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  • Title
  • 1. Introduction
  • 2. Incision
  • 3. Hernia Sac Dissection and Excision
  • 4. Raise Flaps Bilaterally Between the Subcutaneous Tissue and the Anterior Fascia
  • 5. Fasciotomy of the External Oblique Fascia at the Anterior Axillary Line to Release the Fascia to Slide to the Midline
  • 6. Closure
  • 7. Post-op Remarks
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Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision

Prabh R. Pannu, MD; David Berger, MD
Massachusetts General Hospital

General Surgery
Main TextProcedure OutlineTranscript

Main Text

Table of Contents

  1. Abstract 
  2. Keywords
  3. Case Overview 
    1. Background
    2. Focused History of the Patient
    3. Physical Exam
    4. Natural History
    5. Options for Treatment
    6. Rationale for Treatment
    7. Special Considerations
  4. Discussion
  5. Disclosures
    1. Statement of Consent
  6. Citations

Anterior component separation is an abdominal wall reconstruction technique used in the repair of ventral wall defects to avoid the use of prosthetic mesh. The procedure releases the external oblique fascia to provide a tension-free midline approximation. The patient is a 72-year-old, obese female who has multiple large incisional hernias along an upper midline incision. An anterior component separation technique is used to repair the defect. An incision is made over the previous abdominal scar. The dissection is carried down to the hernia sac. The hernia sac is then separated from the surrounding tissue to identify the fascial edges. The hernia sacs are removed from the fascia. Surrounding adhesions are lysed. A colotomy occurred, which was repaired in two layers: the outer layer with interrupted 3-0 silk suture, and the inner layer with running 3-0 Vicryl suture. The fascial incision is extended to ensure complete removal of the hernia sacs along with completion of adhesiolysis. Bilateral subcutaneous flaps separating the subcutaneous fascia from the external oblique fascia are developed. Perforating vessels are ligated with 2-0 or 3-0 silk. The dissection is carried laterally to the anterior axillary line. The external oblique fascia is released bilaterally using electrocautery. The midline defect is then closed with running #1 Prolene. After achieving hemostasis, two drains are placed, and the skin is closed. 

Incisional hernia; component separation; surgical repair.

An Incisional hernia is a protrusion of tissue or organs (most commonly intestine) through an abdominal wall defect at the site of a previous surgical incision. Incisional hernias occur in 10–35% of patients after a midline laparotomy with significant impact on an individual’s quality of life and the healthcare system.1–3 There are over 150,000 operations performed in the US every year to repair incisional hernias with associated costs exceeding 3 billion USD.4 

The etiology leading to incisional hernias is multifactorial. Obesity, smoking, midline incisions, wound infections and/or suboptimal surgical closure are among the most important risk factors leading to development of an incisional hernia.5–8 Incisional hernias vary anatomically based on the size and location of the defect. Clinically, they are categorized as asymptomatic, symptomatic, reducible, incarcerated (irreducible), or strangulated.9, 10

Management of incisional hernias is determined by the type of hernia, clinical presentation, patient comorbidities, and surgeon preference. An incisional hernia does not need to be repaired unless it is strangulated. However, there are reasons to repair them electively, with patient preference being the driving force. Surgical repair of incisional hernias can be performed in an open, laparoscopic, or robotic fashion utilizing either straight suturing, mesh placement, or component separation techniques.11, 12 Outcomes and recurrence rates are highly variable. However, obesity, history of previous interventions, and postoperative complications are independent prognostic factors for recurrence.13

In this video, an anterior component separation technique is used to repair multiple incisional hernias in a 72-year-old patient who has a history of multiple abdominal surgeries. The hernia sacs are dissected free and excised. Bilateral flaps separating the subcutaneous tissue and anterior abdominal fascia are raised. The external oblique fascia is released at the anterior axillary line to allow movement towards the midline. This reduces tension on the suture line and allows for repair without the implantation of a prosthetic mesh.

The patient is a 72-year old female presenting with a large abdominal incisional hernia that is symptomatic and enlarging in size. She underwent an emergency open appendectomy 2 months back following which the hernia developed. Her past medical history includes PMS-2 related Lynch syndrome with hysterectomy and oophorectomy performed 3 years back. She also underwent a thoracotomy and decortication over 50 years ago. In addition, she has hypertension and hyperlipidemia. She had an American Society of Anesthesiologist (ASA) score of 3, and her body mass index (BMI) was 34. 

The patient was examined in the office and was in no apparent distress with normal vital signs. Her abdominal exam was significant for a large upper abdominal incisional hernia and revealed prior surgical scars. The abdomen was obese but soft, with no distension or tenderness to palpation. 

Incisional hernias are a protrusion of structures (tissue or organ), as a consequence of fascial breakdown in the abdominal wall at the site of a previous incision. Trauma, infection, tension, and/or poor surgical technique can lead to the development of incisional hernias.5, 6 Despite identification of several responsible factors, the precise and complex underlying mechanisms remain ambiguous. Hernias do not resolve spontaneously and often enlarge over time. However, short of strangulation there is no absolute indication for surgical repair. 

