Open Incisional Hernia Repair with Mesh and Unilateral Posterior Component Separation with Excision of Unstable Scar

Abstract

Yuri Novitsky's description of the posterior component separation in 2012 has revolutionized the world of ventral hernia repairs.¹ While large hernia defects above 10 to 12 centimeters seemed impossible to close primarily without tension, the technique of transversus abdominis release as described helped achieve posture as well as anterior abdominal wall closure without tension in addition to providing a highly vascularized medium for mesh integration in between these layers. Not only does the posterior component separation allow for medialization of the posterior rectus sheath to be closed in the midline, but it also gives a release to the anterior components of the abdominal wall to allow for recreation of the linea alba without tension.

Keywords

Posterior component separation; TAR; large hernia defects.

Case Overview

Background

Since its original description in 2012 by Dr. Novitsky et al., the posterior component separation technique has revolutionized the world of complex abdominal wall reconstruction. This technique in our opinion is essential in the armamentarium of surgeons that are faced with challenging complex abdominal hernias. In our experience it invariably allows the surgeon to handle large complex defects and achieve a full abdominal wall reconstruction and restoration of the abdominal wall anatomy as close to normal as possible. This technique also allows for placement of a retromuscular mesh with wide overlap in order to reinforce the repair. The location of the mesh also serves as a well vascularized plane to allow for better mesh integration. This provides a very durable repair and reduces morbidity from the procedure.² We caution surgeons about adopting this technique without proper knowledge of abdominal anatomy and training. This video serves as a demonstration for performing a unilateral posterior component separation.

Focused History of the Patient

This was a 55-year-old male patient with a previous history of Roux-en-Y gastric bypass several years prior to presentation. This was complicated by a strangulated internal hernia requiring a laparotomy and small bowel resection. Subsequently the patient developed an incisional hernia in the midline, which was previously repaired using a biological mesh. The patient subsequently developed a hernia recurrence, which was causing him symptoms and impairing his quality of life in addition to an unstable scar over the midline as well as excess skin due to his weight loss procedure.

Physical Exam

This revealed a large ventral hernia defect, which is reducible and as well as an unstable midline scar. There was additional excess skin in the lower abdomen.

Imaging

A preoperative CT scan showed evidence of a 9.5-cm defect containing the small intestine. The retromuscular space measured 8 cm on each side.

Options for Treatment

The main discussion points with this patient is to pursue either a minimally-invasive robotic repair versus an open repair. Due to his previous midline unstable scar as well as the excess skin the patient elected to pursue an open repair in order to obtain a better aesthetic result with performing a panniculectomy as well as excision of the midline scar. Most of the time these large hernia repairs are approached in a minimally-invasive fashion, which improves patient recovery and decreases length of stay as well as reducing wound morbidity; however, the choice of the approach in this particular patient was affected by his decision to obtain an aesthetic procedure at the same time.³

Rationale for Treatment

As mentioned in the video, usually hernia defects up to five to six centimeters could be closed primarily followed by mesh augmentation. Once the defect size reaches 7 to 10 centimeters, the patient would likely need to have a retromuscular repair. Once a defect size reaches 10 to 12 centimeters, usually the patient would need a unilateral or bilateral posterior component separation in order to close the defect without tension and provide adequate mesh overlap. Since our patient had a defect that was about 9.5 centimeters, we discussed pursuing a retromuscular repair versus a unilateral or bilateral posterior component separation based on the tension of closure of the abdominal wall which would be determined intraoperatively.⁴

Special Considerations

In patients undergoing abdominal wall reconstruction procedure, it is very important to consider preoperative optimization especially if the patient has comorbidities such as diabetes or smoking. We do not advise pursuing these extensive procedures for patients who have uncontrolled diabetes or are current smokers prior to preoperative optimization. In addition, these patients will need preoperative as well as postoperative abdominal wall rehab with physical therapy in order to regain the strength of the abdominal wall. Furthermore, it is always advisable to consider preoperative botox injection into the lateral abdominal wall muscles. This was shown to reduce the need for a component separation in some instances as it allows for closure of the defect without tension.⁵

Discussion

Posterior component separation is a salvage technique that should be in the armamentarium of any abdominal wall reconstruction surgeon. We do caution surgeons that are hoping to learn and practice this technique to learn the anatomy and the steps of the procedure from an expert in order to allow its utilization without morbidity to their patients. As mentioned in the video several times, the anatomical landmarks are important to learn in order to avoid morbidity to the abdominal wall. There are several courses and educational videos available that go through the steps of this procedure. We also advise that all abdominal wall reconstruction surgeons have a step ladder approach through their repairs and only use this technique if it's absolutely needed for their patient.

Equipment

Nothing special apart from the instruments and sutures used and mentioned in the video.

Disclosures

• Proctor and consultant for Intuitive Surgical Inc.
• Share Holder at IHC Inc.

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.

Acknowledgments

I would like to acknowledge Dr. Wesley Bean, from plastic surgery and Kendal Towle, ARNP for assisting and participating in this procedure.