Changes in the lateral abdominal wall following endoscopic subcutaneous anterior component separation

Hernia ◽  
2020 ◽  
Author(s):  
J. Daes ◽  
D. Morrell ◽  
E. M. Pauli
Keyword(s):  
Abdominal Wall ◽  
Component Separation ◽  
Lateral Abdominal Wall ◽  
Anterior Component Separation ◽  
Wall Following

scholarly journals O50 ALTERATIONS IN THE ABDOMINAL WALL MUSCULATURE AFTER ENDOSCOPIC ANTERIOR AND OPEN POSTERIOR COMPONENT SEPARATION

2021 ◽  
Vol 108 (Supplement_8) ◽  
Author(s):  
Erling Oma ◽  
Jan Kim Christensen ◽  
Jorge Daes ◽  
Lars Nannestad Jorgensen
Keyword(s):  
Abdominal Wall ◽  
Case Series ◽  
Muscle Thickness ◽  
Component Separation ◽  
Fascial Closure ◽  
Lateral Abdominal Wall ◽  
Transverse Abdominis ◽  
Abdominal Wall Muscle ◽  
Anterior Component Separation

Abstract Aim Effects of component separation (CS) on abdominal wall musculature have only been investigated in smaller case series. The study aimed to compare abdominal wall alterations following endoscopic anterior component separation (EACS) or transverse abdominis release (TAR). Material and Methods Computed tomography scans were evaluated in patients who underwent open ventral hernia repair with TAR or EACS. Lateral abdominal wall muscle thickness and displacement were compared with preoperative images after bilateral CS and the undivided side postoperatively after unilateral CS. Results In total, 105 patients were included. The mean defect width was 12.2 cm. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. Complete fascial closure was achieved in 103 (98%) patients. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm) and 0.82 cm (0.07-1.57 cm) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% [5.8-15.6%]) and insignificantly decreased after TAR (mean decrease 2.6% [-4.8-9.5%]), mean reduction difference EACS versus TAR 0.22 cm (-0.01-0.46 cm). One (1%) patient developed an iatrogenic linea semilunaris hernia after EACS. The recurrence rate was 19% after mean 1.7 years follow-up. Conclusions The divided muscle was significantly more laterally displaced after EACS compared with TAR. The thickness of the lateral muscles was slightly decreased after EACS and unchanged after TAR.

scholarly journals P010 FEASIBILITY OF MIDLINE RECONSTRUCTION WITHOUT MYOFASCIAL RELEASE (COMPONENT SEPARATION) AFTER PREOPERATIVE INFILTRATION OF LATERAL ABDOMINAL WALL MUSCULATURE WITH BOTULINUM TOXIN

2021 ◽  
Vol 108 (Supplement_8) ◽  
Author(s):  
Ana Gabersek ◽  
Franz Mayer ◽  
Stefan Mitterwallner ◽  
Reinhard Kaufmann ◽  
Reinhard Bittner ◽  
...  
Keyword(s):  
Botulinum Toxin ◽  
Abdominal Wall ◽  
Abdominal Wall Reconstruction ◽  
Component Separation ◽  
Ct Scans ◽  
Width Ratio ◽  
Surgical Trauma ◽  
Lateral Abdominal Wall ◽  
Myofascial Release ◽  
Diaphragmatic Hernias

Abstract Aim Aim of the analysis was to evaluate whether preoperative botulinum toxin infiltration may facilitate anatomical midline reconstruction without the need for – otherwise pre-operative assumed – surgical component separation. Material and Methods Total of 58 patients with complex abdominal wall hernias were included in our single-center retrospective analysis between 03/2015 and 12/2020. Size of the defect, HSV/ACV-ratio, rectus-to-defect-width-ratio (“Carbonell-Index”) as well as risk factors were analyzed. In all patients muscles of the lateral abdominal wall were infiltrated with 300-500 IE of botulinum toxin 4 weeks prior to the abdominal wall reconstruction. CT scans were performed before and 4 weeks after the botulinum toxin infiltration. Results Total of 58 patients (M/F-ratio 36:22), with a mean age of 63.8 years were included in our analysis. Mean BMI was 29.5 kg/m². Total of 50 incisional, 3 umbilical, 2 posttraumatic diaphragmatic hernias and 3 scrotal hernias were analyzed. Surgical component separation after the infiltration with botulinum toxin was necessary in 43% of the cases. Conclusions Preoperative infiltration of the lateral abdominal wall musculature with botulinum toxin facilitated midline reconstruction of the abdominal wall without the need for myofascial release in 57%. Reduction of surgical trauma could therefore be achieved in several patients.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

2020 ◽  
pp. 155335062091419
Author(s):  
Jorge Daes ◽  
Joshua S. Winder ◽  
Eric M. Pauli
Keyword(s):  
Abdominal Wall ◽  
Lateral Displacement ◽  
Abdominal Wall Reconstruction ◽  
Component Separation ◽  
Transversus Abdominis ◽  
Lateral Abdominal Wall ◽  
Computed Tomography Images ◽  
Fresh Cadaver ◽  
Semilunar Line ◽  
Internal Oblique

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

scholarly journals P015 ABDOMINAL WALL PREPARATION PRECEDING COMPLEX ABDOMINAL WALL RECONSTRUCTION (CAWR) - SINGLE CENTER INITIAL EXPERIENCES UTILIZING BOTULINUM TOXIN A (BTA) ACCOMPANIED IN SELECTED PATIENTS BY PREOPERATIVE PROGRESSIVE PNEUMOPERITONEUM (PPP)

