Anterior Component Separation Research Articles

Evaluating the Impact of Technique and Mesh Type in Complicated Ventral Hernia Repair: A Prospective Randomized Multicenter Controlled Trial

To our knowledge, there is an absence of prospective randomized multicenter controlled trials evaluating both the impact of technique and mesh type on outcomes in complicated ventral hernia repair. A prospective randomized multicenter controlled trial of 120 patients at 3 sites was conducted in which patients were randomized to either overlay (anterior component separation) or underlay mesh placement (posterior component separation) and mesh type (human acellular dermis [HADM] vs porcine acellular dermis [PADM]). Key inclusion criteria included hernia size (>200 cm2), BMI < 40 kg/m2, hemoglobin A1C < 7%, tobacco free > 6 weeks and primary fascial closure. Primary outcome was hernia recurrence at 1 year, determined by independent examiner/imaging. Secondary outcomes included complications and patient satisfaction (short form [SF]-36v2). Standardized investigator training included a porcine model followed by a proctored first case by the lead investigator. There were no significant differences in demographics between the 4 groups (age 60 ±12 years, BMI 32 ± 5 kg/m2, 51% female). The overall 1-year recurrence rate was 10.8%. There was no significant difference in recurrence rate by location of mesh placement (overlay 9.8%, underlay 11.9%) or mesh type (HADM 10.3%, PADM 11.3%). Overlay patients had a significantly lower surgical site infection rate (1.6% vs 11.9% p= 0.03), reported better physical functioning (p= 0.001) and role limitation scores (p= 0.04) in the early postoperative period, and achieved the highest physical functioning score during the 12-month period (p < 0.03). Recurrence rates were not affected by either anatomic location or type of mesh used. To our knowledge, this represents the first prospective randomized multicenter controlled trial that demonstrates similar clinical outcomes using HADM vs PADM (not inferiority, contrary to previously published literature), with several advantages identified using the overlay technique.

Anatomical study comparing medialization after Rives-Stoppa, anterior component separation, and posterior component separation

Large incisional hernias require medialization of the rectus abdominis muscles to facilitate tension-free closure. Medialization may be achieved by Rives-Stoppa, anterior component separation, or posterior component separation. This study aims to compare medialization achieved by these techniques in postmortem human specimens. First, the Rives-Stoppa procedure was performed. Subsequently, anterior and posterior component separation were performed on one side in each specimen, with each specimen functioning as its own control. Medialization was measured at three levels of the linea alba with three 1-kg weights. Both medialization obtained in addition to initial medialization after opening the linea alba and total medialization were measured. Results are presented as median and interquartile range. A total of 13 postmortem human specimens were included (Rives-Stoppa n = 13, component separation n = 10). Additional medialization after Rives-Stoppa was 1.2 cm (IQR: 0.3-2.2) for the anterior rectus sheath and 2.2 cm (IQR: 1.6-3.0) for the posterior rectus sheath (total medialization: 3.9 and 4.5 cm). For the anterior rectus sheath, additional medialization was 2.6 cm (IQR: 1.2-3.6) after anterior component separation and 1.9 cm (IQR: 0.4-3.4) after posterior component separation (P = .125, total medialization: 6.5 and 5.7 cm). For the posterior rectus sheath, additional medialization was 3.0 cm (IQR: 2.2-3.7) after anterior component separation and 5.2 cm (IQR: 4.2-5.9) after posterior component separation (P < .001, total medialization: 5.8 and 9.4 cm). Posterior component separation yielded significantly more medialization of the posterior rectus sheath compared with Rives-Stoppa and anterior component separation. Anterior component separation may provide marginally more medialization of the anterior rectus sheath.

