Component Separation Technique Research Articles

INTRAOPERATIVE FASCIAL TRACTION FOR TREATMENT OF W2 AND W3 VENTRAL HERNIAS

Abstract Background Component separation techniques are increasingly employed in abdominal wall reconstruction surgery. The use of adjuvant techniques, such as intraoperative vertical dynamic fascial traction, enhances the compliance of the abdominal wall. This facilitates closure of the abdominal wall using less disruptive techniques without compromising effective treatment. Our aim is to retrospective review our results regarding the effectiveness and complication rate of intraoperative fascial traction for the treatment of complex ventral hernias. Method Conducted a retrospective analysis of 10 patients who underwent surgery using intraoperative fascial traction for W2 and W3 ventral hernias. Results Preoperatively, fascial distances measured ranged from 55 cm to 145 cm, with the majority of patients (70%) having a fascial distance greater than 10 cm. Most patients received other adjuvant treatments (nine cases with botulinum toxin injection and one with pre-operative progressive pneumoperitoneum). Posterior component techniques were employed in 40% of patients (half with W2 hernias and the other half with W3 hernias). The complication rate was 10%, with one case of hemorrhage requiring percutaneous embolization. During the average 6-month follow-up period (ranging from 1 to 17 months), one recurrence was observed. Conclusion Intraoperative fascial traction is a feasible and safe adjuvant technique for abdominal wall reconstruction. The use of adjuvants in complex abdominal wall hernia surgery may, in some patients, downstage the hernia, thereby avoiding the need for component separation techniques. This approach enables tension-free closure of the abdominal wall in a less invasive manner.

Anterior versus posterior component separation technique for advanced abdominal wall reconstruction: a proposed algorithm.

The precise indications for employing the anterior component separation technique (ACST) and the Transversus Abdominis Release (TAR) in abdominal wall reconstruction (AWR) remain uncertain, despite the undeniable value of both techniques. The aim of this study was to analyze the anterior fascial closure rate, postoperative wound morbidity, and hernia recurrence rate for both procedures according to the algorithm used for complex AWR. A retrospective analysis of prospectively collected data was carried out. Patients undergoing AWR for midline incisional hernias using either open or endoscopic ACST (E-ACST) or TAR between March 2013 and August 2022 were included. Patients with lateral hernia components were excluded. The surgical technique was depending on the pre- and intraoperative findings regarding hernia width and on the estimated traction to achieve anterior fascial closure (see algorithm). Initially, intermediate hernia defects ranging from approximately 10-14cm in width were repaired using E-ACST. However, as the study advanced, TAR became the preferred method for addressing these types of defects. Open ACST was consistently employed for defects wider than 14-15cm throughout the entire study duration. Outcomes of interest were anterior fascial closure, surgical site occurrences, and hernia recurrence rate. Follow-up was performed at 1month, 1year, and 2years. A total of 119 patients underwent AWR with CST: 63 patients (52.9%) were included in the ACST group and 56 patients (47.1%) in the TAR group. No significant differences were observed in patient and hernia characteristics. The use of botulinum toxin A (BTA) injection and preoperative progressive pneumoperitoneum (PPP) was more frequently used in the ACST group (BTA 19.0%, PPP 15.9% versus BTA 5.4%, PPP 1.8% for TAR patients). Anterior fascial closure was achieved in 95.2% of the ACST group and 98.2% of the TAR group (p = 0.369). The TAR group demonstrated a significantly lower SSO rate at one month (44.3% versus 14.3%, p < 0.001) and required fewer procedural interventions (SSO-PI) (31.1% versus 8.9%, p = 0.003). The recurrence rate at one year was low and there was no statistically significant difference between the two groups (ACST 1.8% vs TAR 4.5%, p = 0.422). Following a proposed algorithm, the anterior fascial closure rate was high and similar for both techniques. As postoperative wound morbidity is significantly increased after ACST, our findings support recommending TAR for defects up to 14cm in width, while favoring open ACST for larger defects.

