Evolving Techniques in Open Ventral Hernia Repair: From Traditional Methods To Component Separation by Dr. Lana Al-Sabe
Uploaded by
Dr. Lana Al-SabeEvolving Techniques in Open Ventral Hernia Repair: From Traditional Methods To Component Separation by Dr. Lana Al-Sabe
Uploaded by
Dr. Lana Al-SabeOpen Ventral Hernia Repair
OVHR
Lana Al-Sabe, PGY-4
Moderated by Dr. Rami Addasi
OUTLINE
•Definition
•Prevention Strategies
•Surgical Techniques
•Anatomy
•Mesh Planes
•Rives-Stoppa
•AWR/CST
Secondary
Parastomal
Primary
Incisional Hernia
• Despite advancements in techniques for abdominal wall closure, the
incisional hernia rate following laparotomy is as high 15% to 20%
• 1% of laparoscopic port-site incisions
• Repair of incisional hernias still has a high failure rate
• Large burden on the healthcare system
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535797/
Incisional Hernia
• Patient, wound and surgeon factors mainly technical failure
• Optimal closure of the abdominal wall is essential to prevent short-term
complications such as surgical site infections or wound dehiscence and
formation of incisional hernias during long-term follow-up
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535797/
The State Of Art
Abdominal Wall Closure in Elective Midline
Laparotomy
The Current Recommendations:
• No tension
• Continuous > Interrupted
• Single mass closure > Layered…. Incorporating fascia with no muscle.
• Monofilament, slowly absorbable
• S:W length ratio of 4:1
• Small bites < 1cm is recommended… Ongoing studies???
• Prophylactic mesh in high risk patients
• Emergency repair?
doi: 10.3389/fsurg.2018.00034
“Never judge the surgeon until you have seen him closing the wound” - Lord Moynihan
Surgical techniques
• Ventral hernia repairs (VHR) are among the most common operations performed by general surgeons
each year
• 70% are still repaired using open techniques
• Primary repairs of incisional hernia include both simple suture closure and components separation
• Primary repair without mesh reinforcement is not recommended today because of the high risk of
recurrence 30-50% and should typically be reserved for defects < 2 cm. However, they may be the only
option in the presence of gross contamination such as peritonitis
• Mesh should be used in all elective repair of incision hernias as they reduce the rate of recurrence <20%
and abdominal pain without increase in complications
https://www.ncbi.nlm.nih.gov/books/NBK435995/
Can Mesh Be Used in
Contaminated or
Clean/Contaminated Fields?
• Clean: For patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel
resection a synthetic mesh is recommended and is associated with lower recurrence rate, without an increase
in the wound infection rate. (Grade 1A recommendation)
• Clean-contaminated: For patients having a complicated hernia with intestinal strangulation and/or
concomitant need of bowel resection without gross enteric spillage a synthetic mesh can be performed
(without any increase in 30-day wound-related morbidity) and is associated with a significant lower risk of
recurrence. (Grade 1A recommendation)
• Contaminated/ Dirty: For stable patients with strangulated hernia with bowel necrosis and/or gross enteric
spillage during intestinal resection, or peritonitis from bowel perforation, primary repair is recommended
when the size of the defect is small (< 3 cm); when direct suture is not feasible, a biological mesh may be
used for repair. (Grade 2C recommendation)
Know The
Anatomy!
Where To Place The
Mesh?
Onlay Premuscular
• Popularized by Chevrel in 1979
• Placing the mesh on the anterior rectus sheath
• High wound morbidity
Inlay
• Previously “interposition”
• Placing the mesh in the defect
• Large defects which cannot be closed primarily
• The mesh acts a bridge between the two fascial edges> primary fascial closure is superior to
bridged repair
• Tension reduction techniques have evolved: ACS and PCS
Sublay
• First described by Rives-Stoppa
• Placing the mesh anterior to the peritoneum and posterior to the rectus abdominis.
• Above the arcuate line: Retrorectus/ prefascial space
• Below the arcuate line: Retrofascial/ preperitoneal space
Intraperitoneal
• Placing the mesh in the peritoneal cavity, intraperitoneal onlay mesh : IPOM
• Previously underlay
• Mesh adhesion, migration and fistulization
Are We Using The Same
Language?