The use of self-gripping mesh with anterior component separation technique in incisional hernia repair: A case series

IntroductionIncisional hernia (IH) is a common postoperative complication that affects 10% of the patients who undergo abdominal surgery. The component separation (CS) technique is suitable for large and/or complex hernias; however, CS alone may not eliminate recurrence and is associated with an increased incidence of wound complications. Self-gripping mesh enhances tissue adhesion and contributes to a reduced risk of migration, chronic pain, and other complications. Here, we present three cases of IH that were successfully repaired by anterior CS (ACS) using onlay self-gripping meshes. Case presentationAll three patients underwent surgery using the following technique: Briefly, a skin flap was created with release of the external oblique muscle and preservation of the perforating vessels. The linea alba was closed with absorbable interrupted sutures. A self-gripping mesh was trimmed and placed with a 4–5 cm overlap bilaterally from the closed linea alba using an onlay technique. For all patients, the postoperative courses were uneventful and there were no complications at the 3-month follow-up. DiscussionThe advantages of our technique include more sufficient abdominal reinforcement, technical simplicity, and minimal time required for mesh placement. The disadvantages are the potential risk of decreased blood flow of the skin flaps, wound infection, intestinal fistula, persisting or chronic pain, and difficulty with subsequent abdominal surgery. ConclusionThe use of self-gripping mesh with ACS can be performed without increasing the operative time or causing short-term surgical complications. This technique may be recommended for large IH because of its simplicity and secure abdominal reinforcement provided.

Postoperative outcome of a giant incisional hernia resolved by anterior component separation technique

Postoperative outcome of a giant incisional hernia resolved by anterior component separation technique

Systematic review of transversus abdominis release in complex abdominal wall reconstruction.

Transversus abdominis release (TAR), as a type of posterior component separation, is a new myofascial release technique in complex ventral hernia repair. TAR preserves rectus muscle innervation, creates an immense retromuscular plane and allows bilaminar ingrowth of the mesh. The place of the TAR within the range of established anterior component separation techniques (CST) is unclear. Aim of this systematic literature review is to estimate the position of the TAR in the scope of ventral hernia repair techniques. MEDLINE, Embase, Pubmed and the Cochrane controlled trials register and Science citation index were searched using the following terms: 'posterior component separation', 'transversus abdominis release', 'ventral hernia repair', 'complex abdominal wall reconstruction'. To prevent duplication bias, only studies with a unique cohort of patients who underwent transversus abdominis release for complex abdominal wall reconstruction were eligible. Postoperative complications and recurrences had to be registered adequately. The rate of surgical site occurrences and recurrences of the TAR were compared with those after anterior CST, published earlier in two meta-analyses. Five articles met our strict inclusion criteria, describing 646 TAR patients. Methodological quality per study was good. Mean hernia surface was 509cm2 and 88% of the hernias were located in the midline. Preoperative risk stratification was distributed in low risk (10%), co-morbid (55%), potentially contaminated (32%) and infected (3%). Pooled calculations demonstrated a mean SSO rate of 15% after TAR (20-35% after anterior CST) and a mean 2-year hernia recurrence rate of 4% (13% after anterior CST). Mean hernia surface was 300cm2 in anterior component separation studies. This review demonstrates that the transversus abdominis release is a good alternative for anterior CST in terms of SSO and recurrence, especially in very large midline ventral hernias.

Anterior component separation versus posterior component separation with transversus abdominus release in abdominal wall reconstruction for incisional hernia

Background Abdominal wall reconstruction after huge incisional hernias considered one of challenges that face surgeons, component separations, either anterior component separation (ACS) or posterior component separation (PCS) with transversus abdominus release (TAR), are novel and less expensive solutions for this problem. Aim This prospective randomized trial compares the results of ACS procedure versus PCS with TAR in repair of incisional hernias. Patients and methods This study included 40 patients who underwent surgical repair for midline incisional hernias with defects larger than 5 cm in width between March 2016 and October 2017 at Ain Shams University Hospitals. Patients were randomly assigned to surgical procedures. Patients in group Ι (n=20) underwent ACS, and patients in group II (n=20) underwent PCS with TAR. Results In group Ι (ACS), wound morbidity significantly exceeded that in group II (PCS with TAR) such that 10 (50%) patients in group I developed surgical wound infection compared with four (20%) patients in group II. Regarding wound dehiscence, seven patients in group I had this sequel, whereas two patients in group II had wound dehiscence. Hernia recurrence occurred in seven (35%) patients in group I, but only one (5%) patient in group II developed this. Conclusion PCS with TAR provides equivalent myofascial advancement with significantly less wound morbidity and recurrence rate when compared with ACS.