Incisional hernias are treated in accordance with their anatomical and clinical classifications. Based on the width of defect, incisional hernias are classified as small (< 3 cm), moderate (3–10 cm) and large or complex (> 10 cm). Small, asymptomatic hernias are usually managed expectantly although they can be repaired per patient preference. Symptomatic small hernias are also repaired if the patient desires. These hernias are usually repaired with simple suturing with or without mesh reinforcement. However, moderate to complex hernias often need more extensive surgical management, with the decision and technique of repair being determined by risk of surgery based on the patient’s comorbidities.14, 15 Incarcerated and strangulated hernias need urgent surgical management to prevent bowel obstruction, infarction, and intestinal perforation.9, 16 The most commonly used techniques include repair with suturing, mesh placement (underlay, sublay, onlay or inlay), and component separation techniques. Surgical approach of repair (as open, laparoscopic or robotic) is decided based on surgeon preference.

The rationale to treat incisional hernias is context dependent. For small, asymptomatic hernias, observation and expectant management are sufficient. Alternatively, urgent surgical repair is necessary for strangulated hernias to prevent serious complications. An elective repair maybe performed based on patient preference and surgeon expertise.

Certain patient populations have a higher risk of developing large and complicated hernias, especially those with obesity, malnutrition, and cirrhosis. A strategic and personalized approach is needed for management of incisional hernias in such cases.17, 18 During pregnancy, elective surgical repair should be delayed until after delivery; however, if necessary, laparoscopic hernia repair can be performed for urgent cases.19, 20  

As shown in the video, the main procedural steps for this surgical technique are: (1) Incision along previous abdominal scar, (2) identify each hernia sac and carry dissection to the fascial edges, (3) lysis of abdominal adhesions and hernia sac excision, (4) adhesiolysis, (5) repair of bowel if indicated, (6) raise bilateral flaps separating the subcutaneous tissue from the anterior fascia with ligation of perforating vessels, (7) release of the external oblique bilaterally at the anterior axillary line allowing the anterior fascia to move more freely to the midline with fascial closure, (8) achieve hemostasis and place drains under bilateral flaps, and (9) closure of the skin. This technique for incisional hernia repair allows a tension-free midline approximation of fascial edges to close the hernia defect without the use of prosthetic material.

Various approaches can be utilized in the surgical repair of incisional hernias. In 1990, Ramirez was the first to define “component separation” as a technique that employed functional transfer of abdominal wall components for reconstruction, instead of using remote flaps or prosthetics.21 Over the years with surgical and technological advancements, this technique has evolved significantly, and is categorized as anterior component separation or posterior component separation, based on the abdominal wall structures divided in each technique. 

An anterior component separation is characterized by fasciotomy of the external oblique muscles bilaterally, to facilitate a tension-free, innervated midline fascial approximation in hernia repair. It is the preferred surgical approach for moderate to large size incisional hernias, contaminated wound site repairs, and recurrent incisional hernia repairs.22 Seroma formation is a common postoperative complication of hernia repair surgery, especially when associated with placement of a prosthetic mesh. Most seromas resolve spontaneously, however chronic or persistent seromas often need surgical reintervention.23–25 Advancements in anterior component separation technique including perforator sparing and minimally invasive component separation, have led to a significant reduction in the number of wound related complications.26–28 Alternatively, posterior component separation is characterized by the division of transversus abdominis muscle via Rives-Stoppa retrorectus dissection and transversus abdominis release (TAR).29, 30 It utilizes the retromuscular space for mesh placement, without the need for creating skin flaps.31 Postoperative outcomes including wound complications and hernia recurrence rates are comparable across both anterior component and posterior component separation and are largely determined by the surgical approach used.32, 33 Contemporary techniques are focused on using minimally invasive endoscopic or robotic approach for component separation hernia surgery. When performed with adequate training and experience, robotic surgery may facilitate faster recovery for patients with shorter length of hospital stay and decreased postoperative complications.34, 35

There were no complications and estimated blood loss was less than 50 ml.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

