Open Ventral Hernia Repair withComponent Separation
Eric M. Pauli, MDa, Michael J. Rosen, MDb,*
KEYWORDS
Ventral hernia Incisional hernia Abdominal wall reconstructionRetromuscular hernia repair Transversus abdominis release (TAR)Rives-Stoppa technique
KEY POINTS
Incisional hernias are the most common complication afterlaparotomy and the most com-mon indication for reoperation afterlaparotomy.
Recent advancements in mesh technology and technical refinementsin the methods ofherniorraphy have dramatically changed the wayopen hernia surgery is conducted.
Abdominal wall reconstructive procedures, which typicallyinclude separation of theabdominal wall layers and release of oneor moremyofascial planes, require a clear under-standing of theanatomy of the abdominal wall.
The authors favored approach to open ventral hernia repair is aposterior component sep-aration (retrorectus dissection withrelease of the transversus abdominis aponeurosis andmuscle) withsublay of appropriately selected mesh between layers ofvascularized tis-sues and subsequent reconstruction of the lineaalba.
Retromuscular hernia repairs have been shown in multiple studiesto have a low recur-rence rate (3%6%) at long-term follow-up andhave been accepted as the gold standardtechnique for open ventralhernia repair by the American Hernia Society.
INTRODUCTION
Despite improved outcomes in many other areas of surgery,abdominal wall herniaformation still complicates 11% to 50% of alllaparotomies.16 It remains the mostcommon complication followinglaparotomy and is the most common indication forreoperation by a3:1 margin over bowel obstruction.7 With more than 2 millionlaparot-omies performed in the United States annually, generalsurgeons are faced with
Disclosures: Eric Pauli is a speaker for Bard and Synthes.Michael Rosen is a speaker for Covidien,Bard, and Lifecell. Hereceives research support from Lifecell, Davol, W.L. Gore, andCook.a Department of Surgery, Penn State Hershey Medical Center,500 University Drive, H149,Hershey, PA 17036, USA; b Department ofSurgery, Case Comprehensive Hernia Center, Univer-sity HospitalsCase Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA*Corresponding author.E-mail address:[emailprotected]
Surg Clin N Am 93 (2013)11111133http://dx.doi.org/10.1016/j.suc.2013.06.010surgical.theclinics.com0039-6109/13/$ see front matter 2013Elsevier Inc. All rights reserved.
mailto:[emailprotected]://dx.doi.org/10.1016/j.suc.2013.06.010http://surgical.theclinics.com
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epidemic numbers of patients requiring ventral herniorraphy.8 Areliable method with alow recurrence rate is still clearlynecessary for the estimated 200,000 patients under-going ventralhernia repairs annually.9
Traditional methods of hernia repair have unacceptably highrecurrence rates.10,11
Primary open suture repair of ventral hernias with simplefascial reapproximationresults in recurrence rates in excess of 50%in long-term follow-up.6,1219 Fifty-fiveyears ago, the meshherniorraphy was introduced.20 The principle of a tension-freemeshreinforced herniorraphy has undergone technical refinements sincethis timeand is still considered to be the gold standardrepair.11,21 Despite the widespreadimplementation of this goldstandard, the addition of mesh to open repairs stillresults inlong-term recurrence rates as high as 32%.1719 Moreover, the idealmethodof mesh implantation is the subject of ongoing debate.Withthe advent of laparoscopic ventral hernia repair in 1993, minimallyinvasive
techniques became the preferential method for many surgeons.22Intuitively, theserepairs had the advantage: they provided widemesh overlap of the hernia defectwithout significant soft tissuedissection. Short-term data suggested decreasedmorbidity and alower recurrence rate.23 Sadly, these data were not borne out inthelong term, where recurrence rates in well-selected populationsstill reach 14% to17%.2427 As a consequence, one of the mostpressing controversies of ventral herniarepair is whether toapproach the problem in an open or laparoscopic fashion.11
Parallel with the evolution of laparoscopic ventral herniarepair, novel methods ofabdominal component separation were beingdeveloped. In 1990, Ramirez andcolleagues28 originally describedtechniques of medial fascial advancement to aid indefinitivereconstruction. In their components separation, Ramirez andcolleagues28
first released the posterior rectus sheath. In 30% of theirpatients, this was insufficientto permit midline closure, and theytherefore created large skin flaps to expose andrelease theexternal oblique muscle. Recurrence rates after such componentsepara-tion hernia repairs range from 10% to 22%, with meanfollow-up periods of 9.5 monthsto 4.5 years.2931 Modifications ofthese myofascial advancement flaps have beendeveloped to reduce themorbidity incurred by creating these skin flaps (and bydefaultreduce the recurrence rate). Such methods include periumbilicalperforatorsparing (PUPS) methods, endoscopic release of theexternal oblique muscle, and,more recently, posterior componentseparation methods that avoid any skinundermining.3238
Posterior component separation methods are based on theRives-Stoppa-Wantzretrorectus repair, which used the 6-cm-wide to8-cm-wide potential space betweenthe posterior rectus sheath andthe rectus muscle to permit mesh positioning in a sub-layfashion.3942 Given its superior track record, this approach wasdeemed to be thegold standard method for open ventral hernia repairby the American Hernia Society in2004.11,38 Although durable, theRives-Stoppa-Wantz technique does not permitdissection beyond thelateral border of the posterior rectus sheath, making itinsuffi-cient to permit adequate mesh overlap and tension-freerepair of larger abdominalwall defects.38,42 Methods to extend thispotential space have been described andinclude preperitonealdissection, intramuscular plane formation, and release ofthetransversus abdominis muscle.35,37,38,43 Using these methods,surgeons have beenable to achieve recurrence rates as low as 3% to6%.35,36,38,43
In this article, we describe our current operative technique foropen ventral herniarepair using component separation. Although wedescribe methods of anteriorcomponent separation, in our currentpractice, we primarily use posterior componentseparation withtransversus abdominis release to permit dissection beyondtheretrorectus space. This method adheres to the literaturesupported principles of a
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tension-free midline fascial closure with wide mesh overlap ofmesh positioned in asublay position. Our experience with thismethod supports a low recurrence rateand reduced woundmorbidity.