Transversalis fascia scoring: a new adjunct to anterior component separation technique

Abdominal wall hernia is a significant cause for reoperation following laparotomy. Anterior component separation (ACS) is a widely used technique for closure of large abdominal wall defects. We propose that adding scoring of transversalis fascia to ACS can provide additional midline advancement of the anterior rectus sheath. Open ACS was performed in eight cadavers. The medial advancement of the anterior rectus sheath was recorded at three points bilaterally during application of constant load, and again following scoring of the transversalis fascia. This technique was then used on two patients with recurrent, complex ventral hernias which could not be closed with ACS alone. In the cadaver model, transversalis fascia scoring provides additional 34.01, 27.12, and 25.05% advancement at each point compared to ACS. Results were significant. In both patients, primary fascial closure of defects over 20 cm width at midline was achieved. Adding transversalis fascia scoring in a controlled standard fashion to ACS may help surgeons achieve closure of abdominal wall defects when ACS alone is not sufficient. Level of Evidence: Level V, therapeutic study.

Outcomes in complex ventral hernia repair with anterior component separation in class III obesity patients

BackgroundConsensus guidelines recommend against elective ventral hernia repair (VHR) in patients with BMI >30 kg/m2 without preoperative weight loss intervention. We aim to compare hernia recurrence and perioperative complications in VHR utilizing anterior component separation (CS) in patients with class III obesity (BMI >40 kg/m2). MethodsA retrospective review of patients undergoing VHR with CS was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound complications, postoperative medical complications, mortality and length of stay. Results185 consecutive patients were identified from 2008 to 2016. There were no significant differences between groups: hernia recurrence (6.9% BMI >40 kg/m2, 2.4% BMI <39.9 kg/m2, p = 0.21), wound complications (58.6% BMI >40 kg/m2, 47.2% BMI <39.9 kg/m2, p = 0.16), postoperative complications (39.7% BMI >40 kg/m2, 26% BMI <39.9 kg/m2, p = 0.08), mortality (1.6% BMI >40 kg/m2, 3.4% BMI <39.9 kg/m2, p = 0.59), and length of stay (10.6 days BMI >40 kg/m2, 11.2 days BMI <39.9 kg/m2, p = 0.5). ConclusionThis study demonstrates similar outcomes in class III obesity patients undergoing elective VHR compared to patients with BMI <39.9 kg/m2.

Continuous Laparoscopic Closure of the Linea Alba with Barbed Sutures Combined with Laparoscopic Mesh Implantation (IPOM Plus Repair) As a New Technique for Treatment of Abdominal Hernias.

Despite extensive experience and significant reduction of complications in recent years, laparoscopic treatment of complex abdominal hernias is a challenge even for the experienced endoscopic surgeon. Patients with severe incisional hernias or symptomatic rectus diastasis benefit from the closure of the linea alba as a morphological and physiological reconstruction of the abdominal wall followed by mesh implantation. Occasionally, an additional component separation is necessary. In open surgery, this is associated with very large wound areas, postoperative seromas, poor wound healing and, in the worst case, mesh infections. To avoid these complications, we operate these complex reconstructions completely endoscopically. Our concept is based on a laparoscopic closure of the linea alba through an ongoing, barbed non-resorbable 1–0 suture (polybutester) and final reinforcement by an intraperitoneal-onlay mesh (IPOM-Plus). For the treatment of complex abdominal hernias with a width of more than 10 cm, we performed an endoscopic anterior bilateral component separation. This allows the surgeon to combine the advantages of the open abdominal wall reconstruction with those of laparoscopic hernia repair. Between May 2015 and June 2017, we treated 42 patients with abdominal hernias by laparoscopic continuous hernia defect closure and complementary mesh implantation, whereby a complex reconstruction with additional endoscopic anterior component separation was performed in five patients. In this article, we will present this innovative technique of endoscopic/laparoscopic hernia repair in complex abdominal hernias.

Evolution of Endoscopic Anterior Component Separation to a Precostal Access with a New Cylindrical Balloon Trocar.

