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Components Separation Technique and Panniculectomy for Repair …
171
Table 1. Statistical significance of the differences between values was determined by the
Wilcoxon test
M +/- SD
(mmHg)
Wilcoxon test
p-value
Preop (T0)
7.6 +/- 1.961
Preop (T0) - Hernia repair (T1)
< 0.0001
Hernia repair (T1)
15.41+/- 3.239
Preop (T0) - Skin closure (T2)
< 0.0001
Skin closure (T2)
16.22 +/- 2.981
Preop (T0) -1 day postop (T3)
< 0.0001
1 day postop (T3)
14 .29+/- 3.167
Hernia repair (T1)- Skin closure (T2)
< 0.0001
Hernia repair (T1) -1 day postop (T3)
< 0.0001
Skin closure (T2) -1 day postop (T3)
< 0.0001
M, mean: SD, standard deviation.
p, probability.
Secure closure of the abdominal defect with midline approximation of the fascia was
achieved in all the patients. Bowel resection, which was performed in nine cases (13.5%), was
due to bowel adherence in seven cases and “loss of domain” in the other two. In these cases,
approximately 50 cm of edematous distal small bowel was resected, and a subtotal colectomy
was performed.
All the patients were extubated on the day of surgery; none required re-intubation
because of severe respiratory compromise. Reduced saturation (under 92%), which was
observed in 15 patients, was treated with oxygen delivery by mask (35%) for more than one
hour in the recovery period (range: 8 to 24 hours) to maintain saturation above 92%. We did
not observe any cases of severe dyspnoea, tachypnoea, reduction of tidal volume or other
respiratory sequelae of the operation.
The mean intensive care unit stay was 0.3 days (range, 0 to 3). The mean length of
hospital stay in the panniculectomy/separation-of-components patients was 9.1 days (range, 5
to 23). Return of bowel function was the predominant reason for this prolonged hospital stay.
There were no instances of deep venous thrombosis or pulmonary embolism. No cases of
pneumonia were recorded.
No major early (up to 3 months) complications occurred in any patients. The most
common minor complication was minor skin necrosis or dehiscence, only requiring local
wound care, which occurred in 12 patients (18.1%). In six of these patients some degree of
necrosis and wound separation, which required additional dressing changes, occurred at the
T-junction, though neither required reoperation for debridement or closure.
Cellulitis, requiring either intravenous or oral antibiotics, occurred in three patients
(4.5%). Infected fluid collection requiring local wound care and antibiotics occurred in three
cases (4.5%). These infections were managed with oral antibiotics and dressing changes on an
outpatient basis and resolved uneventfully. In three patients (4.5%), minor wound infections
developed after discharge from hospital. Seromas formed following drain removal in 12
patients (18.1%), all of which were treated successfully with drain replacement or serial
percutaneous drainage. No patient developed abdominal wall weakness, lateral herniation or
postoperative bowel obstruction.
The mean follow-up time was 26.8 months (range, 12 to 44 months). Hernias recurred in
three patients (4.5%). They presented a small hernia recurrence (ranging from 3x4 cm to 3x6
cm) in the sub-xyphoid area 12 months postoperatively. This hernia recurrence was
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
172
successfully resolved by means of a secondary procedure. Primary closure of the hernia
defect was performed using interrupted figure-of-eight 0 polypropylene suture (Prolene,
Ethicon, Inc., Somerville, NJ).
Intravesical pressure recording showed an increase in the rectus abdominis muscle
(hernia repair) (T1) following repair, when it reached a mean value of 15.41 mmHg, another
slight increase following complete skin closure and application of the dressing (T2) (mean
value: 16.22 mmHg) and, lastly, a slight drop in intravesical pressure 1 day postoperatively
(T3) (mean value: 14.29). The difference in intra-abdominal pressure values was highly
significant (P<0.01) between T0 and T1, T2 and T3 as well as between T1 and T2, T2 and
T3, and T1 and T3.
Forty-six patients were completely satisfied with the appearance of their abdomen (score
2), while twenty-one were satisfied with the improvement (score 1). No patients reported an
absence of improvement (score 0).
DISCUSSION
Incisional hernias frequently complicate abdominal surgery procedures [Pollock et al.,
1979; Millikan, 2003; Burger et al., 2004] and may cause serious morbidity due to various
factors, including bowel or omental incarceration and strangulation.
