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Surgical Endoscopy

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01-06-2020 | 2019 SAGES Oral

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model

Authors: Arnab Majumder, Luis A. Martin-del-Campo, Heidi J. Miller, Dina Podolsky, Hooman Soltanian, Yuri W. Novitsky

Published in: Surgical Endoscopy | Issue 6/2020

Abstract

Background

Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model.

Methods

Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters.

Results

Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535.

Conclusions

Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen.

Graphic Abstract

Ramirez OM, Ruas E, Dellon AL (1990) “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 86:519–526CrossRef

Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 204:709–716. https://doi.org/10.1016/j.amjsurg.2012.02.008 CrossRefPubMed

Hodgkinson JD, Leo CA, Maeda Y, Bassett P, Oke SM, Vaizey CJ, Warusavitarne J (2018) A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias. Hernia 22:617–626. https://doi.org/10.1007/s10029-018-1757-5 CrossRefPubMed

Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ (2012) Posterior and open anterior components separations: a comparative analysis. Am J Surg 203:318–22; discussion 322. https://doi.org/10.1016/j.amjsurg.2011.10.009

Dauser B, Ghaffari S, Ng C, Schmid T, Köhler G, Herbst F (2017) Endoscopic anterior component separation: a novel technical approach. Hernia 21:951–955. https://doi.org/10.1007/s10029-017-1671-2 CrossRefPubMed

Milburn ML, Shah PK, Friedman EB, Roth JS, Bochicchio GV, Gorbaty B, Silverman RP (2007) Laparoscopically assisted components separation technique for ventral incisional hernia repair. Hernia 11:157–161. https://doi.org/10.1007/s10029-006-0175-2 CrossRefPubMed

Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE (2003) Endoscopically assisted “Components separation” for closure of abdominal wall defects. Plast Reconstr Surg. https://doi.org/10.1097/00006534-200002000-00039 CrossRefPubMed

Rosen MJ, Williams C, Jin J, McGee MF, Schomisch S, Marks J, Ponsky J (2007) Laparoscopic versus open-component separation: a comparative analysis in a porcine model. Am J Surg. https://doi.org/10.1016/j.amjsurg.2007.03.003 CrossRefPubMed

Carbonell AM, Cobb WS, Chen SM (2008) Posterior components separation during retromuscular hernia repair. Hernia 12:359–362. https://doi.org/10.1007/s10029-008-0356-2 CrossRefPubMed

10.

Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ (2015) Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia 19:285–291. https://doi.org/10.1007/s10029-014-1331-8 CrossRefPubMed

11.

Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB (2016) Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg. https://doi.org/10.1097/sla.0000000000001673 CrossRefPubMed

12.

Stoppa RE (1989) The treatment of complicated groin and incisional hernias. World J Surg 13:545–554CrossRef

13.

Wantz GE (1993) The technique of giant prosthetic reinforcement of the visceral sac performed through an anterior groin incision. Surg Gynecol Obstet 176:497–500PubMed

14.

Majumder A, Miller HJ, del Campo LM, Soltanian H, Novitsky YW (2018) Assessment of myofascial medialization following posterior component separation via transversus abdominis muscle release in a cadaveric model. Hernia 22:637–644. https://doi.org/10.1007/s10029-018-1771-7 CrossRefPubMed

15.

Raakow J, Schulte-Mäter J, Callister Y, Aydin M, Denecke C, Pratschke J, Kilian M (2018) A comparison of laparoscopic and open repair of subxiphoid incisional hernias. Hernia 22:1083–1088. https://doi.org/10.1007/s10029-018-1815-z CrossRefPubMed

16.

Wantz GE (1998) Giant prosthetic reinforcement of the visceral sac. The Stoppa groin hernia repair. Surg Clin North Am 78:1075–1087. https://doi.org/10.1016/S0039-6109(05)70370-4 CrossRefPubMed

17.

Winder JS, Majumder A, Fayezizadeh M, Novitsky YW, Pauli EM (2018) Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation. Hernia. https://doi.org/10.1007/s10029-018-1732-1 CrossRefPubMed

Title: Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model
Authors: Arnab Majumder
Luis A. Martin-del-Campo
Heidi J. Miller
Dina Podolsky
Hooman Soltanian
Yuri W. Novitsky
Publication date: 01-06-2020
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 6/2020
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-019-07046-9

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model

Abstract

Background

Methods

Results

Conclusions

Graphic Abstract

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Graphic Abstract

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