Open transversus abdominis release in incisional hernia repair: technical limits and solutions.

Incisional hernias with a defect width of more than10cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. The standard PCSTAR can generally be used for a defect width of up to 15-17cm. For defects greater than 17cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0-97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. For a defect width greater than 17cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

The changes in abdominal wall muscles following incisional hernia wall reconstruction.

The objective of incisional hernia surgery is to achieve the restoration of abdominal wall anatomical and physiological functions. This study aims to investigate the impact of abdominal wall reconstruction on abdominal muscle alterations by measuring the preoperative and postoperative changes in abdominal wall muscles in patients undergoing incisional hernia repair. For patients undergoing open incisional hernia abdominal wall reconstruction, preoperative and postoperative abdominal CT scans were analyzed at a minimum of 3months post-surgery. 3D Slicer software was utilized for measuring preoperative and postoperative changes in abdominal cavity volume, abdominal muscle volume, as well as muscle volume, cross-sectional area, and abdominal circumference at specific levels. The acquired data were subjected to statistical analysis using SPSS software. A total of 40 patients meeting the inclusion criteria underwent open incisional hernia repair surgery. Some of these patients required component separation technique (CST) due to the larger size of the hernia sac. The abdominal muscles surrounding the hernia ring were defined as the "damaged group," while the remaining abdominal muscles were defined as the "undamaged group." Measurements revealed a significant increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the damaged group. Similarly, there was a corresponding increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the undamaged group. After abdominal wall reconstruction in incisional hernia patients, not only is their anatomical structure restored, but the overall biomechanical integrity of the abdominal wall is also repaired. The damaged muscles are subjected to renewed loading, leading to the reversal of disuse atrophy and an increase in muscle volume.

Optimizing NILC Extractions of the Thermal Sunyaev–Zel’Dovich Effect with Deep Learning

All-sky maps of the thermal Sunyaev–Zel’dovich effect (SZ) tend to suffer from systematic features arising from the component-separation techniques used to extract the signal. In this work, we investigate one of these methods, known as needlet internal linear combination (NILC), and test its performance on simulated data. We show that NILC estimates are strongly affected by the choice of the spatial localization parameter (Γ), which controls a bias-variance trade-off. Typically, NILC extractions assume a fixed value of Γ over the entire sky, but we show there exists an optimal Γ that depends on the SZ signal strength and local contamination properties. Then we calculate the NILC solutions for multiple values of Γ and feed the results into a neural network to predict the SZ signal. This extraction method, which we call Deep-NILC, is tested against a set of validation data, including recovered radial profiles of resolved systems. Our main result is that Deep-NILC offers significant improvements over choosing fixed values of Γ.

Mesh Strip Repair for Midline Ventral Hernias: A Case Series.

Polypropylene mesh strip repair is a novel method of hernia closure. Currently, there is limited representation in the literature regarding both the reproducibility of this method and its outcomes. The present study sought to analyze a second institution's experience with fascial closure using the mesh strip technique with long-term follow-up. A retrospective review of all patients undergoing abdominal wall reconstruction by the senior author was performed. Patients undergoing midline ventral hernia repair with mesh strip only fascial closure and greater than 1 year follow-up were including for analysis. Demographic data; operative details; and outcomes, specifically presence and timing of hernia recurrence, were recorded. Eighteen patients met inclusion criteria. Average follow-up was 860 ± 307 days. Nine patients (50%) had recurrence of their hernia after repair. Average time to recurrence was 602 ± 406 days, with the earliest recurrence occurring at 126 days postoperatively. Seven patients (39%) underwent concurrent anterior component separation (four unilateral, three bilateral), of which there were three recurrences, all occurring in patients with bilateral anterior component separation. The mesh strip repair is a novel technique that shows uncertain reproducibility of outcomes, specifically with concurrent component separation techniques. With the recent Food and Drug Administration approval of a mesh suture, further multi-institutional analysis will allow for better characterization of the outcomes and indications for this technique.

