Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation

Component separation (CS) has been advocated as the technique of choice to reconstruct complex abdominal hernia defects, especially in the setting of gross contamination. However, open CS was reported to have relatively high incidences of wound complications. Minimally invasive approaches to CS were proposed by several surgeons to reduce wound morbidity. To date, there are limited comparative data between minimally invasive CS (MICS) versus open CS. In this article, we reviewed existing literature on open CS versus MICS with respect to their recurrence and complication rates. Our analysis appeared to show that MICS has comparable recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of complications after MICS, we reported our experience of using MICS to repair a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.     

The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique

Purpose  

The component separation technique for hernia repair results in significant wound morbidity due to the need for large undermining skin flaps. The endoscopic component separation technique allows for advancement of the abdominal wall while preserving the blood supply originating from the epigastric vessels. This study compares the outcomes following hernia repair utilizing these techniques.     

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

Hernia - 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...     

组织结构分离技术在疝外科中的临床应用

近年来,腹壁组织结构分离技术在国内外主要被应用于腹壁缺损的修补与腹壁重建中,特别是针对腹壁巨大缺损的修补,而联合应用腹腔镜微创技术以及人工合成补片更体现出该技术在腹壁重建中的优势.本文着重就组织结构分离技术的手术原理、适应证、优势、操作方法、并发症及相关应用进展作一综述.     

A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias

Purpose

This study aims to compare the outcomes of posterior component separation and transversus abdominis release (PCSTAR) with the open anterior component separation (OACS) technique. OACS, first described by Ramirez et al. (Plast Reconstr Surg 86(3):519–526, 1990), has become an established technique for local myofascial advancement in abdominal hernia surgery. PCSTAR, described by Novitsky et al. (Am J Surg 204(5):709–716, 2012), is being used more frequently and is rapidly becoming the technique of choice in complex ventral hernia repair.

Methods

Analysis was conducted according to PRISMA guidelines. A systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on midline ventral hernia repair were reviewed. Studies describing PCSTAR were selected and compared to matched studies describing OACS. Meta-analysis was used to compare outcomes between the two-pooled groups.

Results

Seven studies describing 281 cases of PCSTAR for midline incisional hernia using a retromuscular mesh placement were identified. Six comparable studies describing 285 cases of OACS and retromuscular mesh placement were identified from the same search. Pooled analysis demonstrated a hernia recurrence rate of 5.7% (3.0–8.5) for PCSTAR and 9.5% (4.0–14.9) for OACS. Comparative analysis demonstrated no significant difference between hernia recurrence rate (p?=?0.23). The use of bridging mesh was not significantly reduced by the use of PCSTAR (3.1%) when compared to ACS (7.5%) (p?=?0.22). No significant difference was found in wound complication rates between PCSTAR and OACS, respectively, ‘superficial’ 10.9 vs 21.6% (p?=?0.15); and ‘deep’ 9.5 vs 12.7% (p?=?0.53).

Conclusions

These data suggest PCSTAR have comparable outcomes to OACS. This analysis is limited by the lack of comparative studies and heterogenicity in the OACS group.

     

Open versus endoscopic component separation: a cost comparison

Background  

The components separation technique (CST) is performed through an open or endoscopic approach. It is unclear whether the costs associated with the endoscopic instruments outweigh any clinical benefit derived from their use and the avoidance of lipocutaneous flaps. This study aimed to compare the direct costs associated with each approach.     

Endoscopic anterior component separation: a novel technical approach

Purpose

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure.

Methods

A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach.

Results

Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8 kg/m² (median; range 21.6–42.5). Transverse width of midline defect accounted for 7 cm (median; range 4–12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n = 13) or a laparoscopic intraperitoneal onlay mesh procedure (n = 2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively.

Conclusions

Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

     

Endoscopic versus open component separation in complex abdominal wall reconstruction

Background

Open component separation has a high wound complication rate. Newer endoscopic approaches are described with no comparative trials.

