Component Separation Technique Research Articles

OC-013 INDIVIDUAL STRATEGY FOR PATIENTS WITH ABDOMINAL WALL EVENTRATION – DIFFERENT COMPONENTS SEPARATION TECHNIQUE WITH MESH AUGMENTATION

Abstract Aim To present individual approach for patients with abdominal wall eventration using various anterior component separation techniques (aCST) with mesh augmentation. Materials and Methods Between January 2008 and April 2022, 194 patients with abdominal wall eventration underwent surgery by single surgeon. Surgical treatment consists: a) enlargement of the abdominal cavity using different aCST (Ramirez CST, modified CST in the presence of enterostomies, “open book” modification CST, “method of wide myofascial release” or combination of these techniques); b) mesh augmentation (sublay or onlay hernioplasty); c) prolonged muscle relaxation and mechanical respiratory support in intensive care unit. Results Type of abdominal wall reconstruction: 143 Ramirez CST, 35 modification CST in the presence of enterostomies, 11“open book” CST modification, 5 “method of wide myofascial release”, 159 onlay mesh hernioplasty and 35 sublay mesh hernioplasty. Mean hernia defect size was 255 cm2 (100–750). During the mean follow-up of 31 months, 78 (40%) patients had one or more complications: intraabdominal hypertension 8 (4,1%), seroma 13 (6,7%), hematoma 10 (5,1%), wound/mesh infections 21 (10,8%), skin necrosis 40 (20,6%), pain 3 (1,6%), and recurrence 5 (2,6%). There were 10 (5,1%) postoperative deaths. The cause of dead was significant comorbidity in 8 patients and postoperative compartment syndrome in two. Conclusion Eventration disease is a complex surgical problem and its treatment is associated with significant complications. Individual strategy for each patient based on multidisciplinary approach using different component separation techniques with mesh augmentation may improve postoperative results.

OC-077 OPEN REPAIR OF FLANK AND LUMBAR HERNIAS (FLH): 145 CONSECUTIVE REPAIRS AT A HIGH-VOLUME, TERTIARY HERNIA CENTER

Abstract Aim FLH present a surgical challenge due to their anatomic location, proximity to boney structures, and lack of elasticity of the surrounding muscle. With less than 1,000 cases reported, there is no uniform operative management. This is the largest study to date evaluating FLH repair (FLHR). Materials & Methods A prospective, single-center, hernia specific database was queried for patients who underwent open flank or lumbar hernia repair from 2004–2021. Demographics, operative characteristics, and outcomes were evaluated. Standard statistical methods were used. Results 145 patients included 109 flank hernias and 36 lumbar hernias. The hernias resulted from prior surgery (73.3%), blunt trauma (19.7%), or primary defects (7.0%). The mean defect size was 125.7±166.8cm2, 46.9% were recurrent, and 11.0% of patients visited a pain specialist preoperatively. Mesh was commonly synthetic (92.4%), a mean of 755.9±373.4 cm2, and placed in the preperitoneal space (92.7%). Component separation technique was utilized in 16.8% of cases and pelvic bone anchor fixation in 13.8%. Preoperative chronic pain was present in 75% of patients receiving bone anchors and only 6.6% postoperatively. Complete defect closure occurred in each case. Wound infection (8.1%) and mesh infection (1.4%) were uncommon. Prolonged, postoperative discomfort was reported in 22%, half of which had chronic pain preoperatively (p<0.01). Hernia recurrence was 3.4% at 29.3±13.2 months follow-up. Recurrences occurred posteriorly in 3 and in 2 mesh infections requiring explantation. Conclusions Open preperitoneal repair of FLHs with synthetic mesh results in low rates of postoperative complications and hernia recurrence. Postoperative pain correlated closely with preoperative pain.

OC-012 THE COMBINATION OF THE THREE MODIFICATIONS OF THE COMPONENT SEPARATION TECHNIQUE IN THE MANAGEMENT OF COMPLEX SUBCOSTAL WALL DEFECT

Abstract Aim 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 defect. Material and Methods Between January 2010 and January 2022, seven patients with complex subcostal hernia defects compromised by infection, radiation, or chemotherapy 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 10 cm. The following were the stages of the operative technique: (a) the “method of wide myofascial release” at the side of the hernia defect; (b) “openbook 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. Results The median (range) length and width of the complex subcostal hernias were 15 cm (10–19) and 15 cm (8–24), respectively. The overall morbidity rate was 57.1% (wound infection, seroma and skin necrosis). There was no hernia recurrence during the median follow-up time of 19 (range 3–84) months. Conclusion 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 defect.