Reconstruction of massive, full-thickness defects involving the abdominal wall has
always represented a formidable challenge for the reconstructive surgeon. Not only are such
defects frequently unsightly, but they also produce abdominal wall weakness associated with
marked contour abnormality and protuberance of abdominal viscera. These sequelae from
massive defects often interfere with the patient’s activities of daily living [Girotto et al.,
2003].
The repair of these defects should ideally be tension-free, provide dynamic muscle
support, and prevent eventration. Primary fascial repair satisfies the last two of these three
criteria, but cannot be achieved in a tension-free environment when the fascial defect is large
[Girotto et al., 1999]. Consequently, recurrence rates associated with primary repair are as
high as 62% [George and Ellis, 1986]. The recurrence rate of incisional hernia is, however,
known to be related directly to certain patient comorbidities, defect characteristics, specific
repair methods and, most importantly, follow-up time. Not surprisingly, the recurrence rate is
related to the size of the hernia, with a 41% recurrence rate for hernias larger than 4 cm, and a
25% recurrence rate for those smaller than 4 cm [Hesselink et al., 1993]. The role of primary
repair in moderately large hernias is therefore limited; moreover, numerous efforts have been
made to reduce tension on the repair, including expansion of the abdominal wall with
prosthetic materials. Although techniques that use mesh, or other prosthetic materials, can
eliminate tension on the closure, they are not ideal owing to the risk of infection, mesh
migration, erosion into the bowel and enterocutaneous fistula. Bioprosthetic mesh has distinct
advantages over synthetic mesh. Healing in bioprosthetic repair sites is due to a regenerative
process as opposed to scar tissue formation. Once remodelled with autologous tissue, there is
theoretically no ongoing foreign body response, thereby reducing the risk of chronic infection
and subsequent erosion through the skin or viscera. Bioprosthetic mesh is reported to adhere
markedly less to abdominal viscera, thus allowing it to be placed directly over the bowel.
Components Separation Technique and Panniculectomy for Repair …
173
However, little is yet known about the biological and physiological mechanisms of action and
long-term outcomes of abdominal wall reconstruction performed with bioprosthetic materials
[Ramirez et al., 1990; Kim et al., 2006]. Another functional drawback of mesh is that since it
does not provide dynamic support, problems occur where the static mesh meets the dynamic
abdominal wall tissue [Sukkar et al., 2001; Borud et al., 2007].
Abdominal component separation has been shown to decrease the risk of recurrence and
to provide a reliable autologous reconstructive option for complex ventral abdominal defects
[Ramirez et al., 1990; Thomas et al.,1993; Di Bello and Moore, 1996; Lowe et al., 2000;
Mazzocchi et al., 2011]. This is an abdominal wall reconstruction technique that uses local
tissue to provide dynamic support for the abdominal wall and permit tension-free closure of
the myofascial layers [Patton et al., 2007]. Ger and Duboys [1983] reported that innervated
and vascularized musculofascial flaps are superior to prosthetic materials or adynamic and
devascularized autologous tissue for the repair of large hernia defects. Abrahamsom and
Eldar [1989] emphasized the importance of recreating the linea alba to provide an anchor for
the lateral abdominal wall anteriorly in order to reduce the risk of recurrence.
Component separation can be used to reconstruct complex ventral abdominal defects with
innervated and vascularized tissue, without the need for distant tissue transfer. The procedure
that we performed recreates the linea alba, thereby successfully providing a midline anchor.
The procedure is described as a separation of the layers, or components, of the abdominal
wall to achieve greater mobility and, consequently, coverage [Ramirez et al., 1990]. It is
begun by making bilateral incisions in the external oblique fascia just lateral to the semilunar
line. The plane is dissected carefully to avoid dissecting down the internal oblique fascia,
since the arteries and nerves that supply the abdominal musculature travel deep within this
fascia. If this does not allow enough mobilization, the posterior sheath of the rectus fascia can
be incised to gain further distance [Borud et al., 2007]. After assessing the total distance on
either side, the surgeon can mobilize the tissues, gaining as much as 10 cm in the epigastrium,
20 cm at the waist and 6 cm in the suprapubic region [Ramirez et al., 1990]. In all 67 of our
patients, we were able to successfully close the fascial defects and avoid the use of permanent
mesh.
