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Lumbar Hernia: Signs, Symptoms and Treatment
161
Figure 3. Identification of the defect and dissection of the peritoneum and retroperitoneal fat in repair of
a superior lumbar hernia.
Figure 4. Attachment of the mesh to the surrounding muscle with an endoscopic multifeed stapler.
Trans-abdominoretroperitoneal laparoscopy is undertaken with three trocars placed into
the peritoneal space along the midline (Moreno-Egea et al., 2005) or along the external border
of the rectus abdominis (Bickel et al., 1967; Burick and Parascandola, 1996; Heniford et al.,
1997). Surgery is undertaken in a wide intraperitoneal space with a scope. In the superior
lumbar hernia, the peritoneal cavity is explored, searching for traumatic lesions of the
digestive tract (Burick and Parascandola, 1996). The dissection is begun by incising the
peritoneum, after dissecting the peritoneum and retroperitoneal fat (Figure 3). Care should be
Junsheng Li and Zhenling Ji
162
given throughout the procedure to preserve nerves or vessels, lateral peritoneum, colon; and
the ureter must be detached to enter the retroperitoneal space. An appropriate sized prolene
mesh is introduced into the abdominal cavity via the 10-mm optical port to repair the defect.
The mesh is positioned in place, and fixed with a stapler to the surrounding muscles (Figure
4). At the end of the procedure, the lateral peritoneum and colon have to be reinserted on the
lateral abdominal wall, (Bickel et al., 1967; Burick and Parascandola, 1996).
Comparison of Open and Laparoscopic Approaches
Moreno-Egea et al. (2005) compared the results of open and laparoscopic procedures in
lumbar hernia repair, and found that the mean operating time, postoperative morbidity, mean
hospital stay, consumption of analgesics, and time to return to normal activities were
significantly lower in the laparoscopic group (p <0.01) (Moreno-Egea et al., 2005).
REFERENCES
Armstrong, O., Hamel, A., Grignon, B., Doye, J. M., Hamel, O., Robert, R., and Rogez, J. M.
(2008). Lumbar hernia: anatomical basis and clinical aspects. Surg. Radiol. Anat. 30:533–
537.
AstarcÂoflu, H., Sökmen, S., Atila, K., and Karademir, S. (2003). Incarcerated inferior
lumbar (Petit’s) hernia. Hernia 7:158–160.
Baker, M. E., Weinerth, J. L., Andriani, R. T., Cohan, R. H., and Dunnick, N. R. (1987).
Lumbar hernia: diagnosis by CT. Am. J. Roentgenol. 148:565–567.
Bickel, A., Haj, M., and Eitan, A. (1967). Laparoscopic management oflumbar hernia. Surg.
Endosc. 11:1129–1130.
Burick, A., and Parascandola, S. (1996). Laparoscopic repair of a traumatic lumbar hernia: a
case report. J. Laparoendosc. Surg. 6:259–262.
Dowd, C. N. (1907). Congenital lumbar hernia at the triangle of Petit. Ann. Surg. 45:245.
Geis, W. P., and Saletta, J. D. (1989). Lumbar hernia. In “Hernia,” Nyhus, L. M., Condon, R.
E. (eds), pp 401–415. J. B. Lippincott Company, Philadelphia.
Grauls, A., Lallemand, B., and Krick, M. (2004). The retroperitoneoscopic repair of a lumbar
hernia of Petit. Case report and review of literature. Acta Chir. Belg. 104:330–334.
Guillem, P., Czarnecki, E., Duval, G., Bounoua, F., and Fontaine, C. (2002). Lumbar hernia:
anatomical route assessed by computed tomography. Surg. Radiol. Anat. 24:53–56.
Habib, E. (2003). Retroperitoneoscopic tension-free repair of lumbar hernia. Hernia 7:150–
152.
Heniford, B. T., Iannitti, D. A., and Gagner, M. (1997). Laparoscopic inferior and superior
lumbar hernia repair. Arch. Surg. 132:1141–1144.
Horovitz, I. L,. Schwarz, H. A., and Dehan, A. (1986). A lumbar hernia presenting as an
obstructing lesion of the colon. Dis. Colon Rectum 29:742–744.