V-006 SIMULTANEOUS TREATMENT OF VENTRAL HERNIAS & GROIN HERNIA & RECTUS ABDOMINIS DIASTASIS BY LAPAROSCOPIC E-TEP REPAIR

Abstract Aims Ventral hernias are a frequent pathology in general surgery.Its association with rectus abdominis diastasis and groin hernias is not uncommon.Currently, the minimally invasive approach of these pathologies is becoming more frequent.We present the usefulness of the e-TEP-approach to treat different types of hernias and diastasis at the same surgical-procedure. Methods Video-case presentation. Results 73-year-old-man,surgical-histories:umbilical-hernioplasty with onlay-mesh and lap-sigmoidectomy. Physical-examination:midline ventral-hernia(M2–3W2:8cm),diastasis(6cm) and right groin hernia. CT-scan: midline ventral-hernia with small-bowel into the hernial-sac and small defect(15mm) in the right flank(L2).We decided to perform a laparoscopic-extraperitoneal-technique(eTEP). We use 4 ports(2×12mm, 2×5mm).The surgery begins dissecting the left and right retromuscular space using a dissector balloon.We continue with the supraumbilical cross-over transecting the left posterior-sheath and then the right posterior-sheath and complete the dissection of the other retromuscular space.The dissection continues down to the pubis, dissecting the right groin space.We continue with the right-TAR,at this area we observe the lateral defect and continue the dissection on the preperitoneal-space.After that we continue with the closure of the posterior-sheath using 2–0 V-lock and the anterior-sheath using Monomax-loop-1.We placed a 3D-PVDF-mesh for right groin-hernia and 30×40cm-PVDF-mesh fixed with glue and left a drainage.The patient had a satisfactory evolution and was discharged in 2°POD. Conclusions The enhanced view totally-extraperitoneal approach (eTEP) is an effective and safe option in cases of ventral hernias associate with groin hernias and rectus abdominis diastasis,as in the case presented.Posterior component separation-techniques(TAR) allow us to achieve a correct and tension-free closure of the abdominal wall and place a wide mesh covering all hernial-defects.

P-151 ROLE OF INDOCYANINE GREEN TO MITIGATE WOUND COMPLICATIONS IN ANTERIOR COMPONENT SEPARATION TECHNIQUE FOR VENTRAL HERNIA REPAIR- OUR EARLY EXPERIENCE

Abstract Aim The subjective ease of anterior component separation technique (ACST) has made it a widely used surgical option amongst budding surgeons for ventral hernia repairs (VHR). However, surgical site occurrences (SSO) like flap necrosis due to compromised perfusion have frequently been reported. This study aims to evaluate the impact of adoption of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion on wound-related complications following open ACST in VHR. Material & Methods We performed a retrospective review of patients who underwent VHR with open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of ACST with onlay meshplasty done before (March 2018–April 2019, n=24) and after (May 2019 to July 2020, n=19) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin. Results The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of SSO was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less number of patients in the post-ICG cohort (29% vs. 5%; p value 0.045). No mesh infection was observed in either group. Conclusion This study demonstrates the effectiveness of perfusion mapping by the use of ICG-FA to determine potential areas of decreased perfusion and thereby minimize wound complications.

OC-084 PRACTICE AND SHORT-TERM OUTCOMES IN VENTRAL HERNIA REPAIR: FIRST PROSPECTIVE MULTICENTER DATA ANALYSIS FROM INDIA

Abstract Aim Recording short and long term outcomes of primary ventral hernia (PH) and incisional hernia (IH) surgeries performed in India. Materials and Methods Members of Indian Association of Gastrointestinal Endo Surgeons (IAGES) were approached via mails and social media. Forty-five centres agreed to participate. The participating surgeons prospectively recorded the data of patients who underwent VHR from January 21, 2021- April 20, 2021, on a predesigned excel sheet. They were followed for 6 months. Results Data from 648 patients were analysed in this study for demographics, hernia characteristics, technical variations, and outcomes. 375 (57.8%) were primary ventral hernias (PH) and 273 (42.15%) were incisional hernias (IH), of which 63 (9.7%) were recurrent hernias. In the PH group, 171 patients underwent minimal access repair (MAS) and 170 patients underwent open repair. The commonest procedure were open onlay and open pre-peritoneal repairs were performed least frequently. There were 3.73% seroma, 3.2% SSI, 0% 90-day readmission, 0% recurrence, and 0.3% mortality. In the IH group, 164 patients underwent open repair and 104 underwent MAS repair. The most commonly performed procedure were open onlay and IPOM/IPOM plus. There were 13.92% seroma, 4.4% hematoma, 9.5% SSI, 1.1% mesh explantation, 0.4% wound sinus, 2.2% 90-day readmission, 0% recurrence, and 1.1% mortality. Conclusion Despite the guidelines favouring sublay repairs, onlay mesh hernioplasty is the commonest procedure practiced in India. IPOM/IPOM plus is the second commonest procedure. TAR is the preferred component separation technique in India. Complication rates in this study are comparable to published world literature.