Comparative Study between Anterior Components Separation Versus Posterior Components Separation Technique in Repairing of Huge Ventral Hernia

Comparative Study between Anterior Components Separation Versus Posterior Components Separation Technique in Repairing of Huge Ventral Hernia

Reconstruction of the abdominal wall with component separation technique in patients with giant omphalocele

BackgroundSeveral techniques have been described to repair giant omphaloceles. Component Separation Technique (CST) is a surgical technique first reported in adults to repair large abdominal wall defects. The purpose of this study is to describe our experience using this technique in repairing large ventral hernias secondary to giant omphaloceles in children. MethodsNine patients with giant omphalocele were treated. The abdominal wall was reconstructed using CST, based on the enlargement of the abdominal wall by separate mobilization of the muscular layers. Patients were monitored for complications during admission, postoperative complications, and all patients were seen for follow-up. ResultsComponent separation technique was performed at a median age of 7.2 years. The median diameter of the hernia was 109.8 cm2. There was no mortality. Minor complications were seen (infection, skin necrosis, and hematoma). There were no recurrences after an average follow-up of 3.3 years (2 - 4 years). ConclusionsComponent separation technique is a valuable method for repairing large ventral hernias as a consequence of giant omphaloceles in children. Our series supports the use of CST in children, in a wide age range, from newborns for primary closure to adolescence in cases of giant ventral hernias secondary to omphaloceles with multiple previous surgeries. Level of EvidenceII

Anterior component separation technique for abdominal wall closure among patients undergoing colorectal surgery: Short-term outcomes and initial experience

IntroductionThe anterior component separation (ACS) is a technique used for abdominal wall closure performed by dissecting and medially advancing the musculature to achieve tension-free closure. Methodsand Materials:This study reviewed our experience with this procedure as used for complex abdominal wall defects encountered during colorectal surgery in a 7-year period. ResultsSixteen patients were included, with 12 having malignancies and the rest for infectious or inflammatory conditions. Defects ranged from 16–400 cm2 and were mostly located at the midline (56%, n = 9). Five cases required additional flaps for closure, attributed either to the size or area of abdominal involvement where benefits of component separation is more limited. Complications include surgical site infection (n = 4), hematoma (n = 2), seroma (n = 1), and wound dehiscence (n = 2). None required ICU admission or assisted ventilation post-operatively. One patient died who had a preexisting cardiac pathology, and the rest were discharged improved. ConclusionThis study demonstrates use of this modality for autologous reconstruction of complex appropriately sized abdominal wall defects from multiple etiologies. Adjunct flaps may be used to achieve reconstruction particularly in areas wherein the effectiveness of ACS is limited. While the study is able to describe immediate outcomes, long-term follow-up is recommended.

Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center.

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center. This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients. 89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date. Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

Prevention of component separation in complex abdominal wall surgery by Botox prehabilitation: a propensity-matched study.

To facilitate midline fascial closure in complex abdominal wall surgery, component separation techniques (CST) are usually required. However, CST is associated with an enlarged morbidity. Prehabilitation could increase the compliance of the abdominal wall and thereby decrease the necessity of myofascial release. This can be accomplished by administration of botulinum toxin type A (BTA) in the lateral abdominal wall musculature. The aim of this study was to determine the effect of BTA on the subsequent necessity to perform CST in patients with complex abdominal wall hernias. Patients with a complex abdominal wall hernia, planned to undergo CST between July 2020 and November 2022 were included. Outcome of procedures with 300U of BTA 4 (2-6) weeks prior to surgery, were retrospectively analyzed by comparison with propensity matched subjects of an historical group. Hernia width difference was assessed by CT and operative details were included. A total of 13 patients with a median hernia width of 12cm (IQR 9-14, range 24) were prehabilitated with BTA between July 2020 and November 2022. A CST was planned for all, however not required in 6/13 patients (46%) to accomplish midline fascial closure. A mean elongation of lateral abdominal wall musculature of 4.01cm was seen in patients not requiring CST. Compared to the propensity score matched control group, a 27% reduction (p = 0.08) in the need for CST was observed. There is a tendency for decrease of necessity for CST by preoperatively administered BTA in patients with complex abdominal wall defects. Although small, as this study used propensity matched comparison, further exploration of BTA should be encouraged.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation

