely orientated
arcuate line, the rectus abdominis muscles fibers are enclosed both anteriorly and posteriorly
in its fascial sheath. The anterior component of this sheath is comprised of the external
oblique fascia and the superficial layer of internal oblique fascia, whereas the posterior
component is comprised of the deep layer of internal oblique fascia and the transversalis
fascia. Inferior to the arcuate line, all fascial contributions to the rectus sheath are directed
superficially to the rectus muscle belly.
The abdominal wall has a complicated blood supply derived from a variety of sources.
The deep system includes the superior epigastric artery, which is the terminal continuation of
the internal mammary or internal thoracic artery. This vessel enters the rectus sheath at the
level of the seventh costal cartilage and arises after the takeoff of the musculophrenic artery.
The deep inferior epigastric artery, a branch of the external iliac artery, enters the rectus
sheath below the arcuate line and gives off perforating blood supply to the muscle and
overlying abdominal skin via perforators. Another smaller contributor to the abdominal wall
vasculature are the lower intercostal arteries which enter the sides of the rectus after traveling
between the oblique muscles. Therefore, the dominant blood supply to the rectus abdominis
muscles is from the superior and deep inferior epigastric arteries, with the inferior epigastric
system usually being more dominant. The entire muscle can theoretically survive however on
either blood vessel. Laterally in the deep abdominal wall, the deep circumflex branch of the
external iliac artery enters the abdominal wall in the region of the iliac crest. Thoracic and
lumbar posterior branches of intercostal arteries also travel between the internal oblique and
transversus layers, and give off direct skin perforators as well.
Superficially the skin has a different pattern of blood supply. An important study by
Huger [1979] classified the vascular blood supply of the abdominal wall into three simple
zones (related to abdominoplasty), but relevant to any incision planning. Zone I is defined by
the central abdominal skin and is supplied primarily by the deep inferior epigastric
perforating blood supply. Zone II is defined by the inferior abdominal skin and is supplied by
branches of the femoral artery that pass superficially over the inguinal ligament: 1) superficial
external pudendal artery; 2) superficial inferior epigastric artery; and 3) superficial circumflex
iliac artery (listed from medial to lateral). Zone III comprises the skin located in the flanks
and lateral abdomen. Blood supply to this area comes from the intercostal thoracolumbar
arteries. The intercostal vessels leave the rib cage and enter the abdominal wall between the
transversus abdominis and internal oblique muscles, where they anastomose with the lateral
branches of the superior epigastric artery and deep inferior epigastric artery.
Motor innervation to the abdomen is derived from the roots of the nerves T7 to L4. These
thoracolumbar nerves travel in the plane between the internal oblique and transversus
abdominis muscles in a lateral to medial direction. These nerves must be preserved during
abdominal wall reconstruction in order to maintain abdominal wall muscular function.
Jennifer Sabino, Jamil A. Matthews and Devinder P. Singh
128
INDICATIONS
A midline incisional hernia is caused by a disruption of the linea alba by surgical
manipulation which in turn leads to unopposed contraction of the lateral abdominal wall
muscles. It is this constant unopposed pull from the lateral muscles, in combination with
intraperitoneal pressure that leads to the gradual increase in size of these hernias and
ultimately loss of abdominal domain. The most common reason for midline disruption is a
previous laparotomy [Sanders and Kingsnorth, 2012].
The preoperative evaluation of a patient with incisional hernia should include a complete
medical history, including any operative reports from previous operations which can
document previous mesh placements and previous flap techniques for closure. It should be
noted in the history whether or not there were wound complications or infections after any of
the previous operations. Factors that predispose patients to hernia formation after abdominal
surgery also predispose them to complications after hernia repair. Risk factors for herniation
and subsequent complications include smoking, obesity, and chronic systemic conditions
such as diabetes, chronic obstructive pulmonary disease (COPD), immunosuppression, and
connective tissue diseases. Patient selection must include careful consideration of the
morbidity related to the hernia and the morbidity related to the repair and likelihood of
postoperative complications. Examples of strategies to mitigate potential risk factors include
losing weight, controlling diabetes, quitting smoking, maximizing nutritional status,
maximizing a patient’s cardio/pulmonary health, and appropriately prophylaxis for
thromboembolic disease.
There are subsets of patients whose comorbities make operative planning for ventral
hernia repair more complex. Obesity is associated with increased incidence of hernia as well
as increased complications after repair. Similarly, “super obese” patients with a body mass
index of greater than 50 should be extensively counseled about the high risk of morbidity and
encouraged to lose weight prior to undertaking elective ventral hernia repair. Cirrhotic
patients with refractory ascites present another such deliberation. Large ventral hernias in
these patients present low likelihood of strangulation but do have a significant risk of rupture.
In patients who are eligible for liver transplant, careful local care with a pressure garment
should be used as a temporizing measure until the hernia can be repaired at the time of
transplantation. If the patient is not eligible for transplantation, a hernia repair is performed
after the ascites is treated with a shunt and/or maximal medical management. Prosthetic
devices should be avoided this group because of high risk of infection [Belghiti and Durand,
1997]. In patients with carcinomatosis, it is generally accepted that hernia repair should be
avoided unless undertaken purely for palliation.
TECHNIQUE
Classic open component separation is primarily distinguished from various other
modified techniques by the elevation of broad skin flaps to gain access to the lateral
abdominal wall. The first step in performing an “open” component separation is lysis of
adhesions from the bowel to the undersurface of the abdominal wall. This allows for a good
underlay of any mesh that may be used but also helps to untether the abdominal wall
Components Separation Technique and Modifications to Improve Outcomes
129
musculature and allow it to advance toward the midline. The next step is identification of the
healthy fascial edges. This is performed by undermining the skin and subcutaneous fat until
healthy rectus abdominis anterior fascia is identified. It is important to understand that
disruption of central peri-umbilical perforating blood supply from the deep inferior epigastric
system will occur (disruption of Huger Zone I). As a result, the distal edge of skin flap is
relatively ischemic and without proper management can result in significant wound
complications.
