Open Ventral Hernia Repair with Component Separation

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Key points

  • Incisional hernias are the most common complication after laparotomy and the most common indication for reoperation after laparotomy.

  • Recent advancements in mesh technology and technical refinements in the methods of herniorraphy have dramatically changed the way open hernia surgery is conducted.

  • Abdominal wall reconstructive procedures, which typically include separation of the abdominal wall layers and release of one or more myofascial planes, require a clear understanding of the anatomy of the

Preoperative planning

Physical Examination

  1. Defect size, location of prior incisions or stomas, draining sinuses, exposed mesh, skin issues (eg, thinning, ulceration, cellulitis) should all be ascertained from physical examination.

Operative History
  1. Review of old operative reports is mandatory to identify what types of repairs have been previously attempted, what type of mesh was used (if any), and into which plane it was placed.

Abdominal Wall Imaging
  1. Computed tomography (CT) of the abdomen and pelvis remains the gold standard preoperative imaging modality for ventral hernia

Clinical anatomy

A thorough understanding of the anatomy of the abdominal wall is mandatory when performing ventral herniorraphy with component separation. This includes not only an understanding of the neurovascular supply to muscle, fat, and skin, but also knowledge of force vectors each of the muscular layers generates. Such knowledge results in the best clinical outcomes by providing a well-vascularized, innervated, and correctly oriented abdominal wall reconstruction.

Normally, 2 vertically oriented rectus

Choice of mesh

  • For patients with clean wounds, we prefer a large (30.5 × 30.5-cm) lightweight, macroporous, polypropylene mesh. There is emerging evidence that use of this mesh is also acceptable in patients with multiple comorbidities (diabetes, obesity, prior mesh infection) or in clean-contaminated circumstances (fistula takedown, enterotomy closure, small bowel resection, stoma formation or relocation).

  • Use of synthetic mesh with an antiadhesive coating can be considered if the viscera will be exposed to

Surgical technique: posterior component separation

Positioning and Marking

  1. The patient is positioned in a supine position with arms abducted.

  2. A Foley catheter and an orogastric tube are placed.

  3. The abdomen is clipped of hair and is widely sterilized with a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution.

  4. All old incisions (including old laparoscopic port sites and drain locations) are marked. Excess skin and old scar to be excised are similarly marked.

  5. An iodophor-impregnated adhesive drape is used.

Incision
  1. A full midline laparotomy incision is made, with an

Surgical technique: anterior component separation

  • Incision, adhesiolysis, and foreign body (mesh) excision proceed identical to posterior component separation methods outlined previously.

Formation of Subcutaneous Flaps
  1. Once the fascia medial to the rectus has been identified, lipocutaneous flaps are created by dissecting the subcutaneous tissues off the anterior rectus sheath. These flaps extend superiorly to the costal margin, inferiorly to inguinal ligament, and laterally to just beyond the linea semilunaris (lateral boarder of rectus muscles) where the external oblique

Postoperative care

Airway Management

  1. In cases with prolonged operative times, patients with underlying pulmonary disease, or cases ending late in the evening, the patient is kept intubated overnight.

  2. If the plateau airway pressure increases more than 6 cm H20 following approximation of the linea alba, the patient is also kept intubated for 24 hours.44

  3. The addition of 24 to 48 hours of chemical paralysis is a useful adjunct for more significant rises in plateau pressure (9 cm H20 or greater).44

Pain Management
  1. Epidural catheters are recommended in

Postoperative complications

Wound Complications

  1. SSIs are a major source of morbidity following open ventral hernia repair.45 In the highest-risk populations, the SSI rate has been reported to be as high as 27% to 41%.46, 47, 48, 49

  2. Wound complications are more common and more severe in anterior component separation than posterior component separation techniques.43

  3. Cellulitis is managed with appropriate antibiotics.

  4. Infected collections (including seromas and hematomas) are drained percutaneously or operatively.

  5. Asymptomatic fluid collections are

Outcomes

Polarizing opinions are common among hernia specialists, and are driven by the lack of well-designed comparative trials evaluating outcomes of open ventral hernia repairs with the techniques described previously. Most of the available literature is retrospective in nature. Techniques vary greatly among investigators, as do definitions of postoperative events and duration of follow-up. The addition of innumerable types and sizes of mesh into this equation makes it difficult to draw firm

Summary

Open ventral hernia repair with component separation represents a group of complex surgical techniques developed to address the ever-growing population of patients requiring abdominal wall reconstruction. The methods described share similar key elements: (1) fascial release permits myofascial advancement and reconstruction of the linea alba, and (2) the creation of vast spaces within the abdominal wall ensure wide overlap of mesh to maximize surface ingrowth. The key difference between anterior

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    Disclosures: Eric Pauli is a speaker for Bard and Synthes. Michael Rosen is a speaker for Covidien, Bard, and Lifecell. He receives research support from Lifecell, Davol, W.L. Gore, and Cook.

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