BackgroundWhile advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear. MethodsA single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years). ResultsOf 219 patients who underwent VHR with CST, 114 patients (52.1 ​%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p ​= ​0.002) and COPD was positively associated with seroma development (OR 20.1, p ​= ​0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p ​= ​0.766). ConclusionsVHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

Impact of anterior component separation technique on lowering the incidence of abdominal wall dehiscence and incisional hernia after emergent laparotomy: a feasibility study

Introduction Abdominal wall dehiscence is one of the critical postoperative complications following abdominal surgeries. Emergency surgery highly contributes to the incidence of a burst abdomen due to a lack of proper preoperative preparation and the presence of intraabdominal sepsis. Anterior component separation was primarily evolved in abdominal wall reconstruction in the open abdomen and huge ventral hernia repair. Methods This prospective study included 50 patients operated by midline laparotomy for non-traumatic abdominal emergencies. Anterior component separation technique was randomly applied in 25 patients before laparotomy closure, the other 25 patients were closed using the traditional midline closure method. Preoperative patient’s demographics, operative time, and different postoperative complications were reported. Incidence of burst abdomen in both groups was reported. Results Preoperative patient’s demographic data showed no significant difference between both groups; the mean age of the patients was 53.69±7.34. Operative time was significantly longer in the Anterior Components Separation (ACS) group (P&lt;0.001). The incidence of abdominal wall dehiscence after ACS technique (4.3%) was significantly less than after traditional technique (24%). Postoperative seroma and hematoma were the common postoperative complications after ACS however the incidence was not statistically significant. Incisional hernia was detected in (13.04%) in ACS group and in (32%) in traditional group. Conclusion Application of ACS technique during laparotomy closure in abdominal emergencies seems to lower the incidence of abdominal wall dehiscence with no increase in different postoperative complications.

Comparison of open anterior component and open transversus abdominus release in repair of large subcostal hernias.

Large subcostal incisional hernias are considered as complex defects, and a few different approaches have been described for repair. The purpose of this comparative cross-sectional study is to evaluate the outcomes of patients with large subcostal incisional hernias treated with either the open anterior components separation technique (ACS) or with the open transversus abdominis release technique (TAR). From the database of patients with large complex incisional hernias who underwent abdominal wall reconstruction with open techniques between April 2007 and October 2022 at our institution, on May 25th, 2023 we identified those whose hernias were located in the subcostal areas and who underwent reconstruction with a components separation technique and mesh. Perioperative variables and outcomes were compared between the patients with large subcostal hernias who underwent abdominal wall reconstruction with either the ACS or the TAR techniques. Thirty-one patients with large subcostal hernias were included in the study. ACS and intra-abdominal mesh was used in 11 patients; TAR and retro-muscular mesh was performed in 20 patients. More postoperative local abdominal wall complications were seen in patients who had ACS as opposed to TAR (55% vs 15%, p = 0.02). Hernia recurrence was more common in patients who had ACS as opposed to TAR (55% vs 5%, p = 0.008). More post-operative complications and recurrences were seen in patients who had ACS as opposed to TAR.

EIT Ambivium, Linea Semilunaris, and Fulcrum Abdominalis.

