Download Component Separation

Component Separation
By– Dr Richa Jain
Facts
• Incisional hernia occurs in 11 % to 18.7 % of patients, within
10 years after laparotomy
• Long term follow up shows that 40 % of patients with an
incisional hernia eventually become symptomatic with
incarceration and strangulation requiring emergency surgery.
Facts
• In longstanding hernia, a considerable amount of abdominal
contents will loose its “abdominal domain” due to abdominal
wall weakness and lateral retraction of the muscles.
• Morbidity of surgery is high and long term results are poor
with recurrence rates varying from 32 – 63 % after 10 years of
follow up.
Facts
• Treatment options can be divided into closing- and bridging
techniques.
• Closing techniques pursue re-approximation of the fascial
edges to reestablish the initial anatomic situation, while a
bridging technique connects these fascial edges by using a
non physiologic compound, replacing the abdominal wall at
the muscular defect.
Facts
• Introduction of prosthetic material indeed lowered the
recurrence rate of incisional hernia repair but was also
accompanied by specific complications such as chronic pain,
infection, seroma formation, fistulation, shrinkage of the
mesh.
• Despite these drawbacks, mesh repair seems the easiest and
therefore often preferred and generally applicable procedure.
CST
• In 1990 Oscar Ramirez introduced Components Separation
Method (CSM): a non-mesh functional repair in which the
external and internal oblique abdominal muscles are
separated after exposure through a midline laparotomy. By
exclusive incision of the external aponeurosis, a separation of
the external and internal oblique muscles can be realised as
far as the posterior axillary line.
CST
Component separation should be considered in the following situations:
1. Infected abdominal wall with or without mesh.
2. Patients with hernias who are also having a colostomy reversed.
3. Very large ventral hernias.
4. Multiple defects.
5. Multiple failed attempts at previous repairs.
6. Treatment or prevention of the abdominal compartment syndrome (ACS).
7. In those patients with Loss of Domain, component separation allows placement of a smaller piece of
mesh, thereby minimizing eventration
The Technique
•
Skin and subcutaneous tissue are mobilized and the aponeurosis of the
external oblique muscle incised pararectally, about 1 cm lateral to the rectus
muscle.
The Technique
•
The external and internal oblique muscles can be separated by blunt dissection
.
The Technique
•
Additionally the rectus muscle can be separated from the posterior rectus Sheath,
though it is believed to be of minor relevance, but it can contribute an additional 2
cm of medial advancement for each muscle complex
The Technique
•
Taking the external oblique out of
action can theoretically allow the
internal
and
transverse
oblique
muscles to rotate medially around its
centre of origin, thereby facilitating a
more medial and caudal translation
of the rectus muscle.
The Technique
•
Position of the retromuscular, prefascial mesh after performing the CSM.
The Technique
•
In patients with an enterostomy, the technique
described cannot be followed, first, because the
vascularization of the skin is endangered and,
second, because no release of the posterior
rectus
sheath
can
be
performed.
As
an
alternative, transection of the external oblique
aponeurosis is performed through a separate skin
incision lateral aspect of the rectus abdominis
muscle. Mobilization of the posterior sheath of
the rectus abdominis muscle should not be
performed in these cases.
The Technique
The Technique
•
Publications on the results of the CSM
Modified Sandwich Technique
• The sandwich technique was originally described in 1988 by
Guarneri et al, isolates prosthetic mesh from the bowel to
prevent adhesions by placing it between the peritoneum and
abdominal wall.
Contd…
• A modification of this technique that combines components
separation closure of the midline, to reconstitute the
abdominal wall myofascial system, with a biologic underlay as
well as onlay mesh to the midline repair. The underlay mesh
may
be
placed
intraperitoneally
depending on preference.
or
retromuscularly,
MICSIB
• In traditional, open component separation, the surgeon accesses external
oblique aponeurosis by elevating the skin flaps over the entire rectus
abdominis muscle, thus separating the subcutaneous fat from the anterior
rectus sheath and dissecting the rectus abdominis myocutaneous perforator.
However, elevating the skin flaps results in subcutaneous dead space, which
can lead to seromas and infections, and the reduced blood flow caused by
cutting the perforator vessels inhibits wound healing.
MICSIB
MICSIB
• Minimally invasive component separation with inlay bioprosthetic mesh
(MICSIB) uses tunnel incisions for external oblique aponeurosis release. It
preserves both the rectus abdominis myocutaneous perforator vessels
that supply the overlying skin and the connection between the
subcutaneous fat and anterior rectus sheath, thereby reducing
subcutaneous dead space and potentially improving overlying skin flap
vascularity. Inlay bioprosthetic mesh reinforces the musculofascial repair.
MICSIB
Traditional CST
MI CST
Lap CST
• The search for an ideal procedure which has merits of CST
while less complications of dissection culminated into
development of laproscopic approach for CST.
Lap CST
Lap CST
• This Approach approach involves a small incision at the costal
margin lateral to the rectus abdominis muscle. The external
oblique is exposed and incised. After exposure of the internal
oblique muscle, a potential space is created using a balloon
dissector between the two oblique muscles to the level of the
inguinal ligament. A second lateral abdominal wall port is placed
that allows for release of the external oblique.
Bilateral anterior rectus sheath
turnover flap
• Koshimoto S et al used anterior rectus sheath turnover flap
for abdominal closure in patients with open abdomen.
• Anterior rectus sheath is incised about 5-6 cm lateral to
midline bilaterally. Rectus sheath is dissected and freed from
underlying rectus muscle. Free rectus sheath flaps are turned
and sutured.
Contd…
Rectus Abdominis Myofascial Splitting
Flap
• If a chronic wound is accompanied by infection, a great deal
of time and effort are necessary for treatment because the
normal wound healing mechanism could be hindered and the
inflammatory reaction could be distorted
Contd…
• If chronic wound infection is treated by surgery using a
myofascial splitting flap, bacterial clearance would be
increased due to the ample blood supply from vessels
distributed on the muscle pedicle, and also the chronic
infected wound would be effectively controlled due to an
increased metabolic turnover rate of the tissue
Contd…
•
A portion of the rectus abdominis muscle that could sufficiently cover the defect size is elevated
along with the anterior muscle sheath, and then the elevated muscle is turned over toward the
midline, by turning over the anterior rectus sheath along with the rectus abdominis muscle, a
horizontal mattress suture was made.
Contd…
•
On the bilateral ends of the overlapping part, an interrupted suture is made.
Contd…
•
The skin and subcutaneous tissue are sutured after confirming circulation by visual
inspection or Doppler.
Robotic Rives Stoppa With Bilateral
Posterior Component Separation
Thank You