Abdominal wall dynamics after component separation hernia repair

Component Separation Decreases Hernia Recurrence Rates in Abdominal Wall Reconstruction with Biologic Mesh

BACKGROUND

It is not clear whether mesh-reinforced anterior component separation (CS) for abdominal wall reconstruction (AWR) results in better outcomes than mesh-reinforced primary fascial closure (PFC) without CS, particularly when acellular dermal matrix is used. The authors compared outcomes of CS versus PFC repair in AWR procedures aiming to determine whether CS results in better outcomes.

METHODS

This retrospective study of prospectively collected data included 461 patients who underwent AWR with acellular dermal matrix during a 10-year period at an academic cancer center. The primary endpoint was hernia recurrence; the secondary outcome was surgical-site occurrence (SSO).

RESULTS

A total of 322 patients (69.9%) who underwent mesh-reinforced AWR with CS (AWR-CS) and 139 (30.1%) who underwent AWR with PFC (AWR-PFC) without CS were compared. AWR-PFC repairs had a higher hernia recurrence rate than AWR-CS repairs (10.8% versus 5.3%; P = 0.002) but similar overall complication (28.8% versus 31.4%; P = 0.580) and SSO (18.7% versus 25.2%; P = 0.132) rates. CS repairs experienced significantly higher wound separation (17.7% versus 7.9%; P = 0.007), fat necrosis (8.7% versus 2.9%; P = 0.027), and seroma (5.6% versus 1.4%; P = 0.047) rates than PFC repairs. The best cutoff with respect to hernia recurrence was 7.1 cm of abdominal defect width.

CONCLUSION

AWR-CS repair resulted in a lower hernia recurrence rate than AWR-PFC but, despite the additional surgery, had similar SSO rates on long-term follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A comparative study to evaluate abdominal wall dynamics in patients with incisional hernia compared to healthy controls

BACKGROUND

Incisional hernia is a common complication following abdominal surgery. It causes change in function of core abdominal muscles leading to change in abdominal wall dynamics. This study aims to objectively measure and compare preoperative abdominal wall dynamics with surface electromyography (sEMG) in incisional hernia patients with healthy individuals.

MATERIALS AND METHODS

In this prospective comparative study, two groups of participants as cases and controls were evaluated for their abdominal wall dynamics by using sEMG. Both cases and controls were evenly matched in terms of age and gender. Statistical analysis was done with STATA 14.1 and p value of < 0.05 was considered significant.

RESULTS

Demographic profile was comparable between the two groups. Mean BMI of cases was higher than controls. The most common index procedure was lower segment cesarean section. The strength and power of all three abdominal wall muscles (rectus abdominis, external oblique, internal oblique) were significantly diminished among cases compared to controls.

CONCLUSIONS

Abdominal wall dynamics can be objectively and correctly interpreted from sEMG of abdominal wall core muscles in patients with incisional hernia. This study shows that there is a decrease in abdominal wall strength and power in patients suffering from incisional hernia in comparison with healthy controls.

Analysis of Superficial Subcutaneous Fat Camper's and Scarpa's Fascia in a United States Cohort

Together, the Camper's and Scarpa's fasciae form the superficial fat layer of the abdominal wall. Though they have clinical and surgical relevance, little is known about their role in body composition across diverse patient populations. This study aimed to determine the relationship between patient characteristics, including sex and body mass index, and the distribution of Camper's and Scarpa's fascial layers in the abdominal wall. A total of 458 patients' abdominal CT examinations were segmented via CoreSlicer 1.0 to determine the surface area of each patient's Camper's, Scarpa's, and visceral fascia layers. The reproducibility of segmentation was corroborated by an inter-rater analysis of segmented data for 20 randomly chosen patients divided between three study investigators. Pearson correlation and Student's t-test analyses were performed to characterize the relationship between fascia distribution and demographic factors. The ratios of Camper's fascia, both as a proportion of superficial fat (r = -0.44 and p < 0.0001) and as a proportion of total body fat (r = -0.34 and p < 0.0001), showed statistically significant negative correlations with BMI. In contrast, the ratios of Scarpa's fascia, both as a proportion of superficial fat (r = 0.44 and p < 0.0001) and as a proportion of total body fat (r = 0.41 and p < 0.0001), exhibited statistically significant positive correlations with BMI. Between sexes, the females had a higher ratio of Scarpa's facia to total body fat compared to the males (36.9% vs. 31% and p < 0.0001). The ICC values for the visceral fat, Scarpa fascia, and Camper fascia were 0.995, 0.991, and 0.995, respectively, which were all within the 'almost perfect' range (ICC = 0.81-1.00). These findings contribute novel insights by revealing that as BMI increases the proportion of Camper's fascia decreases, while the ratio of Scarpa's fascia increases. Such insights expand the scope of body composition studies, which typically focus solely on superficial and visceral fat ratios.