Endoscopic anterior component separation (ECS) techniques facilitate tension-free midline closure of wide ventral hernia defects. We describe a novel approach with a precostal incision and a new cylindrical ballon trocar. A single-center analysis of 19 patients undergoing ECS between January 1, 2014 and August 2, 2017 was performed with regard to improvement of technique. We currently start with a lateral precostal incision. This access in a low-fat and stable area allows for easy identification of the external oblique muscle with the ribs functioning as dorsal abutment for entering the correct plane between external and internal oblique muscles. Then a trocar is inserted with a cylindrical ballon, thus providing sufficient pneumatic widening of the dissection plane. A second 5-mm port is inserted under direct vision below the 12th rib. From there a unidirectional incision of the external oblique aponeurosis is performed from subcostal to the inguinal ligament. If necessary, the cephalad muscular parts of the external oblique can be transected over several centimeters in both directions starting from the precostal incision. We documented no procedure-related complications apart from two hematomas that required no interventions. Four procedures were carried out on one side and the remaining ones bilaterally. In one case, a conversion to conventional open component separation was required due to extensive scarring after open cholecystectomy. There were no notable abdominal bulgings or lateral hernias during a structured postoperative follow-up period of 1 year postoperatively. The technique described offers advantages in terms of determination of the correct entry point for ECS, regardless of abdominal wall conditions and the precostal access allows for unidirectional dissection toward the inguinal ligament with only two trocars in total. The cylindrical shape of the ballon trocar provides adequate widening of the working space and ensures good overview for safe dissection.

Endoscopic anterior component separation: a novel technical approach.

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure. A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach. Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8kg/m2 (median; range 21.6-42.5). Transverse width of midline defect accounted for 7cm (median; range 4-12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n=13) or a laparoscopic intraperitoneal onlay mesh procedure (n=2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively. Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

Abstract: Posterior Sheath Repair in Abdominal Wall Reconstruction: Achieving Retromuscular Mesh Placement

INTRODUCTION: Ventral hernia repair (VHR) remains a difficult surgical problem to manage. Retromuscular sublay mesh placement in VHR consistently provides favorable outcomes regardless of mesh type utilized, presumably highlighting the importance of the posterior rectus sheath. We hypothesized that posterior sheath repair to achieve retromuscular closure demonstrates improved outcomes compared to intraperitoneal repair as well as comparable recurrence and complication profiles to retromuscular sublay repair. METHODS: We performed a single-institution retrospective review over three-years of consecutive hernia repairs for two surgeons. Included patients were grouped according to repair-type: A) sublay placement with reconstructed posterior sheath, B) retromuscular repair with unaltered posterior sheath, and C) intraperitoneal or underlay repair. Primary outcome measures included hernia recurrence and surgical site occurrence (SSO). Analysis included multivariate logistic regression and descriptive statistics. RESULTS: One-hundred seventy-nine patients met inclusion criteria. There were 25 (14.0%) in Group-A, 89 (48.7%) in Group-B, and 65 (36.3%) in Group-C. Groups did not differ in average age 56.5 (p<0.298), BMI 32.4 (p<0.774), incidence of diabetes, hypertension, hyperlipidemia, COPD, tobacco use, OR time, or ostomy reversal. The majority of cases consisted of ASA class 3 (54.2%), Ventral Hernia Working Group (VHWG) class 2 (47.5%), and clean wound classification (63.7%). Prior hernia repairs were performed in 102 (57%) patients. Biologic mesh was used in 56 (31.3%) patients, synthetic in 103 (57.5%), and biosynthetic in 20 (11.2%). Patient post-operative follow-up averaged 15.5 months. Analysis of 11 recurrences yielded significant differences between Groups-B and C (p<0.009), a trend towards significance between Groups-A and C (p<0.058), and no difference between Groups-A and B (p<0.608). Retromuscular mesh placement and anterior components separation demonstrated protective effects on recurrence (OR: 0.148, p<0.081 and OR: 0.259, p<0.067). Postoperative mesh infection (OR: 72.03, p<0.012) and seroma (OR: 8.992, p<0.036) were significant predictors of hernia recurrence. BMI (OR: 1.052, p<0.015), VHWG (OR: 1.617, p<0.036), and hyperlipidemia (OR: 2.157, p<0.049) were significant predictors of SSO on multivariate regression. The posterior sheath was reconstructed primarily using absorbable suture for small defects, or biologic mesh for larger defects. CONCLUSION: Initial analysis of posterior sheath repair to allow for retromuscular VHR suggests noninferiority, when compared to traditional sublay reconstruction. We present the first known description of discrete posterior sheath reconstruction to aid in retromuscular closure of complex ventral hernia.