  1. Fischer JP, Basta MN, Mirzabeigi MN, et al. A risk model and cost analysis of incisional hernia after elective, abdominal surgery based upon 12,373 cases: the case for targeted prophylactic intervention. Ann Surg. 2016;263(5):1010-1017. doi:10.1097/SLA.0000000000001394.
  2. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. The Lancet. 2003;362(9395):1561-1571. doi:10.1016/S0140-6736(03)14746-0.
  3. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24(1):95-101. doi:10.1007/s002689910018.
  4. Howard R, Thompson M, Fan Z, Englesbe M, Dimick JB, Telem DA. Costs associated with modifiable risk factors in ventral and incisional hernia repair. JAMA Netw Open. 2019;2(11):e1916330-e1916330. doi:10.1001/jamanetworkopen.2019.16330.
  5. Bosanquet DC, Ansell J, Abdelrahman T, et al. Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients. PLoS One. 2015;10(9):e0138745-e0138745. doi:10.1371/journal.pone.0138745.
  6. Itatsu K, Yokoyama Y, Sugawara G, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. British Journal of Surgery. 2014;101(11):1439-1447. doi:10.1002/bjs.9600.
  7. Seiler CM, Deckert A, Diener MK, et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg. 2009 Jun;249(6):913-20. doi:10.1097/SLA.0b013e3181a77c92.
  8. Sugerman HJ, Kellum Jr JM, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg. 1996;171(1):80-84. doi:10.1016/S0002-9610(99)80078-6.
  9. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407-414. doi:10.1007/s10029-009-0518-x.
  10. Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia. 2000;4(1):7-11. doi:10.1007/BF01230581.
  11. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ. 2012;344:e2843. doi:10.1136/bmj.e2843.
  12. Blatnik JA, Michael Brunt L. Controversies and techniques in the repair of abdominal wall hernias. J Gastrointest Surg. 2019;23(4):837-845. doi:10.1007/s11605-018-3989-1.
  13. Bittner R, Bain K, Bansal VK, et al. Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))—Part A. Surg Endosc. 2019;33(10):3069-3139. doi:10.1007/s00464-019-06907-7.
  14. Kaoutzanis C, Leichtle SW, Mouawad NJ, et al. Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair. Hernia. 2015;19:113-123. doi:10.1007/s10029-013-1155-y.
  15. Delaney LD, Howard R, Palazzolo K, et al. Outcomes of a presurgical optimization program for elective hernia repairs among high-risk patients. JAMA Netw Open. 2021;4(11):e2130016-e2130016. doi:10.1001/jamanetworkopen.2021.30016.
  16. Birindelli A, Sartelli M, di Saverio S, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017;12(1):37. doi:10.1186/s13017-017-0149-y.
  17. Menzo E lo, Hinojosa M, Carbonell A, Krpata D, Carter J, Rogers AM. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis. 2018;14(9):1221-1232. doi:10.1016/j.soard.2018.07.005.
  18. Petro CC, Haskins IN, Perez AJ, et al. Hernia repair in patients with chronic liver disease - A 15-year single-center experience. Am J Surg. 2019;217(1):59-65. doi:10.1016/j.amjsurg.2018.10.020.
  19. Wai PY, Ruby JA, Davis KA, Roberts AC, Roberts KE. Laparoscopic ventral hernia repair during pregnancy. Hernia. 2009;13(5):559. doi:10.1007/s10029-009-0476-3.
  20. Jensen KK, Henriksen NA, Jorgensen LN. Abdominal wall hernia and pregnancy: a systematic review. Hernia. 2015;19(5):689-696. doi:10.1007/s10029-015-1373-6.
  21. Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519-26. doi:10.1097/00006534-199009000-00023.
  22. Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction: lessons learned from 200 “components separation” procedures. Arch Surg. 2009;144(11):1047-1055. doi:10.1001/archsurg.2009.192.
  23. O’Connor SC, Carbonell AM. Management of post-operative complications in open ventral hernia repair. Plast Aesthet Res. 2019;6:26. doi:10.20517/2347-9264.2019.38.
  24. Morales-Conde S. A new classification for seroma after laparoscopic ventral hernia repair. Hernia. 2012;16:261-267. doi:10.1007/s10029-012-0911-8.
  25. White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. 1998;64(3):276.
  26. Elhage SA, Marturano MN, Prasad T, et al. Impact of perforator sparing on anterior component separation outcomes in open abdominal wall reconstruction. Surg Endosc. 2021;35(8):4624-4631. doi:10.1007/s00464-020-07888-8.
  27. Ghali S, Turza KC, Baumann DP, Butler CE. Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg. 2012;214(6). doi:10.1016/j.jamcollsurg.2012.02.017.
  28. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg. 2002;109(7). doi:10.1097/00006534-200206000-00016.
  29. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13(5):545-554. doi:10.1007/BF01658869.
  30. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204(5):709-716. doi:10.1016/j.amjsurg.2012.02.008.
  31. Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia. 2020;24(2):333-340. doi:10.1007/s10029-020-02150-5.
  32. Hodgkinson JD, Leo CA, Maeda Y, et al. A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias. Hernia. 2018;22(4):617-626. doi:10.1007/s10029-018-1757-5.
  33. Parent B, Horn D, Jacobson L, et al. Wound morbidity in minimally invasive anterior component separation compared to transversus abdominis release. Plast Reconstr Surg. 2017;139(2):472-479. doi:10.1097/PRS.0000000000002957.
  34. Rosen MJ, Williams C, Jin J, et al. Laparoscopic versus open-component separation: a comparative analysis in a porcine model. Am J Surg. 2007;194(3):385-389. doi:10.1016/j.amjsurg.2007.03.003.
  35. Carbonell AM, Warren JA, Prabhu AS, et al. Reducing length of stay using a robotic-assisted approach for retromuscular ventral hernia repair. Ann Surg. 2018;267(2):210-217. doi:10.1097/SLA.0000000000002244.

Cite this article

Pannu PR, Berger D. Anterior component separation for multiple incisional hernias along an upper midline incision. J Med Insight. 2023;2023(341). doi:10.24296/jomi/341.