P-077 SURGICAL TREATMENT OF LARGE INCISIONAL HERNIA WITH BOTULINUM TOXIN A INJECTION: STUDY PROTOCOL FOR A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL

Abstract Aim The best strategy for W3 incisional hernia (IH) repair is not known to date and is associated with high risks of recurrence and morbidity. We aim to demonstrate that preoperative Botulinum Toxin A (BTA) injection in the lateral abdominal wall muscles reduces the rate of postoperative morbimortality after large IH (EHS W3) repair with mesh, compared with placebo injection. Material & Methods This study will be a prospective, national multi-center, double-blinded, randomized (1:1) superiority phase III trial with two parallel arms: BTA versus placebo injection. Participants will be selected based on an abdomino-pelvic CT-scan without contrast injection performed in the 6 months preceding the patient's surgery. Main inclusion criteria will comprise midline anterior primary or recurrent IH (subxiphoidal to suprapubic), of width ≥ 10 cm, without loss of domain. Patients included will be randomized (1: 1 ratio), by using a computer-generated randomization scheme, and randomization will by stratified on the center and width of the IH (10–15 cm and > 15 cm). Participants will be randomized on the day of the injection, at least 4 weeks before the surgery. Results The primary endpoint will be the occurrence of Clavien-Dindo classification grade II or higher post-operative complication during the 90-day postoperative period. Secondary endpoints will include the rates of primary fascial closure, occurrence of component separation techniques, radiological response to injections, consumption of analgesics and pain, and occurrence of clinical and radiological recurrences. Conclusions Protocol version 2.0 is currently being assessed for funding by the French Ministry of Health.

P-100 ANATOMICAL STUDY ON THE PREPERITONEAL FAT DISTRIBUTION IN EXTENDED RETROMUSCULAR PREPERITONEAL DISSECTION: FROM THE FATTY TRIANGLE TO THE FATTY TRIDENT

Abstract Aim 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. Material and methods 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. Results 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. The mean rhomboid area was 35 cm2. 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 mean width of the midline prong at the umbilicus was 2.8 cm. It was easier to tear the peritoneum outside the area reinforced by the fatty trident. Conclusions 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 our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

OC-054 LONG-TERM OUTCOMES OF POSTERIOR COMPONENT SEPARATION WITH TRANSVERSUS ABDOMINIS RELEASE (TAR) IN LARGE AND OTHER COMPLEX VENTRAL HERNIAS: A SINGLE-SURGEON EXPERIENCE

Abstract Aim The application of component separation techniques for the repair of large and other complex ventral hernias, has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these very demanding ventral hernias. Material & Methods A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR technique between January 2016 and May 2021 was performed. Selection of the type of inserted mesh was based on the risk of developing surgical site infection (SSI) and other surgical site occurrences (SSOs). Preoperative, intraoperative, and postoperative data were analyzed. Results A total of 167 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 156 (93.4%) had a history of previous abdominal surgery, 42 (25.1%) had a history of SSI and 11 (6.6%) had active fistulas, of which nine involved previous implanted meshes. Postoperatively, SSOs were presented in 12 patients (7.2%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 3 years, only one recurrence has been observed. Conclusions With a wound complication rate of less than 8% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of large and other complex ventral hernias.