Using the component separation technique, Ramirez et al. [1990] reported an 8%
recurrence rate, Di Bello and Moore [1996] an 8.5% recurrence rate, and Lowe et al. [2000] a
14% recurrence rate. In contrast, Thomas et al. [1993] reported no recurrences. The hernia
recurrence rate in our series, in which there were closed, large defects with complete primary
fascial edge approximation, was low (4.5%). We believe that this low recurrence rate is
worthy of note if compared with those reported in the afore-mentioned studies, even though a
longer follow-up period (at least five years) is required to more accurately assess the
recurrence rate in our series. One of the factors that we feel contributed significantly to the
recurrence rate in our series was the effort made to relieve tension on the fascial closure once
the edges were brought together. This was achieved primarily by using a second running
suture placed on either side of the fascial closure to imbricate the edges, comparable to a
fascial plication in abdominoplasty. This displaced the tension from the closure onto the
imbricating suture line and off the fascial closure. The resulting primary fascial coaptation
ensures dynamic support of the abdominal wall, thereby minimizing the potential bulge
associated with a simple patch closure of prosthetic mesh.
The component separation technique provides local autologous reconstruction for
complex and contaminated wounds. Indeed, autologous reconstruction is the most logical
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
174
option when an infected or contaminated wound is expected during surgery [Lowe et al.,
2000]. However, the surgeon should be fully aware of the risks involved in component
separation before surgery is undertaken. The use of this procedure must be assessed within
the context of the patient’s preoperative medical condition, the complexity of the defect and
the complications related to both hernia takedown and reconstruction.
As the inability to adequately expose incisional hernias is believed to result in a high
recurrence rate, we hypothesise that recurring or recalcitrant hernias may benefit from the
creation of a dynamic abdominal wall, and that wide exposure of the entire anterior
abdominal wall not only permits the identification of additional areas of weakness and
simultaneous hernias, but also relieves the tension imposed by scar and skin contracture. In
our opinion, the usefulness of panniculectomy, a widely used technique to gain access to the
obese abdomen, has yet to be recognised in the literature as an adjunct to the separation-of-
parts hernia repair in obese patients [George and Ellis, 1986; Girotto et al., 2003; Reid and
Dumanian, 2005; Mazzocchi et al., 2011]. Our data support the combination of these
procedures in every type of patient.
The separation of components associated with concomitant bowel resection allows lost
abdominal domain to be recovered, reduces the risk of abdominal compartment syndrome and
may help restore normal bowel motility and function [Buck et al., 210]. Elective bowel
resection is associated with several independent risks that should be borne in mind
preoperatively. First is the complication of short gut syndrome, a condition that generally
arises when less than 200 cm of small bowel remains after resection. The potential for short
gut syndrome confirms the importance of measuring bowel length before considering how
much to resect. Although the length of bowel that must be resected is not predefined, we
believe it is best to remove as much of the dilated atonic bowel as necessary to close the
abdominal contents without undue tension [Buck et al., 2010]. Another important risk that
must be considered is the potential for wound complications when bowel resection is
combined with the separation of components repair. Wound complications may also arise
because of contamination from the spillage of bowel contents during bowel resection [Buck et
al., 2010]. Furthermore, surgical repair in the presence of a contaminated bowel procedure
requiring tenuous soft tissue for the closure may lead to problems related to mesh infection
and extrusion. In our patients, we performed non-supported autogenous repairs to avoid the
risk of such complications. With regard to small bowel resection and spillage of succus, we
recommend standard bowel preparation before the operation as well as a strictly clear liquid
diet for 3 to 4 days preoperatively.
Hernia repair does not appear to be compromised when coupled with abdominal skin
resection [Shermak, 2006]. We believe that panniculectomy reduces tension on the fascial
closure and removes poorly vascularized tissue and eliminates a portion of the subcutaneous
dead space. However, we recognize that this creates an additional incision, thus increasing the
chance of wound infection or incisional breakdown.