PREOPERATIVE PLANNING
Physical Examination Defect size, location of prior incisions orstomas, draining sinuses, exposedmesh, skin issues (eg, thinning,ulceration, cellulitis) should all be ascertainedfrom physicalexamination.
Operative History Review of old operative reports is mandatoryto identify what types of repairshave been previously attempted,what type of mesh was used (if any), and intowhich plane it wasplaced.
Abdominal Wall Imaging Computed tomography (CT) of the abdomenand pelvis remains the goldstandard preoperative imaging modalityfor ventral hernia repair. Typically nocontrast is required.
CT scans demonstrate the size and location of the hernia sac(s),identify syntheticmesh as well as signs of mesh infection (fluidcollections, inflammatory stranding,sinus tracts), and provideinformation about the remaining abdominal musculature.
CT angiography can identify the periumbilical perforatingvessels and may helpin deciding between classical or PUPS anteriorcomponent separation.
Managing Medical Comorbidities Comorbidities associated withhigher rates of recurrence and complicationshould be medicallyoptimized; diabetic blood sugar control, cardiac riskfactors,obesity, malnutrition, pulmonary function,methicillin-resistant Staphylococcusaureus (MRSA) colonization.
Smoking cessation is an absolute requirement. Supplementaloxygen use alsoprecludes surgery.
Obese patients, especially those with a body mass index higherthan 45, shouldundergo a medical bariatric evaluation to facilitateweight loss, improve exercisetolerance, reduce proteinmalnutrition, and possibly steer the patient to surgicalweight losssurgery before herniorraphy is attempted.
Preoperative Counseling A frank discussion with the patientabout the likelihood of one or more complica-tions is part of theinformed consent process. Hernia recurrence, mesh infection(and itspotential consequences), abdominal compartment syndrome,andrequirement for postoperative ventilation are all reviewed.
We specifically address unacceptable outcomes with patients aspart of ourdetermination of what mesh (synthetic or biologic) touse. Some patients willaccept the risk of synthetic mesh infectionor draining sinus for a lower herniarecurrence rate; others willnot.
CLINICAL ANATOMY
A thorough understanding of the anatomy of the abdominal wall ismandatory whenperforming ventral herniorraphy with componentseparation. This includes not only
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an understanding of the neurovascular supply to muscle, fat, andskin, but also knowl-edge of force vectors each of the muscularlayers generates. Such knowledge resultsin the best clinicaloutcomes by providing a well-vascularized, innervated, andcorrectlyoriented abdominal wall reconstruction.Normally, 2 verticallyoriented rectus abdominis muscles originate at the pubic
symphysis and insert on the costal cartilage of ribs 5 to 7.These muscles should lieon either side of the intact, midline lineaalba. On each side of the rectus, 3 flatsemihorizontally orientedmuscles are found layered on one another: the externalobliquemuscle, the internal oblique muscle, and the transversus abdominismuscle(from superficial to deep). Disruption of the linea albapermits unopposed lateral pullon the recti by the lateralmusculature and contributes to increase in size ofincisionalmidline hernias.At the lateral boarder of the rectusmuscle, the aponeurosis of the lateral abdominal
muscles alternately separate or fuse to contribute to the rectussheath. Here, theexternal oblique aponeurosis and rectus sheathfuse to form the linea semilunaris.Above the arcuate line, theinternal oblique aponeurosis splits to contribute to boththeanterior and posterior rectus sheaths (Fig. 1). Below the arcuateline, the aponeu-rosis does not split but rather fuses with theexternal oblique fascia to form the anteriorrectus sheath alone(see Fig. 1). The transversus abdominis muscles medial aponeu-rosismerges with the posterior lamina of the internal oblique to formthe posteriorsheath. For retrorectus repair, it is important tonote that the transversus abdominisdoes not contribute to the lineasemilunaris. Its muscle belly extends medial to thelineasemilunaris, behind the rectus muscle, in the upper one-third ofthe abdomen(Fig. 2).Each rectus muscle receives blood supply fromthe inferior and superior epigastric
arteries as well as intercostal arterial branches that enter themuscle belly laterally.These intercostal branches are also the mainblood supply to the lateral musculature.They travel with thethoracoabdominal nerves (branches of T7T12) in the neurovas-cularplane located between the internal oblique and transversusabdominis muscles.In addition to supplying the lateral abdominalmusculature and skin, these branchesinnervate the rectus muscleposteriorly and slightly medial to the linea semilunaris.Bothanterior and posterior component separations are able to preservethese inter-costal neurovascular bundles due to their location deepto the internal oblique.For anterior component separation, wherelipocutaneous flaps are created, knowl-
edge of the skin vascularity is also critical. For a classiccomponent separation(external oblique release), transection of thedeep epigastric perforating vessels leavesthe central abdominalwall without its major blood supply. PUPS component separa-tionpreserves these vessels to reduce the risk of ischemia-relatedwoundcomplications.