Ipek, T., Eyuboglu, E., and Aydingoz, O. (2005). Laparoscopic management of inferior
lumbar hernia (Petit triangle hernia). Hernia 9:184–187.
Lumbar Hernia: Signs, Symptoms and Treatment
163
Jankovic, Z. B., du Feu, F. M., and McConnell, P. (2009). An anatomical study of the
transversus abdominis plane block: location of the lumbar triangle of Petit and adjacent
nerves. Anesth. Analg. 109:981–985.
Kubalak, G. (1994). Handlebar hernia: case report and review of the literature. J. Trauma
36:438–439.
Lichtenstein, I. L. (1986). Repair of large diffuse lumbar hernias by an extraperitoneal binder
technique. Am. J. Surg. 151:501–504.
Loukas, M., El Zammar, D., Shoja, M. M., Tubbs, R. S., Zhan, L., Protyniak, B., and
Krutoshinskaya, Y. (2008). The clinical anatomy of the triangle of Grynfeltt. Hernia
12:227–231.
Loukas, M., Tubbs, R. S., El-Sedfy, A., Jester, A., Polepalli, S., Kinsela, C., and Wu, S.
(2007) . The clinical anatomy of the triangle of Petit. Hernia 11:441–444.
McCarthy, M., and Lemmon, G. (1996). Traumatic lumbar hernia: a seat belt injury. J.
Trauma 40:121–122.
Moreno-Egea, A., and Aguayo, J. L. (2002). Ambulatory laparoscopic repair of inferior
lumbar or Petit hernia. Surg. Endosc. 16: 1107.
Moreno-Egea, A., Baena, E. G., Calle, M. C., Martınez, J. A., and Albasini, J. L. (2007) .
Controversies in the current management of lumbar hernias. Arch. Surg. 1:82–88.
Moreno-Egea, A., Torralba-Martinez, J. A., Morales, G.，Fernandez, T.，Girela, E., and
Aguayo-Albasini, L. (2005). Open versus laparoscopic repair of secondary lumbar
hernias A prospective nonrandomized study. Surg. Endosc. 19:184–187.
Ng, S. S., Ng, N. C., Liu, S. Y., and Lee, J. F. (2006). Radiology for the surgeon: soft-tissue
case 58. Can. J. Surg. 49:129–130.
Orcutt, T. W. (1971). Hernia of the superior lumbar triangle. Ann. Surg. 173:294–297.
Otero, C., and Fallon, W. (1998). Injury to the abdominal wall musculature the full spectrum
of traumatic hernia. South Med. J. 81:517–520.
Petit, J. L. (1774). Traite′ des maladies chirurgicales et des ope′ rations qui leur conviennent.
Didot, Paris, pp. 256–259.
Ponka, J. L. (1980). Lumbar hernias. In “Hernias of the Abdominal Wall,” Ponka, J. L. (ed),
pp 465-478. Saunders, Philadelphia.
Postema, R. R., and Bonjer, H. J. (2002) Endoscopic retroperitoneal repair of a Grynfeltt
hernia. Surg. Endosc. 16:716–717.
Rishmiller, J. N. (1917). Hernia through triangle of Petit. Surg. Gynecol. Obstet. 24:589.
Skrekas, G., Stafyla, V. K., and Papalois, V. E. (2005) . A Grynfeltt hernia: report of a case.
Hernia 9:188–191.
Somuncu, S., Berbay, F., Rizalar, R., Ariturk, E., Gunaydin, M., and Gurses, N. (1997) .
Congenital lumbar hernia associated with the lumbocostovertebral syndrome: two cases.
Eur. J. Pediatr. Surg. 7:122–124.
Swartz, W. T. (1978). Lumbar hernia. In “Hernia,” Nyhus, L. M., and Condon, R. E. (eds),
2nd Edition, pp 409-426. Lippincott, Philadelphia.
Teo, K. A. T., Burns, E., Garcea, E. G., Abela, J. E., and Mckay, C. J. (2010) . Incarcerated
small bowel within a spontaneous lumbar hernia. Hernia 14:539–541.
Thoreck, M. (1950). Lumbar hernia. J. Int. Coll. Surg. 14:367–393 .
Walsh, M., and Springfield, D. S. (2004). Spontaneous lumbar hernia. A case report. J. Bone
Joint Surg. Am. 86-A:1525–1527.
