Component Separation Technique Research Articles

Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique?

BackgroundAbdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown.MethodsUsing a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed. ResultsA total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST.ConclusionCS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.

Abdominoplasty combined with the anterior component separation technique for reconstruction of midline large ventral hernias: functional and aesthetic outcome clinical study

Abdominoplasty combined with the anterior component separation technique for reconstruction of midline large ventral hernias: functional and aesthetic outcome clinical study

Secondary closure of large omphalocele using component separation technique: A pediatric case report

Introduction and importanceComponent separation technique is utilized in adults to repair large abdominal wall defects but rarely used in children. We report a successfully performed component separation technique in a child after neonatal Gross closure for large omphalocele without biologic mesh placement.Case presentationA 6-year-old girl was treated at the age of 4 days for omphalocele type 2 according to Gross technique. She reconsulted six years later. Clinical examination showed a large eventration measuring 150 ∗ 100 mm. CT scan revealed a broad collar of 150 mm and a large pocket containing liver, transverse colon, stomach and part of the small intestine. The child was proposed for a cure of the eventration using synthetic mesh type GORTEX. Intraoperatively, releasing bowel adhesions with abdominal wall resulted in perforation of the small intestine. Faced with the inability to use the mesh we resorted to abdominal closure with component separation technique. The postoperative was simple without complications or recurrence of the eventration. Follow up was of 4 years.Clinical discussionStaged surgical closure and non-operative delayed closure are the two distinct strategies for managing giant omphaloceles. By providing closure with less intra-abdominal pressure, the Component separation technique is a procedure which can be used in the two strategies. It may minimize the complications associated with large omphalocele management.ConclusionFaced with the impossibility of using a mesh, the component separation technique must be recognized as part of the therapeutic arsenal for secondary closure in children with a giant omphalocele.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia.

The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia. Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position. The median length and width of the complex subcostal hernias were 15cm (10-19) and 15cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19months. The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

Tissue Expander-Assisted Component Separation for Pediatric Abdominal Wall Reconstruction.

Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population. A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure. The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%. Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.

Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results

Bladder exstrophy (BE) is a rare, complex malformation. There are three major approaches to closure. Despite this choice, abdominal wall closure in such patients is usually a challenging procedure specially in large defects and redo cases. Our aim is to present our ten first cases' results, using Anterior Component Separation (ACS) to abdominal wall closure in BE patients. Ten male patients with BE (median age 7 months, range from 3 to 24 months) were operated from March 2020 to March 2021 by a multi-institutional Brazilian group using the Kelly technique. In addition to BE correction, anterior component separation was performed for abdominal closure. Postoperative suprapubic fistulae occurred in two of ten patients, but both closed spontaneously. No evisceration, abdominal wall dehiscence, or herniation was observed at a mean follow-up time of 14 months (range from 10 to 22 months). A 3cm extent of advancement is achievable upon traction in each side (Fig.3). We proposed the use of anterior component separation as an alternative for abdominal closure after BE correction using the Kelly procedure. This new technique avoids mesh usage, loosens the abdominal wall tension, and reduces complications. Even However, further studies are required.

Pathways of the preperitoneal plane: from the "fatty triangle" in Rives to the "fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute toProf. Schumpelick.

Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model and its influence in retromuscular preperitoneal dissections. Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated. The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The peritoneum not covered by the preperitoneal fatty trident was easy to break. Three pathways could be tracked following the distribution of this fat that facilitated the dissection of the preperitoneal space to prepare the landing zone of the meshes in hernia repair. The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow three specific pathways to find our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

A study of venous thromboembolic complications following laparoscopic mesh hernioplasty for midline ventral hernias

