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Transversus Abdominis Release as an Alternative Component Separation Technique for Ventral Hernia Repair

Transversus Abdominis Release as an Alternative Component Separation Technique for Ventral Hernia... What Is the Innovation? The use of myofascial advancement flaps, or component separation technique, dates back more than 25 years. The most commonly mentioned approach is that of Ramirez et al1 from 1990 in which the external abdominal oblique (EO) musculature is divided as a method of providing midline abdominal muscle advancement of up to 10 cm bilaterally. Although effective in rectus muscle medialization, anterior component separation technique requires creation of large, often morbid, lipocutaneous flaps. The Rives-Stoppa retromuscular reconstruction is effective, but it is not applicable for larger defects. Transversus abdominis release (TAR) is the most recent technique to address limitations of traditional reconstructive options. In contrast to creating large skin flaps to access and divide the EO muscle, TAR begins by entering the posterior rectus sheath (Figure). This dissection is carried laterally to 1 cm medial of the linea semilunaris. The posterior rectus sheath is then divided just medial to the neurovascular perforators and linea semilunaris. The underlying fibers of the transversus abdominis muscle are identified and divided to enter a retromuscular/preperitoneal plane. This dissection is then carried out lateral to the psoas muscle. Once this is repeated bilaterally, the posterior rectus sheath is then closed in the midline, completely isolating the visceral contents from any prosthetic mesh. At this stage, there is a space for the placement of a large piece of mesh, reinforcing the entire visceral sac. The type of mesh varies depending on the type of hernia repair. Midweight macroporous mesh is typically selected for midline defects where muscle closure can be obtained. Flank hernias and those for which fascial closure is difficult may benefit from a heavyweight mesh. However, data on how this affects outcomes are unavailable. Drains are placed over the mesh to minimize seroma formation. The drains are removed after the output has decreased to less than 30 to 50 mL/d. Following mesh implantation, the rectus muscle and anterior rectus sheath are closed over the mesh, restoring the midline and recreating a functional abdominal wall.2,3 What Are the Key Advantages Over Existing Approaches? Initial approaches to component separation technique required large skin flaps to access the EO muscle, which was then divided from the costal margin to the pubis to allow for medialization of the abdominal musculature. Although highly effective at restoring the midline, this approach was associated with high wound morbidity due to the skin flaps and also limited options for placement of mesh reinforcement to onlay or underlay. Several variations on this approach have been described, including perforator sparing, minimally invasive approaches, and endoscopic approaches.4 Although these approaches minimize wound morbidity, the challenge of where to place the mesh remains. In contrast to EO release, TAR does not require the creation of large skin flaps, thereby reducing the occurrence of wound morbidity.5 In addition, after TAR is completed, the posterior rectus sheath is closed, excluding the bowel from contact with the mesh. This allows for the placement of a large piece of synthetic mesh to reinforce the entire visceral sac. Furthermore, the risk of bowel herniation around the edge of the mesh, which exists when placed in an underlay, is no longer a factor. Finally, with native tissue apposition on both sides of the mesh, the risk for mesh infection may be reduced in comparison with other reinforcement techniques. In the event of mesh contamination, the technique may have an increased rate of mesh salvage with antibiotics if necessary. How Will This Impact Clinical Care? As is evident in the literature, there is little consensus on the ideal repair technique for ventral hernias, and the approach used is often tailored to the patient and type of hernia (recurrent, incisional, parastomal, flank, etc). In contrast, TAR can be applied to nearly every size and type of hernia with promising results. However, it may not be necessary for all patients, especially those with small to medium-sized hernia defects that can be repaired with a Rives-Stoppa or laparoscopic approach. Additionally, many patients continue to undergo EO release and subsequently develop a recurrence. The TAR technique can be applied to these extremely challenging cases with success.6 Finally, ongoing research is being performed to evaluate the role of robotic, minimally invasive TAR for hernia repair. Is There Evidence Supporting the Benefits of the Innovation? There is increasing evidence to support TAR as a viable and versatile technique for the repair of incisional hernias. Although there are no prospective randomized trials comparing it with alternative techniques, several series of TAR have recently been published.3,5,7 Certainly as this technique continues to gain widespread acceptance and use, more long-term results regarding morbidity and hernia recurrence rates will be reported. What Are the Barriers to Implementing This Innovation More Broadly? There are few barriers to implementing TAR more broadly; however, the greatest barriers are education and experience. As with any new surgical technique, time will allow us to define a learning curve. For those unfamiliar with this approach, there are certainly pitfalls that can drastically affect the success of this surgery; with experience, though, these can be overcome easily. These include division of incorrect layers, inability to close the posterior rectus sheath, and division of perforating nerves or inferior epigastric vessels. Additionally, patient selection is paramount to limit use of this reconstructive technique to the appropriate patients. Identifying which patients require TAR and who may be better served with other, less invasive options is ongoing. In general, we recommend that patients with smaller defects or limited activity may not require such invasive repair. In What Time Frame Will This Innovation Likely Be Applied Routinely? The time frame in which TAR is applied routinely relates more to surgeons coming to a conclusion about the best approach to complex ventral hernia repair. The TAR technique is readily available to be learned and implemented. For those who perform Rives-Stoppa repair, the learning curve for TAR should be about 5 cases. For others, after careful review of the procedural steps and instructional videos, the learning curve should be about 10 to 15 cases. Live demonstrations and proctoring have proven to be of benefit. Section Editor: Justin B. Dimick, MD, MPH. Submissions: Authors should contact Justin B. Dimick, MD, MPH, at jdimick@med.umich.edu if they wish to submit Surgical Innovation papers. Back to top Article Information Corresponding Author: Jeffrey A. Blatnik, MD, Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8109, St Louis, MO 63110 (blatnikj@wudosis.wustl.edu). Published Online: February 17, 2016. doi:10.1001/jamasurg.2015.3611. Conflict of Interest Disclosures: Dr Blatnik reported serving as a consultant for CR Bard and Medtronic. Dr Novitsky reported serving as a consultant for CR Bard, Lifecell, and Cooper Surgical. No other disclosures were reported. Funding/Support: Dr Blatnik is supported by a teaching stipend from Synapse Biomedical. Role of the Funder/Sponsor: Synapse Biomedical had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. References 1. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86(3):519-526.PubMedGoogle ScholarCrossref 2. Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia. 2008;12(4):359-362.PubMedGoogle ScholarCrossref 3. 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.PubMedGoogle ScholarCrossref 4. Jensen KK, Henriksen NA, Jorgensen LN. Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and meta-analysis. Surg Endosc. 2014;28(11):3046-3052.PubMedGoogle ScholarCrossref 5. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: a comparative analysis. Am J Surg. 2012;203(3):318-322.PubMedGoogle ScholarCrossref 6. Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ. Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia. 2015;19(2):285-291.PubMedGoogle ScholarCrossref 7. Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg. 2013;217(6):991-998.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Transversus Abdominis Release as an Alternative Component Separation Technique for Ventral Hernia Repair