Posterior component separation with TAR: lessons learned from our first consecutive 52 cases

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m²) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6-30) and mean defect area was about 267.9 cm². Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm² and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm² was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Morphological alterations of the abdominal wall after open incisional hernia repair with endoscopic anterior and open posterior component separation

PURPOSE

Effects of component separation (CS) on abdominal wall morphology have only been investigated in smaller case series or cadavers. This study aimed to compare abdominal wall alterations following endoscopic anterior CS (EACS) or open transverse abdominis release (TAR).

METHODS

Computed tomography scans were evaluated in patients who had undergone open incisional hernia repair with EACS or TAR. Abdominal wall circumference, lateral abdominal wall muscle thickness, and displacement were compared with (1) preoperative images after bilateral CS and (2) the undivided side postoperatively after unilateral CS.

RESULTS

In total, 105 patients were included. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm, P < 0.001) and 0.82 cm (0.07-1.57 cm, P = 0.032) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% (5.8-15.6%, P < 0.001)) and insignificantly decreased after TAR (mean decrease 2.6% (- 4.8 to 9.5%, P = 0.50)). The abdominal wall circumference was unchanged after bilateral (mean reduction 0.90 cm (- 0.77 to 2.58 cm), P = 0.29) and unilateral CS (mean increase 0.03 cm (- 1.01 to 1.08 cm), P = 0.95).

CONCLUSION

Postoperative changes in the lateral abdominal wall musculature were different following EACS and open TAR. Either technique seems not to compromise the overall integrity of the lateral abdominal wall.

Traumatic abdominal wall hernia and Morel-Lavallee lesion in a pediatric patient

Traumatic abdominal wall hernias and abdominal Morel-Lavallee lesions rarely occur in blunt abdominal trauma. There are only a few documented cases of these occurring simultaneously, especially in the pediatric population. We report a case of a 15-year-old boy with a concomitant traumatic abdominal wall hernia and Morel-Lavallee lesions. Abdominal wall reconstruction was performed successfully via the collaboration of trauma, minimally invasive surgery, and plastic surgery teams.

Changes in the abdominal wall after anterior, posterior, and combined component separation

KEY MESSAGE

Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review.  Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Botulinum Toxin in the Surgical Treatment of Complex Abdominal Hernias: A Surgical Anatomy Approach, Current Evidence and Outcomes

BACKGROUND/AIM

Abdominal wall hernias represent a common problem in surgical practice. A significant proportion of them entails large defects, often difficult to primarily close without advanced techniques. Injection of botulinum toxin preoperatively at specific points targeting lateral abdominal wall musculature has been recently introduced as an adjunct in achieving primary fascia closure rates.

MATERIALS AND METHODS

A literature search was conducted investigating the role of botulinum toxin in abdominal wall reconstruction focusing on anatomic repair of hernia defects.

RESULTS

Injecting botulinum toxin preoperatively achieved chemical short-term paralysis of the lateral abdominal wall muscles, enabling a tension-free closure of the midline, which according to anatomic and clinical studies should be the goal of hernia repair. No significant complications from botulinum injections for complex hernias were reported.

CONCLUSION

Botulinum is a significant adjunct to complex abdominal wall reconstruction. Further studies are needed to standardize protocols and create more evidence.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

Dietary Protein Supplementation Helps in Muscle Thickness Regain after Abdominal Wall Reconstruction for Incisional Hernia

A modern approach to incisional hernia is oriented toward midline restoration to re-establish abdominal wall physiology and to restore muscular strength. A high-protein diet has been demonstrated to improve muscle function and mass. The aim of this prospective study was to evaluate the effect of a high-protein diet on abdominal muscle remodeling in patients submitted to abdominal wall reconstruction (AWR). Forty-five patients submitted to elective AWR were prospectively divided into two groups depending on pre- and postoperative daily protein assumption: Group A patients were submitted to a standard 2300 kcal diet with 103 g of protein intake (males) and 1800 kcal diet with 80 g of protein intake (females) starting one month before surgery and lasting for three months postoperatively; Group B patients were submitted to the same dietary regimen plus 34 g of purified proteins daily. Patients underwent ultrasound scan preoperatively and three and six months after surgery, to evaluate the widest thickness of the rectus abdominis muscle on the transverse umbilical line. Three patients reporting hernia recurrence were excluded. No significant difference among the two groups in muscle thickness growth after surgery was observed at three months after surgery, even if a favorable trend in Group B was noted (10% vs 19%, P = not significant). At six months after surgery, Group B patients showed a significant difference in muscle thickening (13% vs 32%, P < 0.05). The study demonstrates a positive effect of a protein diet on the rectus abdominis muscle thickening after AWR. Further studies are needed.