CHOICE OF MESH
For patients with clean wounds, we prefer a large (30.5 30.5-cm)lightweight,macroporous, polypropylene mesh. There is emergingevidence that use ofthis mesh is also acceptable in patients withmultiple comorbidities (diabetes,obesity, prior mesh infection) orin clean-contaminated circumstances (fistulatakedown, enterotomyclosure, small bowel resection, stoma formation orrelocation).
Use of synthetic mesh with an antiadhesive coating can beconsidered if theviscera will be exposed to the mesh, but this israrely necessary with either tech-nique to be described.
Fig. 1. Normal anatomic positions of the abdominal wallmusculature. Cross-sectional views(left) show the division andfusion of the lateral muscle fascial sheaths at thelineasemilunaris both above and below the arcuate line. (From RosenM, editor. Atlas of abdom-inal wall reconstruction. New York:Saunders; 2011; with permission.)
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Biologic mesh is appropriately considered for patients with ahigher risk of devel-oping a postoperative surgical site infection(SSI). This includes potentiallycontaminated or contaminatedfields, patients with medical comorbidities (dia-betes, obesity,immunosuppression, steroid use) or history of MRSA infection.
SURGICAL TECHNIQUE: POSTERIOR COMPONENT SEPARATION
Positioning and Marking The patient is positioned in a supineposition with arms abducted. A Foley catheter and an orogastrictube are placed. The abdomen is clipped of hair and is widelysterilized with a 2% chlorhexidinegluconate and 70% isopropylalcohol solution.
Fig. 2. CT scan of the upper abdomen. Note that the transversusabdominis (TA) muscle doesnot insert into the lateral boarder ofthe rectus muscle but rather passes medial to the lineasemilunaris(arrow) and posterior to the rectus itself. EO, external oblique;IO, internaloblique.
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All old incisions (including old laparoscopic port sites anddrain locations) aremarked. Excess skin and old scar to be excisedare similarly marked.
An iodophor-impregnated adhesive drape is used.
Incision A full midline laparotomy incision is made, with anelliptical skin component toremove old scar, thin skin over thehernia, or ulcerated wounds.
In the morbidly obese, several other considerations aremade:
The incision is stopped at the level of the pubis; we do notextend the incisiononto or below the pannus where skin care issuesmay compromise the incision
The umbilicus is typically removed during the repair Unlessthere is a compelling indication, we do not perform apanniculectomyconcomitantly with the hernia repair because of thehigher risk of SSI.
Safe access to the abdominal cavity is critical to avoid bowelinjury and is bestachieved by traversing fascia in an area remotefrom the hernia (above or belowthe old incision).
Adhesiolysis and Foreign Body Excision Visceral adhesions to theanterior abdominal wall and pelvis are fully lysed. This iscriticalto allow full medial mobility of the posterior abdominal wallcomponents.
Care must be taken to avoid excess injury to the posteriorlayers of the abdominalwall (peritoneum and transversalis fascia)during this portion of the procedure.
Interloop adhesions are typically ignored unless the patient hasa history ofadhesive related small bowel obstruction.
Any encountered foreign bodies (tacks, suture material, oldmesh) are fully removed. A sterile towel is packed over the viscerato protect them during the componentseparation.
Retrorectus Dissection Using electrocautery, an incision is madein the posterior rectus sheath within0.5 cm of its medial boarder.This incision is extended superiorly and inferiorly,spanning theentire length of the rectus muscle (Fig. 3A).