Conservative pannus resection and the separation-of-parts hernia repair in our series was
achieved without either significantly elevating the diaphragm or creating any postoperative
ventilation difficulties (the “loss of domain” syndrome), as the intra-abdominal pressure
values showed [Reid and Dumanian, 2005]. The low failure rate for ventral hernia repairs
with the component separation technique comes at the expense of an increased wound
complication rate, if compared with standard techniques. The poor vascularity of widely
Components Separation Technique and Panniculectomy for Repair …
175
undermined skin flaps may be partly responsible for this high complication rate. However, the
combination of the component separation technique with an abdominoplasty, in which a part
of the skin flaps is resected, may reduce the likelihood of this complication by eliminating the
poorly vascularized part.
The extensive undermining that is often needed for effective fascial closure can
predispose patients to seroma formation. Seromas are associated with an increased risk of
infection, wound dehiscence, flap necrosis and reoperation. Placement of multiple
suprafascial drains, which we strongly advocate, can reduce the rate of seroma formation. It is
important that these drains be left in place until the skin flap has adhered to the fascia. It may
be possible to apply fibrin sealants, which have been used to reduce the incidence of seroma
formation following breast surgery, to abdominal wall surgery, though this application has so
far met with mixed success.
Normal intra-abdominal pressure in adults is less than 10 mmHg, whilst intra-abdominal
pressure values over 15 mmHg are indicative of intra-abdominal hypertension [Sanchez et al.,
2001; Davis et al., 2005]. Prolonged increased intra-abdominal pressure over 20 mmHg is
known to cause serious conditions such as acute renal failure, pulmonary impairment and
reduced blood flow to the gastro-intestinal organs [Saggi et al., 1998; Gudmundsson et al.,
2002]. Moreover, increased intra-abdominal pressure causes elevation of the diaphragm,
which is in turn followed by increased intra-thoracic pressure, and there is evidence
suggesting that increased intra-thoracic pressure results in increased intra-cranial pressure and
functional obstruction of the cerebral venous outflow via the jugular venous system [Saggi et
al., 1998; Gudmundsson et al., 2002].
The abdomen has a dynamic muscular wall that can accommodate marked variations in
volume, which are accompanied by changes in intra-abdominal pressure [Saggi et al., 1998;
Gudmundsson et al., 2002]. Repair of the incisional hernia causes extrinsic compression of
the abdominal content and elevation of intra-abdominal pressure, as observed in our series.
Although intra-abdominal pressure increased in all of our patients following repair of the
rectus abdominis muscle, and increased even slightly further after complete skin closure and
application of the dressing, it remained well below the danger level. Indeed, intra-abdominal
pressure was below 20 mmHg in all the patients the day after surgery, and no cases of
prolonged increased pressure were reported. The three most reliable methods of indirectly
measuring intra-abdominal pressure are gastric, inferior vena caval and urinary bladder
pressure measurements [Saggi et al., 1998; Gudmundsson et al., 2002]. In this study,
intravesical pressure was measured on account of the simplicity of this measurement in
catheterized patients.
Our data point to the feasibility of combined panniculectomy/separation of components
for the correction of incisional hernias. The high salvage rate of multiple recurrent hernias
associated with this surgical approach suggests that it should be considered when a
laparoscopic technique or the use of biomaterials is contraindicated. Indeed, we strongly
recommend this as the procedure of choice for the autologous tissue reconstruction of
massive midline defects of the abdominal wall.
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.
Marco Mazzocchi, Luca A. Dessy, Silvia Di Ronza et al.
176
CONCLUSION
Hernia repair combined with abdominoplasty provides both functional and aesthetic
benefits and generally creates a highly satisfied patient base. When surveyed, patients with
successful autologous tissue repairs noticed improvements in the appearance of their
abdomen, in their postoperative emotional state, in abdominal strength, as well as in their
ability to lift objects, rise from a chair or bed and exercise. In conclusion, the component
separation technique is, in our opinion, an effective, mesh-free method for the repair of large
midline hernias.