Background: Midline ventral hernia is a common complication of abdominal surgeries. Laparoscopic mesh hernioplasty is novel method of hernia repair but has many complications. Venous thromboembolic complications are one of them.Methods: A prospective observational study in patients with midline ventral hernia was carried out. Based on the size of defect patients were divided into two groups (consisting 60 patients each). Group A with hernia defect size of less than 6cm and group B with more than 6 cm. Group A patients underwent intraperitoneal onlay mesh plus repair and group B patients underwent endoscopic components separation technique with intraperitoneal onlay mesh repair. Each patient was followed up at day 5 and day 30 postoperatively and Well’s score was calculated. The patients with ‘Likely’ score were taken for Doppler ultrasonography. The patients with ‘Unlikely’ score were further evaluated with D-Dimer study. Patients with raised value of D-Dimer were taken for Doppler ultrasonography.Results: Well’s score on post-operative day 1 and 5 did not show any statistical significance between both groups (p<0.05). D-dimer done in Unlikely score showed no statistical significance. In all the patients with Likely score and raised D-dimer, no abnormality was detected on sonography.Conclusions: Performing Wells score preoperatively and postoperatively one can get an idea about the risks of development of thromboembolic events.

A retrospective comparison of outcomes after open anterior and posterior component separation by a single surgical team.

While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience. We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence. One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43months. Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium.

Treatment of patients with large and complex incisional hernia with modified component separation technique and long-term follow-up

Treatment of patients with large and complex incisional hernia with modified component separation technique and long-term follow-up

Repair of giant incisional hernias

BACKGROUND: Incisional hernias are one of the most common postoperative complications encountered by surgeons in daily practice. In our study, we compared the component separation technique (CST) with and without synthetic mesh in large incisional hernia surgery. MATERIALS AND METHODS: The files of 79 patients who underwent surgery for giant incisional hernia between January 2016 and November 2020 were reviewed retrospectively. The patients were divided into two groups: CST with mesh reinforcement (mesh+ group) and CST without mesh reinforcement (non-mesh group). The groups were compared in terms of recurrence, complications, and other clinical features. RESULTS: There were 36 patients in the mesh+ group and 38 patients in the non-mesh group. There was no significant difference between the two groups in terms of demographic parameters and clinical features. There was a statistically significant difference between the groups in terms of recurrence rate (P = 0.007, OR = 0.17). In addition, there was a significant difference between the two groups in terms of mean operation times (2.8 h and 1.9 h for mesh+ and non-mesh, respectively) (P = 0.000, 95% CI). Regardless of the use of mesh, recurrence was significantly higher in the presence of high body mass index (BMI) (P = 0.003, 95% CI) and comorbidity (P = 0.031, OR = 3.4). CONCLUSION: Repair of giant incisional hernias with mesh-reinforced CST is superior to the non-mesh technique in terms of hernia recurrence. Although CST without mesh reinforcement seems advantageous in terms of complications and operation time, we believe that the mesh-reinforced CST should be applied in suitable patients when the total cost, recurrence, and patient satisfaction are taken into account.

DECOMP Report: Answers surgeons expect from an abdominal wall imaging exam.

Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

ECST: The endoscopic-assisted component separation technique for (complex) abdominal wall reconstruction

eCST: The endoscopic-assisted component separation technique for (complex) abdominal wall reconstruction

The open anterior component separation technique for large ventral and incisional abdominal wall reconstruction

The open anterior component separation technique for large ventral and incisional abdominal wall reconstruction

Transversus Abdominis Release Versus Anterior Component Separation in Ventral Abdominal Hernia - A Prospective Comparative Study