Fig. 3. (A) Retrorectus dissection begins by incision of theposterior rectus sheath just medial tothe linea alba. (B)Electrocautery dissection extends the plane to the lineasemilunaris, takingcare to preserve the epigastric vessels on theposterior aspect of the rectus muscle. (From RosenM,editor. Atlasof abdominal wall reconstruction. New York: Saunders; 2011; withpermission.)
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Working medial to lateral, the plane is continued using bluntand electrocauterydissection. Caremust be taken to avoid injury tothe epigastric vessels, which shouldremain with the muscle, not theposterior sheath, during the dissection (see Fig. 3B).
The lateral limit of this dissection is the linea semilunaris atthe lateral boarder of therectus muscle, where the anterior andposterior rectus sheaths fuse (see Fig. 3B).
Identification and preservation of the intercostal neurovascularstructures as theyenter the posterior aspect of the rectus muscleis crucial.
Superiorly, this plane is extended into theretroxyphoid/retrosternal space(Fig. 4A). Inferiorly, the planeextends into the space of Retzius (see Fig. 4B).Blunt dissection inthis avascular plane permits exposure to the midline symphy-sispubis and Coopers ligaments bilaterally. Care must be exercisedhere toavoid injury to the inferior epigastric vessels at theirorigin on the iliac vessels.
Transversus Abdominis Release In many circumstances, dissectionin the retrorectus space just to the linea semi-lunaris isinsufficient to permit adequate abdominal wall reconstructionbecauseof the following considerations:
Non-midline ventral hernias may occur lateral to this landmarkThere may be insufficient retrorectus space to permit adequateprostheticreinforcement of the hernia
Fig. 4. Extension of the retrorectus plane into the (A)retroxyphoid/retrosternal space and(B) the space of Retzius. Notethe exposure of Coppers ligaments (CL) bilaterally. (FromRosen M,editor. Atlas of abdominal wall reconstruction. New York: Saunders;2011; withpermission.)
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There may be insufficient medial advance of both the posteriorrectus sheath(to exclude the mesh from the peritoneal cavity) andof rectus muscles (topermit reconstruction of the linea albaanterior to the mesh)
Methods to extend the retrorectus dissection lateral to thelinea semilunarisinclude intramuscular dissection (by dividing theinternal oblique muscle), dissec-tion within the preperitonealplane, or transversus abdominis release (TAR),which we favor.
Approximately 0.5 cm medial to the linea semilunaris,electrocautery is used toincise the posterior sheath, exposing thetransversus muscle (Fig. 5A). This ismost easily accomplished inthe upper half of the abdomen, where the musclebelly is welldefined.
Using a tonsil (Schnidt) or right-angled clamp to assistdissection, electrocauteryis used to hemostatically transect thetransversus abdominis muscle (seeFig. 5B). Care must be taken toavoid injury to the transversalis fascia/peritoneallayer that laysdeep to this.
Once divided, the muscle can be retracted anteriorly and theavascular retromus-cular plane developed bluntly. Superiorly, thisplane extends beyond the costalmargin to the diaphragm, inferiorlyto the myopectineal orifice, and laterally tothe psoas muscle.
The TAR is then completed on the contralateral side.
Reconstruction of Posterior Layer The posterior rectus sheath isreapproximated in the midline using running 2-0polyglycolic acid(vicryl) suture (Fig. 6).
Any holes created in the posterior layer during dissection mustbe closed; thisprevents bowel from contacting the unprotected meshand prevents bowelfrom slipping in-between the posterior layer andthe mesh, which can result ina bowel obstruction from internalherniation.
Fenestrations in the posterior layer are common in areas wherethe abdominalwall has been traversed (laparoscopic port sites,drain sites, old incisions) andbelow the arcuate line (where thereis no transversus abdominis muscle withinthe posterior layer).
Small holes that cannot be repaired primarily with suture can beclosed withnative tissue (omentum, colon epiploicae, hernia sac).Larger holes are bestclosed by patching the defect with absorbablemesh (vicryl) secured with arunning absorbable suture.
Fig. 5. (A) Incision of the posterior rectus sheath exposes thetransversus abdominis muscle.(B) Transversus abdominis releaseexposes the transversalis fascia/preperioneal plane, whichcan beextended to the psoas muscle. (From Rosen M, editor. Atlas ofabdominal wallreconstruction. New York: Saunders; 2011; withpermission.)
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The newly created visceral sac and abdominal wall are irrigatedwith 3 L ofantibiotic lavage solution.
Mesh Placement The mesh is turned into a diamond configurationand is anchored inferiorly usinga single transfascial stitch justabove the pubic ramus or bilateral sutures placedinto Coopersligaments. We typically use slow-absorbing 0 monofilamentabsorbablesuture (polyglyconate or polydioxanone) to secure the mesh.
