BHSeP44 Extraperitoneal approach to Abdominal Wall Reconstruction (AWR): the ‘closed’ posterior component separation

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Abstract The foundation of AWR is posterior component separation by Rives-Stoppa (RS) retro-rectus sublay mesh repair, and transversus abdominis release (TAR). Traditional teaching dictates an initial laparotomy with full adhesiolysis to enable fascial closure and an intraperitoneal approach to component separation. We describe a novel extraperitoneal AWR approach, performing posterior component separation and sublay mesh repair with the peritoneum remaining closed. This maintains an intact visceral sac for faster dissection, reduced bowel handling, and facilitates take-down of the hernial orifice. We present our 3-year follow-up series of extraperitoneal ‘closed’ AWR. Method Retrospective case-note analysis of consecutive patients (n = 231) undergoing AWR 2018-2021 by a single plastic and general surgeon consultant team, with 3-year follow-up period. Results Extraperitoneal component separation was performed in all 231 patients as either RS (n = 186, 80.5%) or TAR (n = 45, 19.5%). Radical skin excision provided surgical access in 225 patients (97.4%), mean excision weight 1297 g (85–18000 g), mean BMI 30.9 (16.9–55.4). Direct fascial closure achieved in 97% (bridged repair n = 7, 3%). Hernia recurrence 1.7% (n = 4) at 3 years. Intraperitoneal procedures (bowel resection/anastomosis) performed in 2 patients (1.5%). Postoperative ileus 0%. Mean inpatient stay 4.6 days (SD 2.5). Post-operative complications; surgical site occurrence (SSO) (n = 26, 11.3%); respiratory (n = 21, 9.1%): VTE (n = 4, 1.7%): seroma (n = 16, 6.9%). Subsequent small bowel obstruction/laparotomy (n = 1, 0.4%). Conclusion The extraperitoneal approach to AWR is a safe, effective and reproducible technique, minimising postoperative ileus and bowel injury risk, promotes shorter duration of surgery and early postoperative discharge. This provides excellent outcomes and low hernia recurrence rate.