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 13
DIAPHRAGMATIC HERNIAS
Ivan Martinez Serna
*
and Antonio Pablo Gamez Garcia
Thoracic Surgery Department, "12 de Octubre" Hospital, Madrid, Spain
ABSTRACT
Thoracic hernia can be defined as the presence of thoracic organs beyond the limits
of the rib cage or as abdominal structures present in the thoracic cavity as a result of
passing through diaphragmatic defects. Diaphragmatic hernias are characterized by
migration of abdominal structures into the chest through a diaphragmatic defect. They
may be classified as congenital or acquired (traumatic). In hiatal hernia, the upper part of
the stomach ascends through the hiatal orifice to the thorax, and although they are usually
asymptomatic, hiatal hernia may present as gastroesophageal reflux. Congenital hernias
are usually observed in neonates or infants, and the presence of abdominal organs in the
thoracic cavity may result in severe pulmonary hypoplasia. In traumatic hernia, the
diaphragmatic defect is due to blunt or penetrating thoracoabdominal trauma and may be
accompanied by injury to other organs as a result of severe trauma. The diagnosis of
thoracic hernia can be sometimes difficult because symptoms are somewhat non-specific.
Treatment is focused on reduction of herniated tissues and surgical correction of the
thoracic or diaphragmatic defect.
Keywords: Diaphragmatic, hiatal, hernia, thorax, anatomy, congenital, traumatic, Bochdalek,
Morgagni, treatment
INTRODUCTION
The diaphragm forms the lower limit of the chest cavity, separating it from the abdominal
cavity. It also has great functional importance because it is the major muscle of ventilation.
Pathologic diseases of the diaphragm can be diverse (e.g., malformations, functional,
*
Corresponding author: Thoracic Surgery Department., "12 de Octubre" Hospital, Madrid, Spain, Email:
ivanabiacity@yahoo.es.
Ivan Martinez Serna and Antonio Pablo Gamez Garcia
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traumatic, neoplastic). In this chapter, the development, clinical manifestations, diagnosis,
and treatment of diaphragmatic hernia will be discussed.
EMBRYOLOGY
The diaphragm forms from four structures: the septum transversum, pleuroperitoneal
membranes, dorsal mesentery of the esophagus, and mesenchyme of the lateral abdominal
wall [Langer, 1997]. The septum transversum is composed of mesoderm, which comes to lie
between the pericardium and the abdomen after ventral folding of the embryonic head during
the 4
th
week of development. This structure forms the central tendon of the diaphragm. The
pleuroperitoneal membranes occur on either side of septum trasversum. The dorsal mesentery
of the esophagus attaches the developing foregut to the dorsal body wall, and ultimately
forms the crura of the diaphragm. The fourth component of the diaphragm comes arises from
the mesenchyme of the lateral abdominal wall, which grows in to join the other components
starting around 12 weeks after conception.
Abnormalities of development may result in diaphragmatic defects, leading to herniation
of abdominal viscera into the chest. Diaphragmatic hernias usually occur posterolaterally
(foramen of Bochdalek) owing to inadequate fusion of the pleuroperitoneal membrane with
the other components of the diaphragm. Because the right pleuroperitoneal membrane is
thought to close first, left-sided Bochdalek hernias occur more commonly than right-sided
ones. In severe cases, bilateral hernias or unilateral complete diaphragmatic agenesis may be
found. Diaphragmatic hernias may also occur in the anterior midline through the sternocostal
hiatus (foramen of Morgagni). The embryologic basis of this malformation is less clear,
although it is thought that this retrosternal space exists owing to the superior epigastric
vessels.
ANATOMY OF DIAPHRAGM AND PHRENIC NERVE
The Diaphragm
The diaphragm is the major muscle of ventilation. It originates from the lower six ribs
bilaterally, from small slips at the posterior aspect of the xiphoid process, and from the
external and internal arcuate ligaments. The left crus of the diaphragm originates from the
anterior surface of the upper two lumbar vertebrae. The right crus is thicker and longer, and
originates from the upper three lumbar vertebrae. The medial and lateral arcuate ligaments are
tendinous bands that extend the vertebral attachment of the diaphragm across the upper
portion of the psoas major and quadratus lumborum muscles. The right crus forms the
esophageal hiatus in the most of the cases. The dome-shaped muscular mass inserts into the
central tendon, a roughly trifoliate fascial aponeurosis. Contraction of the costal portion of the
diaphragm causes the lower ribs to elevate with the concomitant flattening of the
diaphragmatic convexity, thus enlarging the thoracic cavity. Contraction of the crural portion
aids downward displacement of the diaphragm with a lesser effect on overall ventilation.
Diaphragmatic contraction also occurs during the early phases of exhalation in quiet