For inferior midline defects, the mesh can be positioned deep inthe space ofRetzius and the anchoring stitch(es) backed off theedge to permit adequateoverlap (at least 4 cm). For concurrentinguinal or femoral hernias, the meshcan be positioned to cover themyopectineal orifice(s).
For superior midline defects, the mesh is positioned well beyondthe costalmargin (at least 4 cm to allow adequate overlap of thedefect) and is anchoredwith transfascial sutures placed around thexyphoid process.
Fig. 6. Reconstruction of the posterior layer. (From Rosen M,editor. Atlas of abdominal wallreconstruction. New York: Saunders;2011; with permission.)
Figfasstr
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Working on one side and then the other, full-thicknesstransfascial sutures areplaced to secure the mesh in 3 cardinalpoints (Fig. 7). We prefer using a Rever-din needle (Fig. 8) tofacilitate transfascial suture placement.
Kocher clamps are placed on the medial edge of the rectus muscleon the ipsi-lateral side and the abdominal wall is pulled towardthe midline as the transfascialsutures are placed. This permits themesh to be tensioned physiologically,which has several advantagesin the repair: The mesh absorbs much of the force needed to movethe rectus musclestoward the midline. This not only permits primaryfascial closure over themesh, but also reduces the tension on themidline closure.
. 7. Mesh is secured in the retromuscular space using theReverdin needle to place trans-cial sutures in cardinal locations.(From Rosen M, editor. Atlas of abdominal wall recon-uction. NewYork: Saunders; 2011; with permission.)
Fig. 8. Reverdin needle: curvilinear suture passer with an eye 1cm from the distal end.
Fig. 9positmidliSaun
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The mesh will not buckle or wrinkle when the linea alba isre-created, reducingthe space for seroma to accumulate.
Reconstruction of the Anterior Layers With the meshcircumferentially secured, the linea alba is re-created bysuturingthe anterior rectus sheaths to each other in the midlineusing multiple figure-of-eight stitches of slow-absorbing 0monofilament absorbable suture (Fig. 9).
Before these stitches are tied, closed suction drains (typically2) are positionedanterior to the mesh and in the dependent(inferior and lateral) portions of therepair.
Because of the substantial rectus medialization afforded by TARand by physio-logically tensioning the mesh, it is uncommon to notcomplete the anterior fascialclosure over the mesh.
The subcutaneous tissues can be closed in layers with absorbablesuture. Theskin is stapled. Subcutaneous drains are placed only incircumstances in whichthere is a large dead space not effectivelyclosed with sutures.
. Cross-sectional view of the completed reconstruction. Mesh issecured in a sublayion with transfascial sutures. The linea alba isrecreated anterior the mesh in thene. (From Rosen M, editor. Atlasof abdominal wall reconstruction. New York:ders; 2011; withpermission.)
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SURGICAL TECHNIQUE: ANTERIOR COMPONENT SEPARATION
Incision, adhesiolysis, and foreign body (mesh) excision proceedidentical toposterior component separation methods outlinedpreviously.
Formation of Subcutaneous Flaps Once the fascia medial to therectus has been identified, lipocutaneous flaps arecreated bydissecting the subcutaneous tissues off the anterior rectussheath.These flaps extend superiorly to the costal margin,inferiorly to inguinal ligament,and laterally to just beyond thelinea semilunaris (lateral boarder of rectusmuscles) where theexternal oblique fascial release will occur.
PUPS Variation
Fig.cutanSaund
Two subcutaneous tunnels are created just above the anteriorrectus sheathwith electrocautery.- The epigastric tunnel extendsfrom the xyphoid to 4 cm above umbilicus and
runs laterally along the costal margin to just beyond the lineasemilunaris.- The suprapubic tunnel extends from the pubic tubercleto 6 cm below the
umbilicus and runs laterally along the inguinal ligament to justbeyond thelinea semilunaris.
The tunnels are then connected to each other lateral to thelinea semilunaris.This method preserves the umbilicus andperiumbilical branches of the inferiorepigastric vessels (Fig.10).
Use of a fiber-optic lighted retractor greatly facilitates thisdissection.
External Oblique Release With electrocautery, the externaloblique aponeurosis and muscle fibers aredivided 1 to 2 cm lateralto the linea semilunaris from just above the costal marginto justabove the inguinal ligament (Fig. 11).
10. PUPS technique. Superior and inferior flaps are connectedwith a lateral sub-eous tunnel. (From Rosen M, editor. Atlas ofabdominal wall reconstruction. New York:ers; 2011; withpermission.)
Fig. 11. Division of the external oblique fascia and musclefibers lateral to the linea semilu-naris. (From Rosen M, editor.Atlas of abdominal wall reconstruction. New York: Saunders;2011;with permission.)
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This maneuver is similar whether the classic or PUPS techniqueis being imple-mented. With PUPS, the lighted retractor againfacilitates visualization.