From Rives-Stoppa to TAR
The Evolution…
Hernia
Albanese Rives Chevrel
recognized
CST Retrorectus repair Onlay
as problem
Tension-free Stoppa Combined VHR
mesh repair Preperitoneal repair and
of groin hernias panniculectomy
GPPR
Novitsky
Watnz Transversus
LeBlanc Rosen
Retromuscular abdominis
Laparoscopic Laparoscopic
repair release
repair anterior CST
GPRVS TAR
Ramirez Saulis Carbonell
Anterior CST Perforator Posterior CST
preserving
anterior CST
American Ambassador to French
Surgeons
How to enter the
retrorectus
space?
The Rive-Stoppa technique
has gained global acceptance and has become the
world’s standard approach to the complex repair
of ventral hernias
due to its durability, excellent long term outcomes, low
recurrence rates and minimal morbidity.
One major pitfall:
Dissection does not extend lateral to the linea
semilunaris
-Limited myofascial advancement 6-8cm; difficult to achieve a tension-free repair
for larger abdominal wall defects
-Limited surface area in the retrorectus space prevents wide mesh overlap
• Because Rives-Stoppa technique was not sufficient, large defects were
not closed but rather bridged (interposition mesh) which led physiological
derangement of the abdominal wall and high RR up to 30%
• Tissue transfer wound morbidity and high RR
Alternative?
Component separation techniques
Release one of the lateral muscles to allow myofascial advancement
toward the midline which aids in primary fascial closure
Combined PRS release with EOR
The classic ACS (Ramirez)
Can
• Start achieve a bilateral advancement of 10cm, 20cm, 6cm in
as Rives-Stoppa
the upper, middle and lower third respectively.
• Extensive flap elevation to expose the E.O
• Division of E.O lateral to linea semilunaris; From
costal margin to inguinal ligament
Pitfalls:
-RRE.O22%
• Dissection in the avascular plane between and
I.O
-SSO 26% “Significant flap necrosis”
• Combined with freeing the rectus from its
attachments to the posterior sheath, this
technique created myofascial advancement flaps
with potential
Shouldfor significant
only be done medialization
endoscopicorto
R.Aavoid raising flap or perforator preserving
Wider space of mesh coverage
Pitfall of this technique:
Division of the neurovascular bundles resulting in denervation of the
recti
Why PCS-TAR
“Retromuscular retrorectus
space”
0
But very long and technically
very challenging.
Steps:
Gain access to the retro-rectus space by
The plane between
incision the transversus
the posterior rectus sheath near
Start
abdominis muscle ventrally off
and
transversalis fascia/peritoneum
theas a
Division
linea alba cephalocaudalof the transverses
abdominis muscle in a
direction; Frome the
Rives-Stoppa repair…
dorsally is developed. costal margin to the space of
Retzius
(The release).
Reapproximation of the posterior
A mesh is placedsheath.
in the sublay plane and secured with full-thickness,
Incision of the posterior rectus
transfascial sheath 0.5cm medial to
sutures.
Thejunction Dissect
anterior rectus toare
of thesheaths linea semilunaris
anterior/posterior rectus to
then reapproximated sheath
restoreto
linea
expose thealba ventral to the
transversus mesh.
abdominis muscle
The five most widely used techniques in the
management of incisional hernias
CST vs. no CST
Can ACS and PCS/TAR Be
Performed At The Same Time?
PRINCIPLES
• Abdominal wall reconstruction AWR… Restoring the native
biomechanics of the abdominal wall (anatomy + function)
• Closure of the fascial defect …. If not feasible CST
• Mesh augmentation… Different surgical planes: Retromuscular sublay
is the preferred one!
• Closure of the anterior rectus sheath & Recreation of the Linea alba
Tailored Surgery Is Always The Best
VHR
Robotic Laparoscopic Open
Mesh
Primary repair
reinforcement
Suture Underlay/
CST Only Inlay Sublay
closure
IPOM
PCS Retrorectus
ACS Preperitoneal
CCS
Any
Questions?
REFERENCES