Junsheng Li and Zhenling Ji
164
Witherspoon, J., Chakravartty, S., Parry, C. R., Williams, G. L., and Stephenson, B. M.
(2012). Open sutureless lumbar hernia repair using a ‘memory ring’ Patch. Hernia
16:227–228.
Woodward, A. M., Flint, L. M., and Ferrara, J. J. (1999). Laparoscopic retroperitoneal repair
of recurrent postoperative lumbar hernia. J. Laparoendosc. Adv. Surg. Tech. A 9: 181–
186.
Zamir, G., Gross, E., Simha, M., Pikarsky, A. J., and Rivkind, A. (1998). Incarcerated lumbar
hernia: delayed consequence of a seat belt injury. Injury 29:561–563.
Zhou, X., Nve, J. O., and Chen, G. (2004). Lumbar hernia: clinical analysis of 11 cases.
Hernia 8:260–263.
In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 12
COMPONENTS SEPARATION TECHNIQUE
AND PANNICULECTOMY FOR REPAIR OF
INCISIONAL HERNIA
Marco Mazzocchi
1*
, Luca A. Dessy
2
, Silvia Di Ronza
2
and Nicolò Scuderi
2
1
Department of Plastic and Reconstructive Surgery, University of Perugia, Perugia, Italy
2
Department of Plastic and Reconstructive Surgery, ‘‘Sapienza’’
University of Rome, Rome, Italy
ABSTRACT
Abdominal wall hernias complicate between 5 and 11 % of abdominal surgery
procedures. The repair of these often massive ventral hernias remains a challenging
problem for surgeons. Many surgeons discourage abdominal wall reconstruction because
of the technical difficulties, the high morbidity and the relatively high recurrence rate
associated with this procedure. Primary incisional hernia repair is rarely successful, with
recurrence rates ranging from 18% to 62%, depending on the defect size. Ramirez et al.
[1990] introduced the ‘‘components separation” technique. This is based on the
enlargement of the abdominal wall surface by separation and advancement of the
muscular layers. By using this technique, up to 10 cm of unilateral advancement can be
achieved, thus permitting a tension-free abdominal closure with medialization of the
rectus abdominus muscle in large ventral hernias based on enlargement of the abdominal
wall surface by separation and advancement of muscular layers. We describe the
integration of panniculectomy with separation-of-parts herniorrhaphy combined with
intra-abdominal pressure monitoring and clinical appearance of the abdomen evaluation.
Sixty-seven patients were treated for incisional hernia repair. Standard
panniculectomies and component separation were performed. Secure abdominal defect
closure with midline approximation of the fascia was achieved in all the patients. No
major early complications occurred, nor did any patient develop abdominal wall
weakness, lateral herniation or postoperative bowel obstruction. Hernia recurred in three
*
Corresponding author: Department of Plastic and Reconstructive Surgery, University of Perugia, Perugia, Italy
Email: mazzocc@mclink.it.
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
166
patients (4.5%). Intra-abdominal pressure increased in all the patients in our series but
remained well below the danger level for compartment syndrome. Forty-six patients were
fully satisfied with the appearance of their abdomen, while twenty-one were satisfied
with the improvement.
We believe that the separation of components technique combined with
panniculectomy of the abdominal wall greatly simplifies and facilitates reconstruction of
massive midline defects. This procedure affords dynamic autologous tissue repair and
avoids additional donor-site morbidity. Abdominal component separation reduces the risk
of recurrence and provides a reliable autologous reconstructive option for complex
ventral abdominal defects. Hernia repair combined with abdominoplasty provides
functional and aesthetic benefits, and generally highly satisfies patients. We believe that
panniculectomy reduces the tension on the fascial closure and removes poorly
vascularized tissue. In conclusion, the component separation technique is, in our opinion,
an effective, mesh-free method for the repair of large midline hernias.
