Endoscopically assisted "components separation technique" for the repair of complicated ventral hernias.

Abstract

Repair of large incisional hernias and abdominal wall defects by primary closure is often impossible or leads to reherniation rates of up to 46%. The use of prosthetic material reduces the risk of reherniation but carries the risk of infection and other complications such as erosion of the skin or viscera. In addition, the use of prosthetic material in a contaminated environment is contraindicated, because the risk of infection and the recurrence rate are unacceptably high. In 1990, Ramirez and colleagues described a new method to repair large abdominal wall defects. Their technique is based on translation of the muscular layers of the abdominal wall to enlarge its surface. Transection of the external oblique muscle, just lateral from the rectal sheath, is the most important part of their technique. A compound flap is created that can be advanced 10cm at the waistline on both sides, and primary closure without undue tension can almost always be reached. The method is of special interest in the reconstruction of contaminated abdominal wall defects, because it avoids the use of prosthetic material. Until now, the results of the original technique have been reported in 130 patients. Reherniation rates ranged from 0% to 14%, although there was no followup of at least 1 year in most cases. In our own series of 43 patients, we found a reherniation rate of 31% after a median followup of 15.6 months. The original technique has the disadvantage that the skin and subcutaneous (SC) tissues must be mobilized over a wide area to reach and expose the aponeurosis of the external oblique muscle, which extends far laterally into the flank. This creates a very large wound, which predisposes to wound complications. Hematoma, seroma, and infection are reported in 11% to 40% of patients, and skin necrosis was a frequent complication in the series of Lowe and colleagues. In addition, the original technique is difficult to perform in the presence of an enterostomy. Release of the external aponeurotic fascia through two separate incisions avoids these disadvantages. The present endoscopically assisted technique further reduces the extent of the operation and preserves the blood supply through the intercostal and the epigastric arteries, which may prevent the previously mentioned complications.