Ventral abdominal hernia (VAH) repair is considered a surgical challenge especially hernias with large defect size and loss of domain (1-3). The incidence of recurrence after VAH repair ranges from 18.1% in primary VAH to 30.6% in secondary VAH (incisional hernia) (4). The principle of any hernia repair is to achieve a tension free repair with re-enforcement by mesh to decrease the incidence of recurrence (5). Many techniques had been studied and evaluated to address the problem of complex VAH with large defects and loss domain (1,6). In 1973, Rives et al. described their technique of retro rectus space dissection for incisional hernia (IH) repair allowing medial mobilization of myofascial flap and sub-lay mesh insertion (7, 8). But this technique has limitation in cases of large VAH as it doesn’t allow major myofascial advancement due to lateral limitation of linea semilunaris (LS) (9). In 1990, Ramirez et al. at described their technique of open anterior component separation (ACS) (10). In this technique, the external oblique aponeurosis is separated from internal oblique lateral to LS to achieve more medial mobilization of myofascial flap (9). ACS was successfully utilized in cases of large VAH, but the technique had its drawbacks. ACS was found to be associated with high rates of wound complications (seroma, wound infection, and flap necrosis) due to excess subcutaneous dissection with the possibility of lateral abdominal wall hernia at area of external oblique incision. The recurrence rate after ACS ranges from 9-18% (4). In 2012, Novitsky et al. were the first to describe the technique of posterior component separation and transversus abdominis release (PCS-TAR). The technique involved retro rectus space dissection reaching the LS, then an incision is made at posterior rectus sheath to access the space between internal oblique and transversus abdominis muscles. Dissection is carried on in this space until reaching psoas muscle laterally. This technique has the advantage of allowing maximum medial myofascial mobilization without major subcutaneous dissection. In addition, the technique allows for sub-lay mesh placement (11). All these different component separation techniques aim to reestablish a functional abdominal wall through autologous tissue repair by separating between myofascial layers of anterior abdominal wall (AAW). This allows medial mobilization of myofascial flap to obliterate large size defects (12-14). Due to the relative novelty of these techniques, a knowledge gap still persists regarding which CS technique is suitable to different types of VAH. The aim of our study is to compare the outcomes of TAR with ACS as regard short term postoperative complication and recurrence rate.

Incisional Hernias with Loss of Abdominal Domain: A New Look to an Older Issue or the Elephant in the Living Room. Literature Review.

Incisional hernia (IH) is a postoperative defect of the abdominal wall through which the contents of the peritoneal cavity are externalized beneath the skin in a peritoneal sac. IH differs in anatomic complexity, but also in its associated comorbidities and surgical history. As IH enlarges, complications occur and these become part of its natural history. The goal of the study is to review the impact of loss of domain upon abdominal wall before and after abdominal wall reconstruction. The absence of anatomical and functional linea alba leads to a combination of muscular disturbances, chronic respiratory and gastrointestinal conditions, and psychosocial issues. The pathophysiological changes are also due to the decrease of the intra-abdominal pressure (IAP). During repair, the sudden reintroduction of the viscera into an unprepared cavity leads to a sudden increase in cavity volume and an increase in IAP with fatal pathophysiological implications. For an optimal repair, preoperatively, the abdominal wall must be augmented by achieving the following objectives: reducing the volume of the sac contents, optimizing compliance, enlargement of the container. At the same time, for the optimal repair, the following must be taken into account: increased knowledge about this condition to manage systemic and local changes, CT scan evaluation, monitoring IAP, plateau pressure (PP), and Positive End Expiratory Pressure (PEEP). In conclusion, the goals can be achieved by systemic optimization with a multidisciplinary team, using Preoperative Progressive Pneumoperitoneum (PPP) and/or Botox (BTX), and abdominal wall reconstruction through a mesh with augmented component separation technique.

P045 MEDIALIZATION AFTER COMBINED ANTERIOR AND POSTERIOR COMPONENT SEPARATION IN GIANT INCISIONAL HERNIA SURGERY, AN ANATOMICAL STUDY

Abstract Aim To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation (ACS, PCS) is often performed. In extreme patients, ACS and PCS may be combined. The aim of this study was to assess the additional medialization after simultaneous ACS and PCS. Material and Methods Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), ACS and PCS, the order in which the component separation techniques (CST) were performed was reversed for the contralateral side. Medialization was measured at three reference points. Results ACS provided most medialization for the anterior rectus sheath, PCS provided most medialization for the posterior rectus sheath. After combined CST 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 PCS after ACS provided 15% to 16%, and additional ACS after PCS provided 32% to 38% of the total medialization after combined CST. For the posterior rectus sheath, additional PCS after ACS provided 50% to 59%, and additional ACS after PCS provided 11% to 17% of the total medialization after combined CST. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization. Conclusions ACS provided most medialization of the anterior rectus sheath and PCS provided most medialization of the posterior rectus sheath. Combined CST provides marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks.