An assessment is thenmade as to whether the linea alba can bere-created at themidline without undue tension. If no tension isfound, mesh placement and fascial closure can begin. If the midlinefascia will not reapproximate, retrorectus dissection (asdescribedfor posterior component separation) can be performed topermitgreater medialization of the rectus muscle.
Mesh Placement Mesh can be placed as an underlay (within theperitoneal cavity), sublay(within the retrorectus space), or as anonlay, depending on the types ofrelease performed, whether midlinefascia can be approximated, and surgeonpreference.
Underlay mesh is secured via transabdominal sutures passedthrough thelateral cut edge of the external oblique fascia. Ifsynthetic mesh is usedhere, it must have an antiadhesivebarrier.
Sublay mesh is placed within the retrorectus space after theposterior layer hasbeen closed. Transabdominal sutures are passedthrough the medial cut edgeof the external oblique at the level ofthe linea semilunaris.
Onlay mesh is placed over the closed midline repair, and issecured to thelateral cut edges of the external oblique bilaterally(Fig. 12).
Regardless of implant location or type (biologic or synthetic),mesh should besecured with slowly absorbing monofilament suture andplaced under physio-logic tension.
Drains are generally placed above the mesh regardless of itsimplant location.
Fig. 12. Onlay mesh placement following external obliquerelease. The mesh is secured tothe lateral cut edges of theexternal oblique fascia. (From Rosen M, editor. Atlas of abdom-inalwall reconstruction. New York: Saunders; 2011; withpermission.)
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Reconstruction of the Anterior Layers Because of the large skinflaps created with anterior component separation,several maneuvershave been proposed to reduce the risk of woundoccurrences:
Subscarpa fat may be removed if ischemic. Redundant skin may beremoved from the midline. Skin flaps may be sutured to theabdominal wall to reduce dead space. Multiple closed suction drains(24) are placed to evacuate fluid from the deadspace. Thesesubcutaneous drains are left in place for several weeks.- For PUPS,drains are specifically positioned in the right, left, andcentral
subcutaneous compartments. The subcutaneous tissues can beclosed in layers with absorbable suture. Theskin is stapled.
POSTOPERATIVE CARE
Airway Management In cases with prolonged operative times,patients with underlying pulmonary dis-ease, or cases ending latein the evening, the patient is kept intubated overnight.
If the plateau airway pressure increases more than 6 cm H20following approxi-mation of the linea alba, the patient is alsokept intubated for 24 hours.44
The addition of 24 to 48 hours of chemical paralysis is a usefuladjunct for moresignificant rises in plateau pressure (9 cm H20 orgreater).
44
Pain Management Epidural catheters are recommended in allpatients and are maintained for 3 to4 days postoperatively.
For patients in whom an epidural cannot be placed (or iscontraindicated) or whohave delayed bowel function at the time ofepidural removal, an intravenouspatient-controlled analgesia deviceis used.
Patients are transitioned to oral narcotic analgesia when theytolerate a diet.
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Diet We are conservative with dietary advancement to avoidretching and emesis,which can jeopardize the repair.
Patients are kept nil per os until flatus is passed, atwhichtime clear liquids are begun. When bowel function has returned,patients are advanced to an appropriate diet(eg, regular,diabetic).
Nasogastric tube decompression is used only in patients withextensiveadhesiolysis or in whom small bowel resection has beenperformed.
Drains (anterior component separation) Subfascial drains aretypically removed before hospital discharge (within 7 days).Subcutaneous drains are left until output is less than 30 mL perday for 2 con-secutive days. This can result in drains that are inplace for several weekspostoperatively.
Drains (posterior component separation) When synthetic mesh isused, drains are removed when then the output is lessthan 30 mL perday or on the day of discharge (whichever is first). Thistypicallyoccurs on day 4 to 7.
When biologic mesh is used, we leave drains in place for 2 weeksirrespective ofthe output volume.
Abdominal Binder We routinely use an abdominal binder in theimmediate postoperative period. Following discharge, the patientmay wear the binder as desired. If there is concern for theviability of lipocutaneous skin flaps, most will not placeabinder.
General Postoperative Issues Mechanical and pharmacologic venousthromboembolism prophylaxis is in-stituted in all patientsbeginning in the operating room.
Following Surgical Care Improvement Project (SCIP) guidelines,prophylactic antibi-otics are given within 1 hour of skin incisionand are discontinued within 24 hours.
For patients with active mesh or soft tissue infections,antibiotics are given untilresolution of the infection.
POSTOPERATIVE COMPLICATIONS
Wound Complications SSIs are a major source of morbidityfollowing open ventral hernia repair.45 In thehighest-riskpopulations, the SSI rate has been reported to be as high as 27%to41%.4649
Wound complications are more common and more severe in anteriorcomponentseparation than posterior component separationtechniques.43
Cellulitis is managed with appropriate antibiotics. Infectedcollections (including seromas and hematomas) are drainedpercutane-ously or operatively.