Undermining of skin should continue only until the lateral edge of the rectus abdominus
is identified. Here, the semilunar line is often able to be visualized, however a useful way to
feel it is to pinch the abdominal wall musculature by placing the hand and fingers
intraperitoneally and the thumb above the fascia and feeling for the thickening of the edge of
the rectus muscle as the hand is slid medially.
Next, a fasciotomy is created in the external oblique layer. To do so, a small nick in the
external oblique fascia should be made just 1 cm lateral to the lateral aspect of the rectus
abdominis muscle. If the surgeon notices that there are vertically oriented muscle fibers under
the fascia, then the nick has been made too medial and inside the rectus sheath. Once the
incision in the external oblique fascia layer is made, it is important to carry this incision all
the way down to just below the hernia defect (stopping short of the inguinal ligament) and all
the way up over the costal margin superiorly. This allows for a much easier closure in the
epigastric area or sub-xiphoid hernias.
The next maneuver is to undermine the external oblique fascia / muscle all the way to the
anterior axillary line, stopping short of the large intramuscular perforating blood vessels
supplying the external oblique near the anterior axillary line. When separating the external
from the internal oblique layers, one can see the cephalad orientation of the internal oblique
muscle fibers, and thus gain further confidence the correct plane is being opened. At this
moment, one can appreciate the elegance of the component separation technique; the result of
dissection is now a robust dually vascularized, bipedicled, fully innervated, medially
advancing rectus abdominus muscle flap. It is important to note here that while most muscles
have a single neurovascular pedicle, the rectus abdominus has segmental innervation that
enters laterally while the blood supply is orientated vertically. It is this unique anatomic
relationship that enables the power of component separation in creating a functional rectus
muscle flap.
Once the external fascia is divided on both sides, the surgeon should assess the tension on
the closure and whether or not the fascia will actually come together in the midline. If more
advancement is required, the posterior rectus sheath can be released on each side. Posterior
rectus sheath release should be approached cautiously as it increases the risk of nerve
damage. External oblique and posterior rectus sheath release allows for rectus abdominus
advancement of up to 5, 10, and 3 cm in the upper, middle, and lower abdomen, respectively,
on each side in cadaver studies, with more even more advancement possible clinically. In
those cases where the rectus muscles will come together in the midline, the surgeon can
perform a running closure with a #1 size loop suture made of monofilament slowly resorbable
material (polydioxanone). In those situations where the fascial edges do not come together,
then a fascial bridge must be performed with some sort of mesh placed as a bridging underlay
on onlay.
Jennifer Sabino, Jamil A. Matthews and Devinder P. Singh
130
TECHNIQUE MODIFICATIONS
Mesh Choice
Synthetic and bioprosthetic mesh materials are often used to reinforce the repair even
when midline fascial apposition is achieved. Mesh reinforcement helps to decrease the rate of
recurrence [Luijendijk et al., 2000; Burger et al., 2004] and is now used in over 80% of
ventral hernia repairs [Ghazi et al., 2011]. Synthetic and bioprosthetic meshes each have their
role in complex ventral hernia repair based on cost, choice of technique, and risk of
complication [Korenkov et al., 2001]. The Ventral Hernia Working Group developed a
surgical site occurence risk grading system to help guide appropriate mesh choice. Grade 1
hernias are low risk patients with low risk of complications and no history of prior wound
complications. Grade 2 hernias are patients with comorbidities causing increased risk. Grade
3 hernias are potentially contaminated. Grade 4 hernias are actively infected [The Ventral
Hernia Working Group, 2010].
Prosthetic mesh is indicated in a clean environment with low risk of infection or wound
complications, Grade 1 ventral hernias. The advantages of synthetic mesh include reduced
recurrence rate and low cost. Synthetic mesh should be avoided in circumstances where there
is bacterial contamination or infection and also in those patients where comorbidities put the
patient at an unacceptably high risk for developing a surgical site infection or wound
breakdown, Grade 2, 3, and 4 ventral hernias. For those patients where synthetic mesh is
undesirable, a biologic material should be used. A myriad of biologic products characterized
by source material, processing techniques, and sterilization techniques. Which biologic mesh
to use is based on hernia and patient characteristics as well as surgeon preference and
experience. While expensive, biologic mesh carries the advantage of some resistance to
infection [Brewer et al., 2011; Patel et al., 2012].
Mesh Location
In a classic “open” component separation, mesh may be placed superficial to the primary
repair in the onlay position, intraperitoneally deep to the primary repair in the underlay
position, or in the retrorectus space between the posterior rectus sheath and the posterior
surface of the rectus abdominus in the underlay position [den Hartog et al., 2008]. There
exists no clear consensus on whether the onlay versus underlay placement of mesh results in
the lowest recurrence rate.
Mesh is placed in the onlay position by suturing the material to the cut lateral free edge of
the external oblique fascia. The material is then pulled taught across the midline and sutured
to the cut lateral edge of the opposite external oblique fascia under physiologic tension. This
position allows reinforcement not only of the midline repair, but also the lateral areas of the
abdominal wall where the external oblique has been divided. Furthermore, by placing the
material under some tension it re-medializes the two external oblique muscles which
otherwise retract laterally and become useless. By effectively re-inserting the two external
muscles across the midline to one another it allows these muscles to continue to act as
functional muscle units; in a very real way, the onlay position of mesh when sutured from