P-126 GIANT UMBILICAL HERNIAS: EMERGENCY SURGICAL TREATMENT AND DEFINITIVE SURGERY. A CLINICAL CASE

Abstract Aim Complex hernias with loss of domain are a challenge for the surgeon, especially when presenting with complications in the emergency room. The emergency treatment differs from definitive surgery, as the patient's scenario is very different and they often present hemodynamic instability, intestinal perforation, etc.. Clinical Case 58-year-old male patient who underwent emergency surgery for septic shock due to intestinal perforation secondary to intestinal occlusion from a primary umbilical hernia, with loss of domain. Through a median laparotomy on the hernia, intestinal resection was performed. Abdominal wall closure wasperformed directly with the hernia sac, without abdominal wall repair. The patient was discharged for outpatient follow up. We planned the definitive surgery. Prehabilitation of the patient begins with botulinum toxin infiltration one month prior to surgery and by creating a progressive pneumoperitoneum. The definitive surgical procedure consists in performing retromuscular umbilical hernioplasty with a posterior component separation technique with placement of four 30×30 cm polypropylene meshes in the retromuscular space and closure of the anterior wall, associated with dermolipectomy. The patient evolved favorably and was discharged. Conclusions The treatment of this type of hernia in the emergency room must be personalized in each case, prioritizing damage control, and followed up by a definitive repair of the hernia. For this repair, it is advisable to perform prehabilitation with botulinum toxin, associated or not, with progressive pneumoperitoneum depending on the characteristics of the patient and the hernia, to avoid an increase in intra-abdominal pressure and the consequent compartment syndrome.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BackgroundComplete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. MethodsA prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. ResultsMatched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%–39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4–34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). ConclusionIn a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

EVOLUTION OF COMPONENT SEPARATION TECHNIQUE (REVIEW)

The problem of treatment of incisional ventral hernias is currently very relevant. The appearance of a hernial defect in the area of a previous operation is one of the most frequent long-term complications of any surgical treatment. Component separation techniques are the most modern and promising methods for the treatment of large ventral hernias. The review focuses on the main stages in the development of separation technique, as well as the results of treating patients with incisional ventral hernias using various options for posterior separation repair, which are currently frequently used. It has been established that posterior component separation is an effective and safe method of treatment, however, there is currently insufficient data on the long-term postoperative period and patients quality of life.

Inguinal single-port approach of endoscopic component separation for abdominal wall defects: A case series.

BackgroundThe component separation (CS) technique is widely used for abdominal wall defects, particularly in infected wounds. CS is associated with many wound complications due to subcutaneous blood flow disturbance. Endoscopic component separation (ECS) has fewer wound complications compared to CS and has been performed recently. However, there are various port required placements for ECS, and this technique requires proficiency. One approach for ECS is the inguinal single-port approach, which can be performed from an inguinal incision similar to that used in open surgery for inguinal hernias.Case presentationWe performed ECS with an inguinal single-port approach in three older adults. All patients had abdominal wall defects with infection at the central abdominal wound site. A 2–3-cm incision was created in the middle of the inguinal ligament, and a single-port surgical device with two 5-mm trocars was placed in the incision. The external oblique muscle was separated from the internal oblique muscle, and the external oblique aponeurosis was released. The muscle flap of the abdominal wall was moved to the central line. Tension-free abdominal wall closure was possible using a one-handed approach.ConclusionsECS, which has fewer wound complications, requires proficiency. This procedure is a simple and easy-to-perform procedure using an inguinal incision that surgeons are familiar with.

Open abdominal management after ruptured abdominal aortic aneurysm repair: from a single-center study in Japan

PurposeWe investigated the utility of the open abdominal management (OA) technique for ruptured abdominal aortic aneurysm (rAAA).MethodsBetween January 2016 and August 2021, 33 patients underwent open surgery for rAAA at our institution. The patients were divided into OA (n = 12) and non-OA (n = 21) groups. We compared preoperative characteristics, operative data, and postoperative outcomes between the two groups. The intensive care unit management and abdominal wall closure statuses of the OA group were evaluated.ResultsThe OA group included significantly more cases of a preoperative shock than the non-OA group. The operation time was also significantly longer in the OA group than in the non-OA group. The need for intraoperative fluids, amount of bleeding, and need for blood transfusion were significantly higher in the OA group than in the non-OA group. Negative pressure therapy (NPT) systems are useful in OA. In five of the six survivors in the OA group, abdominal closure was able to be achieved using components separation (CS) technique.ConclusionsNPT and the CS technique may increase the abdominal wall closure rate in rAAA surgery using OA and are expected to improve outcomes.

Is the type of biomesh relevant in the prevention of recurrence following abdominal wall reconstruction? A randomized controlled trial.