Keywords: Component separation, panniculectomy, ventral hernia, incisional hernia
INTRODUCTION
Abdominal wall hernias complicate between 5 and 11 % of abdominal surgery
procedures [Pollock et al., 1979; Bucknall et al.,1982]. The repair of these often massive
ventral hernias remains a challenging problem for surgeons. Many surgeons discourage
abdominal wall reconstruction because of the technical difficulties, the high morbidity and the
relatively high recurrence rate associated with this procedure. Primary repair is rarely
successful, with recurrence rates ranging from 18% to 62%, depending on the defect size
[Luijendijk et al., 2000; Millikan, 2003; Burger et al., 2004; Sauerland et al., 2005]. If
synthetic mesh is added, recurrence rates drop significantly to between 2% and 32%
[Luijendijk et al., 2000; Burger et al., 2004; Sauerland et al., 2005; Lomanto et al., 2006].
However, many patients with large hernias have invalidating symptoms, such as bulging of
the abdominal wall, chronic wounds, immobility and back pain, which require surgical
treatment [de Vries Reilingh et al., 2007].
The options the surgeon has are open primary repair, open repair with mesh, laparoscopic
repair, or autologous tissue transfer or mobilization. The use of autologous tissue to repair
abdominal wall hernias has been described in detail. The tensor fascia lata, sartorius and
rectus femoris can be used as either free flaps or pedicled flaps to close large defects.
However, the lack of sufficient tissue may require the insertion of prosthetic material or
transposition of autologous material to bridge the fascial gap. Reconstruction using pre-
peritoneally placed prosthetic material is still the most frequently used reconstruction method
[Luijendijk et al., 2000; Sauerland et al., 2005; Lomanto et al., 2006]. The increased risk of
infection in case of wound complications is a relative contraindication against the use of
prosthetic materials. However, the use of large sheets of synthetic material for hernia repair
often results in a rigid, non-compliant, adynamic abdominal wall and is contraindicated in
case of contamination [Rosen et al., 2007]. Moreover, as the interposition of either the
peritoneum or greater omentum between the bowel and the prosthesis is often impossible, the
use of prosthetic material should, if possible, be avoided.
Components Separation Technique and Panniculectomy for Repair …
167
Commercial biological prostheses have recently become available. These prostheses are
useful when the wound is contaminated or the risk of infection high. Acellular dermal matrix,
porcine intestinal mucosa and porcine dermal collagen have been used safely and effectively
as an alternative to traditional mesh to successfully repair hernias in contaminated operating
fields and in conditions that would not be safe if traditional permanent prostheses were used
[Kim et al., 2006; Patton et al., 2007].
Ramirez et al. [1990] introduced the “components separation technique” to bridge the
fascial gap without the use of prosthetic material. The technique is based on the enlargement
of the abdominal wall surface by separation and advancement of the muscular layers. By
using this technique, up to 10 cm of unilateral advancement can be achieved, thus permitting
a tension-free abdominal closure with medialization of the rectus abdominus muscle in large
ventral hernias [Di Bello and Moore, 1996; Girotto et al., 1999; Shestak et al., 2000; Sukkar
et al., 2001; de Vries Reilingh et al., 2003 Jernigan et al., 2003; Lowe et al., 2003]. Recent
modifications of the original procedure, including preservation of periumbilical perforators,
have led to decreased wound complications in large hernia repairs [Saulis and Dumanian,
2002].
Incisional hernias may result in significant functional impairment as they enlarge, in
addition to presenting obvious cosmetic concerns with the abdominal bulge [Millikan, 2003].
The objectives of abdominal wall reconstruction include restoring structural support,
providing stable soft-tissue coverage, and optimizing aesthetic appearance while minimizing
morbidity and postoperative disability. The traditional approach to incisional hernia repair
usually involves a surgical approach via the previous scar, which is usually vertical. However,
an approach via a low transverse incision may, in some instances, be considered. Indeed,
techniques that have been developed for the surgical approach to abdominoplasty include the
use of a transverse lower abdominal incision and the resection of excess skin. Numerous
studies in the literature, most of which have been gynaecological in nature, have advocated
pannus resection in conjunction with intra-abdominal procedures, with all reporting
successful outcomes [Hopkins et al., 2000; Tillmanns et al., 2001]; very few of these reports
have addressed the challenges involved in the repair of incisional hernia [Hughes et al., 1996;
Reid and Dumanian, 2005]. The benefits of this approach are full exposure of the abdominal
wall defect, a surgical approach through known tissue planes, and fascial repair far from the
skin incision. By incorporating these aspects into hernia repair, the safety of the procedure is
maintained, the recurrence rates are reduced, and the aesthetic outcome is enhanced
[Robertson et al., 2003]. We describe our experience regarding the safety and effectiveness of
panniculectomy with the separation-of-parts herniorrhaphy. In our study, intra-abdominal
pressure was monitored during closure as well as post-operatively.
