Anterior Component Separation for Multiple Incisional Hernias Along an Upper Midline Incision

Abstract 

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. 

Keywords

Incisional hernia; component separation; surgical repair.

Case Overview 

Background

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.

Focused History of the Patient

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. 

Physical Exam

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. 

Natural History

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. 

Options for Treatment

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.

Rationale for Treatment

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.

Special Considerations

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  

Discussion

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.

Disclosures

Nothing to disclose.

Statement of Consent

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.