Background:Complex abdominal wall reconstruction technique remains controversial. The use of biologic mesh products is also debated in active infection, sepsis prophylaxis and high-risk patients. Differences in biologic mesh technology and cost remain significant. We aimed to compare the efficacy of 2 commonly used biologic meshes in regards to hernia recurrence at 1 year.Methods:This study was a parallel, dual-arm, double-blind randomized controlled trial involving adult patients undergoing complex abdominal wall reconstruction with a biologic mesh at a quaternary care institution (2017–2020). Patients were randomly assigned to receive Permacol (cross-linked) compared with Strattice (not crosslinked). The main outcome measure was hernia recurrence at 1 or more years following the index repair.Results:We included 94 patients randomized to undergo reconstruction with 1 of 2 commonly used biologic mesh products (mean age 59.4 yr, standard deviation [SD] 9.9; 51% female; body mass index 32.9, SD 6.8). We found no significant differences between the groups (patient comorbidities, hernia recurrence risk factors, hernia size or infection profiles). Hernia recurrence rates (15%) were similar between groups (median 783 days of follow up, interquartile range 119). We found there was significantly less of a need for a component separation technique in the Strattice group (69% v. 87%). All other secondary outcome measures were equivalent between study arms. Multivariate analysis identified hepatic transplantation (odds ratio [OR] 1.94, 95% confidence intervals [CI] 0.33–4.41), active abdominal wall infection (OR 2.01, 95% CI 0.50–7.01), and more than 1 previous hernia repair (OR 2.68, 95% CI 0.41–5.99) as risk factors for subsequent hernia recurrence; however, there was no difference in recurrence factors between patient study groups.Conclusion:Given similar clinical performance between the 2 most commonly used biologic mesh products, the most cost effective mesh should be used in cost-conscious health care systems.

Open Anterior Component Separation for Complex Incisional and Ventral Hernias—When and How? Case Series Analysis

Abstract Closing the midline in patients with incisional hernias is the cornerstone for a functional reconstruction with low morbidity, low recurrence rates, and good cosmetic results, which is the ideal outcome for every hernia surgeon. However, in patients with large hernias (usually over 10 cm width) or in loss of domain cases, this goal is difficult to achieve. Anterior component separation with or without mesh reinforcement has been the procedure of choice for these patients despite its high rate of wound complications. The goal of our study is to evaluate the opportunity and necessity of the anterior component separation in patients with complex incisional or ventral hernias (defects larger than 10 cm, infected meshes). Data of patients with large incisional/ventral hernia operated using anterior component separation technique in the past 10 years were re-visited and analyzed from hospital records between January 2012 and December 2020. Demographic data (age, gender, body mass index, ASA score) and the main steps of the technique were recorded. Data were reported as mean and standard deviation. We used the anterior component separation in 66 cases, mainly for septic conditions (open abdomen, chronic and extended infections of the abdominal wall, chronic-infected meshes). For large parietal defects with aseptic local condition, we used mesh-reinforced anterior component separation (five patients). Mean age was 68.7 years. Among them, 29 patients developed wound complications (hematoma, seroma, infection). Mean hospital stay was 12.6 days. Recurrence was 18% in patients without mesh and zero in patients with mesh reinforcement after a minimum one-year follow-up. Anterior component separation is still a valid procedure in patients with large abdominal defects especially when a septic wound is to be closed. For large parietal defects, if a wide subcutaneous dissection is required, mesh-reinforced anterior component separation remains a valid alternative in abdominal wall reconstruction in certain cases (mainly aseptic conditions).

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital.

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

The external oblique muscle flap technique for the reconstruction of abdominal wall defects

PurposeSeveral modifications to the anterior component separation technique (ACST) have been reported to facilitate the closure of abdominal wall defects. In this study, the external oblique (EO) muscle flap for modified ACST during major abdominal wall defect reconstructions has been described. MethodsA retrospective review of consecutive patients undergoing modified ACST was conducted. The clinical data were collected and retrospectively analyzed. ResultsAmong the 36 patients admitted to our hospital from December 2014 to December 2020, 9 cases had rectus abdominis tumors, 1 case had rectus abdominis trauma, and 26 cases had incisional hernias. The average age was 61.17 ± 13.76 years, and the mean BMI was 24.25 ± 3.18 kg/m2. The average width of the defect was 14.33 ± 2.90 cm. Unilateral EO muscle flap technique was used to reconstruct the abdominal wall. 3 cases of surgical site infection (8.3%), 4 cases of grade III or IV seroma (11.1%) and 2 cases of intestinal obstruction (5.5%)were reported postoperatively. Ischemic necrosis of the abdominal EO muscle flap, incision dehiscence, intestinal fistula, or other complications were not observed. 1 case of incisional hernia recurrence (2.8%) was reported. Recurrence of tumors or abdominal wall bulging were not noted during the follow-up period of 32.53 ± 14.21 months. ConclutionsThe EO muscle flap technique is associated with low postoperative morbidity and recurrence rate, which approves it a reliable technique for selected groups of patients. Further research are needed to confirm the effectiveness of this technique.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair.

Purpose: Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods: A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results: Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects.Rives-Stoppa sublay mesh repair has become the “gold” standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature.Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned.Conclusions: Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

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