MATERIAL AND METHODS
A prospective, non-controlled study (cohort study) was planned. From January 2006 to
July 2012, 67 patients were treated in the Department of Plastic Surgery of “ La Sapienza”
University of Rome for incisional hernia repair and were then followed. The reasons for
surgery were recurrent incisional hernia in 43 cases (64.2%) and incisional hernia in the
remaining 24 cases (35.8%). The etiological procedures included bariatric operations, bowel
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
168
resection, cholecystectomy and a variety of obstetric/gynaecological procedures. Within the
subgroup of patients with recurrent hernias, the number of prior repairs ranged from 1 to 4
(mean: 1.85). The overall incidence of prior mesh encountered perioperatively was 71.5% (30
cases). The type of mesh that had been used in the previous surgical treatment was composite
(Prolene/ PTFE dual mesh) in six cases and non-absorbable (Polytetrafluoroethylene-PTFE)
in four cases. The mesh was infected in nine cases. Forty-six patients were women (68.7%)
and 21 patients were men (31.3%). The patients’ age ranged between 48 and 72 years
(median: 59 years and 2 months). The patients’ body mass index ranged from 19.8 to 58.2
kg/m
2
(mean: 42.6 kg/m
2
). Some patients had at least one risk factor for recurrence, including
morbid obesity (28 patients, 41.8%), diabetes mellitus (18 patients, 27.0%), recent massive
weight loss after bariatric surgery (15 patients, 22.5%). Fifteen patients (22.5%) had a history
of smoking. None of the patients had severe asthma or a chronic respiratory tract disorder.
The size of the defects was assessed preoperatively by means of computed tomography
scan. All defects were midline; according to Chevrel’s classification [Chevrel and Rath,
2000], they were supraumbilical (M1) in 9 cases, juxtaumbilical (M2) in 15 cases,
subumbilical (M3) in 12 cases and xypho-pubic (M4) in the remaining 31 cases. All the
defects were longer than 11 cm transversally and varied in length vertically. According to
Chevrel’s classification [Chevrel and Rath, 2000], they were 10 to 15 cm wide (W3) in 37
cases and > 15 cm in the remaining 30 cases (W4). The size of the defects ranged from 225
cm
2
(11x13 cm) to 980 cm
2
(24x26 cm), the mean being 525 cm
2
. In two patients, the
computed tomography scan clearly demonstrated the loss of abdominal domain. Indeed, the
abdominal viscera in this patient were predominantly outside the abdominal cavity, the size of
the abdominal cavity being substantially reduced because of the lateral contraction of the
abdominal wall musculature.
Deep venous thrombosis prophylaxis, with subcutaneous heparin injections and
sequential compression devices, and intravenous cephalosporine were administered to all the
patients. Preoperative bowel preparation was routinely used. All the surgical procedures were
performed under general anaesthesia.
A lower abdominal incision was made in all the patients. A vertical incision was added
only in the patients with a previous midline scar, resulting in an inverted T incision (41%).
The latter afforded greater exposure, especially in cases of epigastric hernias. The location of
the low transverse skin incision allows dissection from the normal tissue planes around the
hernia toward the fascial edge and hernial sac, thereby minimizing the risk of enteric injury.
Each end of the skin paddle was grasped with a clamp, and the segment was avulsed. This
ensured a good alignment of the superior and inferior skin edges because the flaps were of
similar thickness. The skin edges were checked to ensure that primary closure could be
achieved without aggressive undermining. Panniculectomies were accomplished by excising a
large horizontal ellipse with corners based at the bilateral iliac crests. Pannus specimens were
sent to the pathology laboratory for weights and gross inspection.
The initial lipectomy served to optimize exposure of the hernia sac and the rectus
musculature. Care was taken to elevate the skin flaps only as far as necessary to clearly
identify the hernial defect and the semilunar lines in order to preserve as many perforators as
possible. In general, attempts were made to limit exposure to the suprapubic/hip incision by
means of conservative undermining under the costal margins.