2021 ◽  
Vol 108 (Supplement_8) ◽  
Author(s):  
Henrik Husu ◽  
Sanna Valle ◽  
Tom Scheinin ◽  
Jaana Vironen
Keyword(s):  
Abdominal Wall ◽  
Botulinum Toxin A ◽  
Abdominal Wall Reconstruction ◽  
Component Separation ◽  
Fascial Closure ◽  
Abdominal Wall Defects ◽  
Closure Rate ◽  
Loss Of Domain ◽  
Lateral Abdominal Wall ◽  
Preoperative Progressive Pneumoperitoneum

Abstract Aim Complex ventral hernia (CVH) treatment due to large abdominal wall defects or loss of domain is challenging. BTA-injection in lateral abdominal wall causing flaccid paralysis and elongation, so called chemical component separation (CCS), might facilitate closure of large fascial defects. Combining preoperative progressive pneumoperitoneum might help restore abdominal content in severe loss of domain situations. We studied the results after CAWR following abdominal wall preparation with BTA and possible PPP. Primary aim was to report fascial defect closure rate without need for surgical component separation. Material and Methods All electively operated patients to date that were treated preoperatively with BTA, including all patients treated with PPP. Results Hospital index patient received preoperative BTA in January 2018. Since then, altogether 42 patients underwent CCS prior to CAWR. Average patient suffered from obesity (mean BMI 31), 30% had diabetes, and a third were active smokers. Mean hernia defect area exceeded 200 cm2. All operations were mesh repairs. Surgical approach was mostly (88%) open retromuscular. Abdominal wall reconstruction via fascial closure was achieved in 93% of cases with only 21% needing surgical component separation. Preoperative morbidity was common in patients undergoing PPP. Around 40% of all patients had postoperative complications, half of which were surgical complications. One patient died of a yet unknown cause on the third postoperative day. There were no recurrences within median 15 months follow-up. Conclusions Restoring abdominal wall continuity without frequent need for surgical component separation seems likely in CVH following CCS.

scholarly journals Robotic hernia repair

Der Chirurg ◽  
2021 ◽  
Author(s):  
Ulrich A. Dietz ◽  
O. Yusef Kudsi ◽  
Miguel Garcia-Ureña ◽  
Johannes Baur ◽  
Michaela Ramser ◽  
...  
Keyword(s):  
Abdominal Wall ◽  
Abdominal Wall Reconstruction ◽  
Component Separation ◽  
Transversus Abdominis ◽  
Nerve Sparing ◽  
Complication Rates ◽  
Robotic Hernia Repair ◽  
Lower Complication ◽  
Anterior Component Separation ◽  
Abdominal Reconstruction

AbstractThe principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results—as well as reports from the literature—are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction.

scholarly journals Combining anterior and posterior component separation for extreme cases of abdominal wall reconstruction

Hernia ◽  
2020 ◽  
Vol 24 (2) ◽  
pp. 369-379 ◽  
Author(s):  
J. Lopez-Monclus ◽  
J. Muñoz-Rodríguez ◽  
C. San Miguel ◽  
A. Robin ◽  
L. A. Blazquez ◽  
...  
Keyword(s):  
Abdominal Wall ◽  
Abdominal Wall Reconstruction ◽  
Component Separation ◽  
Posterior Component Separation ◽  
Posterior Axillary Line ◽  
The Mean ◽  
Anterior Component Separation ◽  
Midline Closure

Abstract Purpose The closure of midline in abdominal wall incisional hernias is an essential principle. In some exceptional circumstances, despite adequate component separation techniques, this midline closure cannot be achieved. This study aims to review the results of using both anterior and component separation in these exceptional cases. Methods We reviewed our experience using the combination of both anterior and posterior component separation in the attempt to close the midline. Our first step was to perform a TAR and a complete extensive dissection of the retromuscular preperitoneal plane developed laterally as far as the posterior axillary line. When the closure of midline was not possible, an external oblique release was made. A retromuscular preperitoneal reinforcement was made with the combination of an absorbable mesh and a 50 × 50 polypropylene mesh. Results Twelve patients underwent anterior and posterior component separation. The mean hernia width was 23.5 ± 5. The majority were classified as severe complex incisional hernia and had previous attempts of repair. After a mean follow-up of 27 months (range 8–45), no case of recurrence was registered. Only one patient (8.33%) presented with an asymptomatic bulging in the follow-up. European Hernia Society’s quality of life scores showed a significant improvement at 2 years postoperatively in the three domains: pain (p = 0.01), restrictions (p = 0.04) and cosmetic (p = 0.01). Conclusions The combination of posterior and anterior component separation can effectively treat massive and challenging cases of abdominal wall reconstruction in which the primary midline closure is impossible to achieve despite appropriate optimization of surgery.

scholarly journals Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report

2021 ◽  
Vol 8 ◽  
Author(s):  
Branko Bakula ◽  
Marko Sever ◽  
Andrija Karačić ◽  
Mirko Bakula ◽  
Martin Grbavac ◽  
...  
Keyword(s):  
Abdominal Wall ◽  
Ventral Hernia ◽  
Skin Necrosis ◽  
Component Separation ◽  
High Morbidity ◽  
Case Presentation ◽  
Abdominal Skin ◽  
Large Ventral Hernia ◽  
Anterior Component Separation ◽  
Extensive Necrosis

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

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