Anterior Components Separation (ACS) by Endoscopic Pathway: Alternative Pathway to Approach the Abdominal Wall

IntroductionThe abdominal wall hernias constitute a great challenge to the surgeon. The Giant, classified with a hernia orifice greater than or equal to 10cm, and the Complex, associated with diseases, infection, digestive or urinary ostomies present complications in the reconstruction of the abdominal wall. Primary closings with sutures, relaxing incisions in aponeuroses, positioning of supraponeurotic, bridge, subaponeurotic and intraperitoneal prosthetics, in addition to the shifting of the wall muscles, by open surgery or laporoscopy (robotic or not), are part of the alternatives for restitutio ad integrum of the wall. Knowledge of the stratigraphy of the wall allowed for the sectioning of muscles and aponeuroses, now called components. The Anterior Components Separation (ACS), described in 1990, is the sectioning of the aponeurosis of the external oblique muscle, parallel to the lateral border of the rectus abdominis muscle, in the craniocaudal direction, which is detached from the internal oblique muscle. For adequate execution of this technique, the lateral detachment of the skin and subcutaneous tissue is extensive, to the point of damaging the perforating vessels and paraumbilical branches of the lower epigastric artery, with ischemia and necrosis of the scar and umbilical region. The advent of video‐assisted procedures promoted access to these anatomical repairs. The objective of this study was to verify the viability of using a cadaver fixed in modified Larsen solution to perform ACS for teaching and training.MethodThe sectioning of the aponeurosis of the external oblique muscle was performed by means of a transverse incision of 12mm in the left iliac fossa, followed by divulsion by digitoclasy of the space between the internal oblique muscle and aponeurosis of the external, positioning the metal dilator, 10mm in diameter, in this space, promoting blunt dissection in the caudocranial direction to the left costal margin. Next came the insertion of 10‐mm optics at a 30‐degree angle, so as to visualize the aponeurosis and section it with Metzembaum scissors. To verify the efficacy of the procedure, two transversal flaps 25mm in depth were confectioned in order to demonstrate if the aponeurosis had been adequately sectioned or not (Figure 1).ResultsThe external oblique muscle aponeurosis was adequately sectioned.Discussion and conclusionThe ACS, perfectly performed by the video‐assisted method, diminished the quantity of detached and dissected tissue. We believe the procedure to be anatomically safe and that it effectively attends to the sectioning and shifting of the denominated components. The use of a cadaver fixed in modified Larsen solution presents a safe and reliable alternative for the teaching of video‐assisted anatomy and for the training of the resident surgeon.

Combined submuscular tissue expansion and anterior component separation technique for abdominal wall reconstruction: Long-term outcome analysis

We report the long-term outcome analysis of 12 patients who underwent two-stage abdominal wall reconstruction using combined submuscular tissue expansion and anterior components separation (CS) technique. Outcome measures were (1) the patients were assessed for the presence or absence of recurrence; (2) patient-reported outcomes on physical functioning in relation with the abdominal wall reconstruction were evaluated using the SF 36-item health survey. The mean age, average expansion volume, and mean time expansion were 37.5 years, 1250cc, and 9.5 weeks, respectively. The average soft tissue deficiency size was 15.5 (width)×19.5 (length)cm2. The average fascial defect was 17 (width)×21.5 (length)cm2. No mesh-assisted technique was required. Primary closure was obtained in all. The average follow-up was 39.6 months. Hernia recurrence was noted in one patient (8.3%). All 12 patients completed the SF 36-item health survey. Moreover, 75% of the patients reported 100%, indicating "Not limited in vigorous activities," and 25% indicated "limited a little." All patients reported 100% "not limited at all" in lifting or carrying groceries, climbing several flights of stairs, climbing one flight of stairs, bending, kneeling, stooping, walking more than a mile, walking several blocks, walking one block, bathing, or dressing. Parietal laxity obtained with tissue expansion increases the possibility of direct closure of the fascial layer, skin, and subcutaneous tissue components. Combined use of tissue expansion and CS may result in favorable long-term outcomes as evidenced by patient-reported physical functioning data and low rate of hernia recurrence.