The abdomen was opened, the posterior aspect of the abdominal wall was cleared of
adhesions, and bowel resection was performed when necessary with the help of a general
Components Separation Technique and Panniculectomy for Repair …
169
surgeon. Any prior prosthetic mesh encountered was removed. Component separation was
performed in the standard fashion by incising the aponeurosis of the external oblique muscle
longitudinally about 2 cm laterally of the rectus sheath, and dissecting the external oblique
muscle until the internal oblique fascia was encountered (Figure 1). The external oblique
muscle was then elevated to the level of the midaxillary line bilaterally. After debridement of
the scar and separation of the tissue from the medial edges of the rectus muscle, the
myofascial rectus flaps were advanced. This mobilization allowed primary closure of the
hernia defect with minimal tension using interrupted figure-of-eight 0 polypropylene suture
(Prolene, Ethicon, Inc., Somerville, NJ). Plication of the midline abdominal wall from the
xyphoid to pubis was performed, thereby approximating adjacent fascia over the hernia
repair, reinforcing the repair and improving the contour and tone of the lax abdominal wall
using uninterrupted 2/0 polydioxanone suture (Vicryl, Ethicon, Inc., Somerville, NJ) (Figure
2). No mesh was used in any of the cases. Suction drains were used routinely.
After meticulous hemostasis, layered skin closure was performed. Skin closure was
performed with interrupted deep 2/0 polydioxanone suture (Vicryl, Ethicon, Inc., Somerville,
NJ), dermal 3/0 Poliglecaprone 25 (Monocryl, Ethicon, Inc., Somerville, NJ) and
uninterrupted cutaneous 3-0 nylon (Ethilon, Ethicon, Inc., Somerville, NJ). If the umbilicus
had previously been released from the abdominal wall, it was reattached.
Figure 1. Component separation was performed in the standard fashion by incising the aponeurosis of
the external oblique muscle longitudinally about 2 cm laterally of the rectus sheath.
Figure 2. Following the component separation, primary closure was accomplished easily, thereby
approximating adjacent fascia over the hernia repair, reinforcing the repair and improving the contour
and tone of the lax abdominal wall.
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
170
The patients were maintained on nothing-by-mouth status postoperatively until the return
of bowel function defined by the passage of flatus. Nasogastric tubes were used if extensive
intra-abdominal dissection was required as part of the procedure. A pressure dressing was
maintained during the immediate postoperative period, and a pressure bandage was kept in
place for four weeks.
Intra-abdominal pressure was measured through urinary bladder pressure measurements.
Following the induction of general anaesthesia, a standard Foley catheter was inserted and the
bladder emptied as best as possible by gravity. Upon the return of four muscular twitches, 100
ml of sterile saline was instilled into the emptied bladder and the catheter tubing clamped
distally to the aspiration port. A Stryker compartmental pressure monitor (Stryker-Leibinger,
Kalamazoo, MI) was used to measure intravesical pressure, at the end of expiration, through
the catheter aspiration port. Measurements were taken at the following intervals:
preoperatively (T0), after hernia repair (T1), after skin closure (T2), postoperative day one
(T3). Any differences between these measurements were compared by means of Wilcoxon’s
matched pairs signed rank sum test; statistical significance was set at p < 0.05.
Follow-up visits were scheduled 1, 3 and 6 months, and then every year, after the surgical
procedure. The presence of complications or hernia recurrence was evaluated at each follow-
up visit. A physical examination was also conducted at each follow-up visit and the condition
of the abdominal wall evaluated by means of an ultrasound examination and CT imaging.
The clinical appearance of the abdomen was subjectively evaluated by patients after
surgery. The subjects’ global impression of clinical improvement was recorded using a scale
ranging from 0 to 2 (0 = no improvement; 1 = satisfaction with improvement; 2 = complete
satisfaction).
RESULTS
The resection of redundant fat and skin, which was straightforward in all the patients,
afforded a wider exposure for hernia repair (Figure 3). The extent of panniculus resection
ranged from 850 g to 3650 g, with a mean of 1560 g.
Figure 3. Panniculectomy/separation-of-parts procedure. Preoperative views (above), postoperative
views (below) of the same patient.