Changes in the abdominal wall after anterior, posterior, and combined component separation.

Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. PurposeComponent separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sourcesto identify articles describing abdominal wall changes after CS ResultsAfter excluding non-pertinent articles, 14 articles constituted the basis for this review. Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

VP007 MULTIRECIDIVATED DESMOÍD TUMOR OF THE THORAX-ABDOMINAL WALL

Abstract Aim Treatment of recurrent desmoid tumors represents a real challenge for the surgeon. The purpose of the video is to show the treatment of a multirecidivated complex desmoid tumor that affects the lateral thoracoabdominal wall. Material and Methods 24-year-old woman with the diagnosis of recurrent desmoid tumor. She was operated in 2014 for a 10 cm desmoid tumor in the left chest wall with affected margins in the biopsy. In 2016 she underwent surgery for a 5 cm recurrence, which was excised en bloc along with the 6th, 7th, 8th and 9th rib arches. In 2018 she presented a recurrence in the scar treated by radiotherapy. She now presents a recurrence that in the CT scan is seen as an 8 cm tumor that affects the thoraco-abdominal wall. Results We perform a complete resection with free margins and “en bloc” resection of the 8th, 9th, 10th and 11th rib arches. We repair the defect using a reverse TAR and rebuild the wall with the Madrid APPROACH technique with BioA and polypropylene meshes. The patient was discharged 11 days after surgery without any complications. The pathological study showed an 8 cm desmoid tumor with free surgical margins. The patient a year after surgery remains disease free. Conclusions The resection of a desmoid tumor that affects the abdominal and/or thoracic wall, especially if it is recurrent, represents a challenge for the surgeon. Component separation techniques and Madrid APPROACH may be very useful to achieve an optimal repair.

P013 HOW TO IMPROVE TREATMENT OF COMPLEX INCISIONAL HERNIAS IN OBESE PATIENTS: A SINGLE-CENTRE STUDY, AN EVALUATION OF LESS-OPEN TECHNIQUE AND FREE-FIXATION TECHNIQUE

Abstract Aim Surgery of a complex incisional hernia in an obese patient is a challenging procedure for hernia surgeons. The aim of a new approach is to reduce complications such as pain and wound events, without increasing the number of recurrences. Material and Methods Adults with BMI more than 35 who underwent open, elective operation of a complex incisional hernia (with horizontal diameter more than 12cm) including posterior component separation technique with TAR (transversus abdominis muscle release) and retromuscular synthetic large-pore mesh placement, were identified. Patients were divided into 2 groups: The first group was treated with standard open technique with fixation using interrupted stitches, and the second group was treated with a technique using light hook and no or reduced fixation in the upper and lower pole of the mesh. For post-operative complication evaluation, the Clavien-Dindo classification was used. We have also evaluated an average operation time, length of stay, duration of opioid need. The long-term follow-up was 6 – 48 months. Results There was no significant difference in length of stay, the need of analgetic treatment, and hernia recurrence. Shorter operation time, and lower occurrence of surgical-site infections were reported in the second group, but it was not significant. Conclusions Open posterior component separation technique with TAR using large-pore mesh and no/minimal fixation seems to be a safe and sufficient method of treatment for complex incisional hernias in obese patients. Alternative methods may reduce early complications and pain and do not increase number of recurrences. A larger group of patients and longer follow-up should be needed to improve these findings.