Asymptomatic fluid collections are generally followedconservatively. Necrosis of skin or subcutaneous tissues isaddressed with early operativedebridement.
Prophylactic use of negative-pressure vacuum therapy on a closedsurgical incisiondoes not reduce the 30-day SSI rate followingabdominal wall reconstruction.50
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Pulmonary Complications Diaphragm function and pulmonary toiletare both negatively affected by abdom-inal wall reconstruction,leaving patients vulnerable to pulmonary complications.
On evaluation of the 2007 National Inpatient Sample, ventralhernia patientsdischarged with a diagnosis of respiratory failureand mechanical ventilationhad a 4-fold greater length of stay andan 18-fold greater death rate.44
As many as 20% of patients will experience a postoperativerespiratory com-plication following component separation herniarepair.44
Aggressive pulmonary toilet, including incentive spirometer use,chest physio-therapy, adequate analgesia, and upright posture, areall critical to minimizingthese complications.
Gastrointestinal Complications Paralytic ileus is commonfollowing ventral hernia repair, although the exact rateis notreported.
Prolonged ileus, or symptoms suggestive of an early small bowelobstruction,should prompt further investigation. A CT scan of theabdomen and pelvis willdemonstrate an internal hernia (bowel isseen protruding through a rent in theposterior layer). Promptsurgical reexploration in this case is mandatory.
Intra-Abdominal Hypertension Except in the smallest ventralhernia repairs, some degree of intra-abdominal hy-pertension (IAH)is likely created in the course of reapproximating the lineaalba.
We do not routinely follow bladder pressure measurements, butare aggressive inour management of the secondary consequences ofIAH, including the following:
Liberal use of paralytic agents if needed to permit adequateventilation Aggressive fluid resuscitation to permit adequate urineoutput Maintaining endotracheal intubation for 24 to 48 hourspostoperatively (asoutlined previously)
Death Mortality following open ventral hernia repair is uncommon(0%1%). Cardiac, pulmonary, and thromboembolic events are theleading sources ofpostoperative mortality.
OUTCOMES
Polarizing opinions are common among hernia specialists, and aredriven by the lackof well-designed comparative trials evaluatingoutcomes of open ventral hernia repairswith the techniquesdescribed previously. Most of the available literature isretrospec-tive in nature. Techniques vary greatly amonginvestigators, as do definitions of post-operative events andduration of follow-up. The addition of innumerable types andsizesof mesh into this equation makes it difficult to draw firmconclusions. There is stilla clear need to address these issues inwell-designed, prospective randomized trials.
Anterior Component Separation
The separation of components technique described by Ramirez andcolleagues28 hasundergone many technical refinements since itsoriginal description. This method per-mits mobilization andmedialadvancement of the abdominal wall musculature, permit-tingreconstruction of the midline and obliteration of the herniadefect. Anteriorcomponent separation has gained wide acceptancetoday. Table 1 summarizes the
Table 1Outcomes of anterior component separation herniarepair
Author, Year n Method Wound Complication, % Mortality, % MeanFollow-up, mo Recurrence Rate, %
Ramirez et al,28 1990 11 ACS 442 0
Jernigan et al,51 2003 73 Modified ACS 0 24 5.5
de Vries Reileigh,52 2003 43 ACS 32.6 2.3 15.6 32
Girotto et al,53 2003 96 ACS with onlay mesh 26 26 22
Gonzalez et al,9 2005 42 ACS with onlay mesh 63 0 16 3
Hultman et al,54 2005 13 ACS mesh 11.5 15.4Jin et al,55 2007 22ACS with onlay or
underlay AHDM 0 21.4 9.7
Espinosa-de-los-Monteroset al,56 2007
39 ACS with onlay AHDM 26 15 5
Diaz et al,57 2009 31 ACS with onlay AHDM 41.9 10.5 6.5
Abbreviations: ACS, anterior component separation; AHDM,acellular human dermal matrix.Data from Refs.9,28,5157
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salient results from a number of trials involving anteriorcomponent separation. Themajor drawback to anterior componentseparation remains the need to createextensive skin flaps, whichpredisposes the patient to a variety of surgical site events.Woundcomplication rates as high as 26% to 63% have been found.9,53,56Other inves-tigators cite difficulty managing subxyphoid,suprapubic, and non-midline defectswith this technique because ofthe absence of a reliable space for prosthetic reinforce-ment withwide overlap.38
PUPS Method