Building upon the recent advancements in posterior component separation techniques for complex abdominal wall hernia repair, highlights the critical importance of a thorough understanding of the abdominal wall anatomy. To address anatomical concepts with a pivotal role in hernia repair, we propose two new terminologies: "EIT Ambivium" referring to the lateral border of the rectus sheath, and "Fulcrum Abdominalis" demarcating the point where the Linea Arcuata intersects with the EIT Ambivium.

Early outcomes of open anterior versus posterior components separation with transversus abdominis release for large median incisional hernias: a retrospective stepwise analysis.

Complex incisional hernia is still a debatable topic, with increasing incidence and an increased local and systemic postoperative morbidity and mortality. The size of the defect is a risk factor for both difficult closure and 30-day readmission due to complications. The main option for closure such defect is a mesh augmented component separation technique. The goal was to evaluate 30-day wound events and general complications including 90days mortality. We present a retrospective study that includes patients from two different university hospitals who underwent open incisional hernia repair with anterior component or posterior component separation between January 2015 and December 2021. Only non-contaminated adult patients (over 18years old) with postoperative primary or recurrent median abdominal wall defects larger than 6cm and with complete fascial closure were included. Demographics (age, gender, Body Mass Index-BMI, American Society of Anesthesiologists Classification-ASA score), recurrence rank, and co-morbidities), operative details, patient outcomes complications were collected. A native abdomen/pelvis computerized tomography (CT) scan was performed preoperatively in all patients and the anatomy of the defect and volumetry (abdominal cavity volume, incisional hernia volume and peritoneal volume) were evaluated. One of the component separation technique was performed according to Carbonell's equation. Two hundred and two patients (101 from each group) were included. The patients with posterior component separation were more comorbid and with larger defects. The procedure was longer with 80min but overall length of hospital stay shorter (p < 0.001) for posterior component separation. Seroma, hematoma and skin necrosis were equally distributed for both group of patients and there was no direct relation to surgery (OR 0.887, 95% CI 0.370-2.125, p = 0.788; OR 1.50, 95% CI 0.677-3.33, p = 0.318 and OR 0.386, 95% CI 0.117-1.276, p = 0.119). Surgical Site Infection rate was increased for anterior component separation (p =0.004). Complex incisional hernia repair is a challenge given by a large amount of wound complications. Choosing between anterior and posterior component separation is still a source of significant debate. We were not able to depict significant different rates of complications between the procedures and we couldn't find any specific factor related to complications.

A Comparison of Outcomes of the Component Separation Techniques in Large Incisional Hernias: Mesh vs. No Mesh

A Comparison of Outcomes of the Component Separation Techniques in Large Incisional Hernias: Mesh vs. No Mesh

Impact of cadaver training for learning abdominal wall reconstruction: our early experience.

Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique. Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees. Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course. The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

Botulinum toxin A in complex incisional hernia repair: a systematic review.

To evaluate the safety, efficacy, and short and long-term postoperative results of using BTA. We conducted a systematic review following the recommendations of the PRISMA method. We systematically reviewed the MEDLINE/PubMed and SCOPUS electronic databases for studies published between January 2010 and September 2021. This systematic review was registered in PROSPERO, with registration number CRD42021252445. After applying the selection criteria, 11 relevant articles were selected. The total sample size was 1058 patients. Most studies aimed to assess the rate of fascial closure, followed by the rate of recurrence and reporting of postoperative complications, as well as the need for the components separation technique (CST). None of the studies reported serious complications from using BTA. Regarding fascial closure, all articles had rates above 75%, except for one. Surgical site events ranged between 19% and 29.4%. No recurrence in the group that used BTA was recorded in five studies. The other articles reported recurrence rates ranging from 6.4 to 11.4% in the groups that received BTA. The studies had varying follow-up times ranging from 1 to 49months, with a mean of 18.6months (± 11.2). This review described most of the key points about the preoperative use of BTA in hernia repair. It can be concluded that the use of BTA is a safe and effective practice that promotes good short and long-term results. However, the limitations of the current literature prevent more accurate conclusions on the subject.

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.