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
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2168-6254
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2168-6262
DOI
10.1001/jamasurg.2015.3611
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Abstract

What Is the Innovation? The use of myofascial advancement flaps, or component separation technique, dates back more than 25 years. The most commonly mentioned approach is that of Ramirez et al1 from 1990 in which the external abdominal oblique (EO) musculature is divided as a method of providing midline abdominal muscle advancement of up to 10 cm bilaterally. Although effective in rectus muscle medialization, anterior component separation technique requires creation of large, often morbid, lipocutaneous flaps. The Rives-Stoppa retromuscular reconstruction is effective, but it is not applicable for larger defects. Transversus abdominis release (TAR) is the most recent technique to address limitations of traditional reconstructive options. In contrast to creating large skin flaps to access and divide the EO muscle, TAR begins by entering the posterior rectus sheath (Figure). This dissection is carried laterally to 1 cm medial of the linea semilunaris. The posterior rectus sheath is then divided just medial to the neurovascular perforators and linea semilunaris. The underlying fibers of the transversus abdominis muscle are identified and divided to enter a retromuscular/preperitoneal plane. This dissection is then carried out lateral to the psoas muscle. Once this is repeated bilaterally, the posterior rectus sheath is then closed in the midline, completely isolating the visceral contents from any prosthetic mesh. At this stage, there is a space for the placement of a large piece of mesh, reinforcing the entire visceral sac. The type of mesh varies depending on the type of hernia repair. Midweight macroporous mesh is typically selected for midline defects where muscle closure can be obtained. Flank hernias and those for which fascial closure is difficult may benefit from a heavyweight mesh. However, data on how this affects outcomes are unavailable. Drains are placed over the mesh to minimize seroma formation. The drains are removed after the output has decreased to less than 30 to 50 mL/d. Following mesh implantation, the rectus muscle and anterior rectus sheath are closed over the mesh, restoring the midline and recreating a functional abdominal wall.2,3 What Are the Key Advantages Over Existing Approaches? Initial approaches to component separation technique required large skin flaps to access the EO muscle, which was then divided from the costal margin to the pubis to allow for medialization of the abdominal musculature. Although highly effective at restoring the midline, this approach was associated with high wound morbidity due to the skin flaps and also limited options for placement of mesh reinforcement to onlay or underlay. Several variations on this approach have been described, including perforator sparing, minimally invasive approaches, and endoscopic approaches.4 Although these approaches minimize wound morbidity, the challenge of where to place the mesh remains. In contrast to EO release, TAR does not require the creation of large skin flaps, thereby reducing the occurrence of wound morbidity.5 In addition, after TAR is completed, the posterior rectus sheath is closed, excluding the bowel from contact with the mesh. This allows for the placement of a large piece of synthetic mesh to reinforce the entire visceral sac. Furthermore, the risk of bowel herniation around the edge of the mesh, which exists when placed in an underlay, is no longer a factor. Finally, with native tissue apposition on both sides of the mesh, the risk for mesh infection may be reduced in comparison with other reinforcement techniques. In the event of mesh contamination, the technique may have an increased rate of mesh salvage with antibiotics if necessary. How Will This Impact Clinical Care? As is evident in the literature, there is little consensus on the ideal repair technique for ventral hernias, and the approach used is often tailored to the patient and type of hernia (recurrent, incisional, parastomal, flank, etc). In contrast, TAR can be applied to nearly every size and type of hernia with promising results. However, it may not be necessary for all patients, especially those with small to medium-sized