PUPS component separation has the advantage of preservation ofthe lipocutaneousblood supply while permitting external obliquerelease. Table 2 summarizes thelargest reports involving PUPScomponent separation. These studies have beengenerallyretrospective comparisons of classic anterior separation methodswith thePUPS technique. Although recurrence rates were notdifferent between the groups,these studies have highlightedstatistically significant differences in rate and severityofsurgical site occurrences (skin necrosis, wound infection,abscess). Clarke59 noteda 25% rate of skin necrosis when usingclassical methods and 0% with PUPS tech-nique. Similarly, Dumanianand colleagues32 at Northwestern University outlined theirresultsfrom a series of 41 patients who had a 2% rate of woundcomplicationscompared with a 20% rate when using classic anteriorcomponent separationmethods.58 Data suggest that with longer-termfollow-up, the recurrence rate afterPUPS rises to as high as13.8%.59
Posterior Component Separation
Although PUPS techniques address the wound-related morbidity ofanterior compo-nent separation, it does not address issues withnon-midline defects, suprapubic orsubxyphoid hernias, or the needfor a large space to permit wide mesh overlap ofthe hernia defect.Posterior component separation addresses all of theseconcerns.Table 3 summarizes the available data on posteriorcomponent separation methods.Overall, these studies consistentlydemonstrate a long-term recurrence rate wellbelow 10%, far superiorto the other techniques described.3538,6163 Although thewoundcomplication rate appears to be no different from anteriorcomponent separa-tion rates, it should be emphasized that theseverity of the complications noted was far
Table 2Outcomes of PUPS hernia repair
Year n MethodWoundComplication, % Mortality, %
MeanFollow-up, mo
RecurrenceRate, %
Sukkar et al,58
200151 PUPS 13.7 24 3.9
Saulis et al,32
200241 PUPS 4.9 7.3
Clarke,59 2010 56 ModifiedPUPS
3.1 1.5 38 13.8
Butler &Campbell,60
2011
38 PUPS 26.3 0 12.4 3
Abbreviation: PUPS, periumbilical perforator sparing.Data fromRefs.32,5860
Table 3Outcomes of posterior component separation herniarepair
Year n Method Wound Complication, % Mortality, % Mean Follow-up,mo Recurrence Rate, %
Paajanen &Hermunen,61 2004
84 Retrorectus dissection only 6 0 18 5
Israelsson et al,62 2006 228 Sublay Mesh 1224 7.3
Novitsky et al,35 2006 128 Preperitoneal 12.5 0 28.1 3.1
Iqbal et al,36 2007 254 Retrorectus dissection only 13 0 705
Carbonell et al,37 2008 20 Posterior component,intramuscular
15 5 12 5
Wheeler et al,15 2009 90 Retrorectus dissection only 31 0 537
Krpata et al,43 2012 55 Posterior Component with TAR 25.5 0 6.83.6
Mehrabi et al,63 2010 174 Retrorectus dissection only 3.4 0 911.1
Novitsky et al,38 2012 42 Posterior Component with TAR 23.8 026.1 4.7
Abbreviation: TAR, transversus abdominis release.Data fromRefs.15,3538,43,6163
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less. Few patients required operative debridement, and many ofthese data wereprospectively collected to assess for a wide varietyof wound related issues.
SUMMARY
Open ventral hernia repair with component separation representsa group of complexsurgical techniques developed to address theever-growing population of patientsrequiring abdominal wallreconstruction. The methods described share similar keyelements:(1) fascial release permits myofascial advancement andreconstruction ofthe linea alba, and (2) the creation of vastspaces within the abdominal wall ensurewide overlap of mesh tomaximize surface ingrowth. The key difference between ante-rior andposterior component separation techniques is the location of thispotentialspace. Anterior separation methods create largelipocutaneous flaps and are usuallyaccompanied by onlay of mesh.Posterior separation methods create no such flapsand permit asublay of mesh. Differences in wound complications andrecurrencerates are likely directly related to these 2facts.Posterior component separation with TAR detailed previouslyhas several advan-
tages over anterior component separation and other methods ofposterior separation.First, it permits extensive lateral dissectionin the avascular potential space beneaththe transversus abdominismuscle. This creates an ideal space for mesh implantation,while atthe same time preserving the entire neurovascular supply to theanteriorabdominal wall. The release of the transversus abdominalmuscle itself permits suffi-cient medicalization of the rectusmuscles, so as to permit complete reconstruction ofthe abdominalwall layers posterior and anterior to the mesh. This places themesh in awell-vascularized pocket, remote from the skin surface.Moreover, the retromuscularposition of the mesh permits wideoverlap of difficult defects (subxyphoid, sub-costal, suprapubic).Based on these advantages, as well as its quoted 3% to 5%recurrencerate, posterior component separation with transversus abdominisreleasehas become our preferred method of choice for the managementof patients requiringopen ventral hernia repair.
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Open Ventral Hernia Repair with Component SeparationKeypointsIntroductionPreoperative planningClinical anatomyChoice ofmeshSurgical technique: posterior component separationSurgicaltechnique: anterior component separationPostoperativecarePostoperative complicationsOutcomesAnterior ComponentSeparationPUPS MethodPosterior Component Separation
SummaryReferences