Wound Morbidity in Minimally Invasive Anterior Component Separation Compared to Transversus Abdominis Release

Transversus abdominis release is a novel approach for myofascial advancement in ventral hernia repair and has been hypothesized to have lower rates of wound complication than anterior component separation. Patients who had a ventral hernia repair with either transversus abdominis release or minimally invasive anterior component separation from January of 2010 to January of 2016 were enrolled in this retrospective cohort study. Patient characteristics were collected through chart review. Primary outcomes were operative time and wound complications. Multiple linear/Poisson regression and Fisher's exact test were used to determine statistical significance. Of 142 patients analyzed, 75 subjects underwent Butler minimally invasive anterior component separation and 67 underwent transversus abdominis release. There were no differences in baseline characteristics between groups, except that the anterior component separation group had more immunosuppressed patients (35 percent versus 19 percent). Median operative time for anterior component separation was 6.3 hours versus 6.1 hours for transversus abdominis release (p = 0.6). Overall wound complications did not differ between the groups (p = 0.5). Compared with anterior component separation, transversus abdominis release had a similar incidence of seroma/hematoma (relative risk, 0.9; 95 percent CI, 0.5 to 1.7), wound infection (relative risk, 1.1; 95 percent CI, 0.5 to 2.2), and mesh infection (relative risk, 0.7; 95 percent CI, 0.2 to 3.4). Hernia recurrence was 12 percent for anterior component separation and 6 percent for transversus abdominis release (relative risk, 0.6; 95 percent CI, 0.2 to 1.7). Reoperation was required in 19 percent of anterior component separation and 12 percent of transversus abdominis release subjects (relative risk, 0.5; 95 percent CI, 0.2 to 1.2). Transversus abdominis release patients had similar operative times, wound complications, reoperations, and hernia recurrences compared with Butler minimally invasive anterior component separation patients. This contemporary comparison helps inform operative decisions for reconstructive surgeons. Therapeutic, III.

Discussion: Wound Morbidity in Minimally Invasive Anterior Component Separation Compared to Transversus Abdominis Release.

Discussion: Wound Morbidity in Minimally Invasive Anterior Component Separation Compared to Transversus Abdominis Release.

Wound Morbidity in Abdominal Wall Reconstruction Can Be Reduced Using Transversus Abdominis Release Compared to Anterior Component Separation Technique

Wound Morbidity in Abdominal Wall Reconstruction Can Be Reduced Using Transversus Abdominis Release Compared to Anterior Component Separation Technique

Endoscopic subcutaneous component separation as an adjunct to abdominal wall reconstruction.

Proper defect closure during abdominal wall reconstruction (AWR) is a key to improving cosmetic and functional results, and reducing morbidity. We have completed the initial prospective evaluation of a technique we previously described and published: endoscopic subcutaneous anterior component separation (ACS) as an adjunct to mainly laparoscopic AWR. We now present the long-term clinical and imaging follow-up results. Data were prospectively collected over a 3-year period (2012-2015) on patients who underwent AWR with endoscopic ACS. Inclusion criteria included the following: defects of 6-15cm that are longer than wider; no skin dystrophy; no loss of domain; no active infection; no previous multiple, complex repairs; no previous multiple mesh repairs; and no high probability of severe adhesions. All patients were followed up clinically at 3, 6, and 12months postoperatively and then annually. All patients underwent CT scanning of the abdominal wall (sagittal, axial, coronal, and 3D reconstruction) at 3months and 1year postoperatively and then annually. Twenty consecutive patients underwent adjunctive endoscopic ACS: 17 laparoscopic AWRs, 2 open repairs, and 1 hybrid repair. Up to 38months (mean 21months) of follow-up, there were no ventral hernia recurrences or de novo hernias at the ACS site. One patient experienced partial primary closure failure. Morbidity consisted in one case each of hematoma, seroma, and transient neuralgia. Cosmetic results and patient satisfaction were excellent. We confirmed that endoscopic subcutaneous ACS is a safe, effective, reliable, reproducible technique that facilitates primary closure of defects during AWR in selected patients.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure

BackgroundSandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure. MethodsWe conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence. ResultsA total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo–Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months). ConclusionsUse of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches.

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.