Conventional versus endoscopic components separation technique: New anthropometric calculation for selection of surgical approach

Background/aim

Giant ventral incisional hernias (GVIHs) are hard to manage for surgeons. This problem was resolved in 1990 with the components separation technique (CST). We aimed to compare endoscopic and conventional CST for GVIHs and find a new anthropometric calculation.

Materials and methods

In this prospective nonrandomized clinical trial, 21 patients were treated with endoscopic or conventional CST between 2012 and 2016. Eight patients (38.1%) were operated endoscopically and 13 (61.9%) conventionally on the basis of preoperative tomography results, hernia surface area (HSA), number of recent abdominal operations, comorbidities, and the presence or history of ostomy. Groups in which prosthetic material was applied were also compared with groups in which it was not.

Results

There was no statistically significant difference between endoscopic and conventional CST groups in terms of complications. A weakly statistically significant difference (P = 0.069) was found between the components separation index (CSI) of mesh-applied and not-applied patients. HSA/body surface area (BSA) was statistically significantly different between endoscopic and conventional CST groups.

Conclusion

According to our results, HSA/BSA and CSI are statistically successful for preoperative prediction of mesh placement. Furthermore, HSA/BSA preoperatively successfully predicts whether conventional or endoscopic CST should be used in patients with GVIH.

Visceral obesity is a significant risk factor for incisional hernia after laparoscopic colorectal surgery: A single-center review

INTRODUCTION

Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery.

METHODS

The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve.

RESULTS

Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P < 0.01), VFA (P = 0.02), and BMI >25 kg/m² (P < 0.01) were significant risk factors for incisional hernia. The predictive cut-off values were as follows: age, 72 years; subcutaneous fat area, 110 cm² ; VFA, 110 cm² ; and albumin concentration, 3.9 g/dL. On multivariate analysis, a VFA >110 cm² (P < 0.01) and female sex (P = 0.01) were retained as independent risk factors for incisional hernia.

CONCLUSION

After laparoscopic colorectal cancer surgery, a higher VFA and female sex are independent risk factors for incisional hernia.

Incisional Hernia Repair: What the Radiologist Needs to Know

OBJECTIVE

Incisional hernias are becoming more prevalent with increases in the obesity of the population and the complexity of abdominal surgeries. Radiologists' understanding of these hernias is limited. This article examines abdominal wall anatomy, surgical techniques, the role of imaging (current and emerging), and complications from the surgical perspective, to enhance to the role of the radiologist.

CONCLUSION

Knowledge of the relevant anatomy, surgical techniques, and postoperative complications in patients with incisional hernial repair can help the radiologist improve care.

Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.

Component Separation vs. Bridged Repair for Large Ventral Hernias: A Multi-Institutional Risk-Adjusted Comparison, Systematic Review, and Meta-Analysis

BACKGROUND

Repair of large ventral hernia defects is associated with high rates of surgical site occurrences (SSO), including surgical site infection (SSI), site dehiscence, seroma, hematoma, and site necrosis. Two common operative strategies exist: Component separation (CS) with primary fascial closure and mesh reinforcement (PFC-CS) and bridged repair (mesh spanning the hernia defect). We hypothesized that: (1) ventral hernia repair (VHR) of large defects with bridged repair is associated with more SSOs than is PFC, and (2) anterior CS is associated with more SSOs than is endoscopic, perforator-sparing, or posterior CS.

METHODS

Part I of this study was a review of a multi-center database of patients who underwent VHR of a defect ≥8 cm from 2010-2011 with at least one month of follow-up. The primary outcome was SSO. The secondary outcome was recurrence. Part II of this study was a systematic review and meta-analysis of studies comparing bridged repair with PFC and studies comparing different kinds of CS.

RESULTS

A total of 108 patients were followed for a median of 16 months (range 1-50 months), of whom 84 underwent PFC-CS and 24 had bridged repairs. Unadjusted results demonstrated no differences between the groups in SSO or recurrence; however, the study was underpowered for this purpose. On meta-analysis, PFC was associated with a lower risk of SSO (odds ratio [OR] = 0.569; 95% confidence interval [CI] = 0.34-0.94) and recurrence (OR = 0.138; 95% CI = 0.08-0.23) compared with bridged repair. On multiple-treatments meta-analysis, both endoscopic and perforator-sparing CS were most likely to be the treatments with the lowest risk of SSO and recurrence.

CONCLUSIONS

Bridged repair was associated with more SSOs than was PFC, and PFC should be used whenever feasible. Endoscopic and perforator-sparing CS were associated with the fewest complications; however, these conclusions are limited by heterogeneity between studies and poor methodological quality. These results should be used to guide future trials, which should compare the risks and benefits of each CS method to determine in which setting each technique will give the best results.