hernia defects that can be repaired with a Rives-Stoppa or laparoscopic approach. Additionally, many patients continue to undergo EO release and subsequently develop a recurrence. The TAR technique can be applied to these extremely challenging cases with success.6 Finally, ongoing research is being performed to evaluate the role of robotic, minimally invasive TAR for hernia repair. Is There Evidence Supporting the Benefits of the Innovation? There is increasing evidence to support TAR as a viable and versatile technique for the repair of incisional hernias. Although there are no prospective randomized trials comparing it with alternative techniques, several series of TAR have recently been published.3,5,7 Certainly as this technique continues to gain widespread acceptance and use, more long-term results regarding morbidity and hernia recurrence rates will be reported. What Are the Barriers to Implementing This Innovation More Broadly? There are few barriers to implementing TAR more broadly; however, the greatest barriers are education and experience. As with any new surgical technique, time will allow us to define a learning curve. For those unfamiliar with this approach, there are certainly pitfalls that can drastically affect the success of this surgery; with experience, though, these can be overcome easily. These include division of incorrect layers, inability to close the posterior rectus sheath, and division of perforating nerves or inferior epigastric vessels. Additionally, patient selection is paramount to limit use of this reconstructive technique to the appropriate patients. Identifying which patients require TAR and who may be better served with other, less invasive options is ongoing. In general, we recommend that patients with smaller defects or limited activity may not require such invasive repair. In What Time Frame Will This Innovation Likely Be Applied Routinely? The time frame in which TAR is applied routinely relates more to surgeons coming to a conclusion about the best approach to complex ventral hernia repair. The TAR technique is readily available to be learned and implemented. For those who perform Rives-Stoppa repair, the learning curve for TAR should be about 5 cases. For others, after careful review of the procedural steps and instructional videos, the learning curve should be about 10 to 15 cases. Live demonstrations and proctoring have proven to be of benefit. Section Editor: Justin B. Dimick, MD, MPH. Submissions: Authors should contact Justin B. Dimick, MD, MPH, at jdimick@med.umich.edu if they wish to submit Surgical Innovation papers. Back to top Article Information Corresponding Author: Jeffrey A. Blatnik, MD, Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8109, St Louis, MO 63110 (blatnikj@wudosis.wustl.edu). Published Online: February 17, 2016. doi:10.1001/jamasurg.2015.3611. Conflict of Interest Disclosures: Dr Blatnik reported serving as a consultant for CR Bard and Medtronic. Dr Novitsky reported serving as a consultant for CR Bard, Lifecell, and Cooper Surgical. No other disclosures were reported. Funding/Support: Dr Blatnik is supported by a teaching stipend from Synapse Biomedical. Role of the Funder/Sponsor: Synapse Biomedical had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. References 1. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86(3):519-526.PubMedGoogle ScholarCrossref 2. Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia. 2008;12(4):359-362.PubMedGoogle ScholarCrossref 3. 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.PubMedGoogle ScholarCrossref 4. Jensen KK, Henriksen NA, Jorgensen LN. Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and meta-analysis. Surg Endosc. 2014;28(11):3046-3052.PubMedGoogle ScholarCrossref 5. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: a comparative analysis. Am J Surg. 2012;203(3):318-322.PubMedGoogle ScholarCrossref 6. Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ. Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia. 2015;19(2):285-291.PubMedGoogle ScholarCrossref 7. Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg. 2013;217(6):991-998.PubMedGoogle ScholarCrossref

Journal

JAMA Surgery – American Medical Association

Published: Apr 1, 2016

Keywords: reconstructive surgical procedures,surgical flaps,transversus abdominis muscle,abdominal surgery,ventral hernia repair

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