Medialization after combined anterior and posterior component separation in giant incisional hernia surgery, an anatomical study

Dimitri Sneiders,Gijs H.J De Smet,Floris Den Hartog,Laura Verstoep,Anand G Menon,Filip E Muysoms,Gert-Jan Kleinrensink,Johan F Lange

doi:10.1016/j.surg.2021.06.018

Dimitri Sneiders, Gijs H.J De Smet + Show 6 more

Open Access

https://doi.org/10.1016/j.surg.2021.06.018

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Journal: Surgery	Publication Date: Aug 18, 2021
Citations: 9	License type: cc-by

Affiliation: Erasmus MC, AZ Maria Middelares, IJsselland Ziekenhuis

Abstract

BackgroundTo obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation. MethodsFresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points. ResultsAnterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization. ConclusionAnterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

Highlights

Incisional hernia (IH) repair for giant hernias remains surgically challenging and often requires component separation.Dimitri Sneiders and Gijs H.J. de Smet contributed and should both be considered as joint first authors.Reported recurrence rates after anterior component separation (ACS) and posterior component separation (PCS) are heterogeneous, ranging from approximately 3% to 21% for PCS and 5% to 32% for ACS.1e3 Differences in follow-up and diagnostic protocols may contribute to this heterogeneity
For the anterior rectus sheath, retro-rectus dissection provided a maximum of 40%, 34%, and 41% of total medialization obtained after combined CST
For the posterior rectus sheath, retro-rectus dissection provided a maximum of 36%, 27%, and 24% of total medialization obtained after combined CST

Summary

Introduction

Incisional hernia (IH) repair for giant hernias remains surgically challenging and often requires component separation.Dimitri Sneiders and Gijs H.J. de Smet contributed and should both be considered as joint first authors.Reported recurrence rates after anterior component separation (ACS) and posterior component separation (PCS) are heterogeneous, ranging from approximately 3% to 21% for PCS and 5% to 32% for ACS.1e3 Differences in follow-up and diagnostic protocols may contribute to this heterogeneity. The most common technique to obtain this is the Rives-Stoppa procedure (ie, dissection of the retro-rectus space).[5,6] for large defects, this technique often does not provide sufficient medialization, and additional medialization is required. This can be obtained through release of 1 or more of the lateral abdominal muscles and subsequent dissection of intermuscular planes (ie, component separation techniques, [CSTs]). Methods: Fresh-frozen post mortem human specimens were used Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks

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