Methods

A retrospective review (2005-2009) of patients undergoing open or endoscopic component separation was performed.

Results

Forty-four cases were identified (22 endoscopic; 22 open). All perioperative variables were the same except age (65 open vs 55 endoscopic; P < .05). Hospital length of stay was 11 days in the open group versus 8 days in the endoscopic group (P = .09). Wound complications were 52% in the open group versus 27% in the endoscopic group (P = .09). Wound-related interventions occurred in 45% of the open group and 33% of the endoscopic group. Hernia recurrences rates were similar (open, 32%; endoscopic, 27%; P = .99).

Conclusions

Open and endoscopic components separation have similar rates of recurrence. The endoscopic group had shorter lengths of stay and less major wound complications. The endoscopic approach may be the ideal technique for complex abdominal wall reconstruction.     

内镜组织结构分离技术治疗腹壁缺损

如何有效进行复杂腹壁缺损的修复与重建一直是困扰腹壁外科医师的一个难题，传统的组织结构分离技术虽然能够通过自体组织推进实现腹壁缺损的功能性修复，但其广泛皮瓣分离所导致的切口并发症是其重要不足。而内镜组织结构分离技术由于可保护腹壁穿支血管，因此具有并发症少、恢复快、术后住院时间短的优点。作为一种自体组织修复的重要手段，内镜组织结构分离技术必将在腹壁缺损修复重建中发挥越来越重要的作用。     

双极人工股骨头置换术后组件分离1例

正患者,男,79岁,因右股骨转子间骨折于2014年12月25日入院。入院前3年有脑梗死病史,右侧肢体偏瘫,右髋部肌力Ⅲ级,肌张力不高。于2014年12月29日在腰硬联合麻醉下行右人工双极股骨头置换术。手术采用后外侧入路,暴露股骨大小转子及股骨上段骨折处。见股骨大小转子粉碎移位,将骨折块拼凑复位,用巾钳临时固定,将股骨大小转子恢复近解剖位。于小转子上方1cm处截骨,取出股骨头,将股骨转子间     

The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysis

Hernia - The main objective was to assess the prevalence of hernia recurrence, wound complications (surgical site infections [SSI], seroma and hematoma) and mortality after anterior component...     

Ventral hernia repair with lateral component separation and onlay Biodesign graft

Background

Ventral hernia is common, complicating up to 20 % of laparotomies. Plication of the rectus sheath with lateral component separation (LCS) provides a durable repair with acceptable functional outcomes. Additional support to the anterior abdominal wall may be provided by synthetic or biological mesh. Biological grafts invoke local tissue remodeling and result in strong fibrocollagenous tissue able to support the dynamic stressor of the anterior abdominal wall. Biodesign graft is a new graft derived from porcine small-intestine submucosa. We aim to review the use of Biodesign mesh for repair of ventral hernia with LCS.

Methods

Patients underwent ventral hernia repair completed with plication of the rectus sheath, LCS, and use of an onlay Biodesign graft. Data was collected retrospectively. Key outcome measures included post-operative complications and recurrence.

Results

Twelve patients were included for analysis. Mean age was 51.2 years, with 50 % males and a median weight of 87 kg (65–111 kg). Median operative time was 210 min (147 to 278 min) and median length of stay was 4 days. At a mean follow-up of 14.0 months, 8/12 (66 %) developed seroma, 1/12 (8 %) developed abdominal wall abscess, and 1/12 (8 %) suffered flap failure requiring vacuum dressings for closure. No patients were complicated by ventral hernia recurrence.

Conclusions

Our results describe an early Australian experience of onlay Biodesign graft in the context of rectus sheath plication with LCS. We report acceptable rates of post-operative complications and recurrence.Level of evidence: IV, therapeutic study.

     

BMI: does it predict the need for component separation?

Hernia - Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher...     

成分分离技术在切口疝手术中的应用体会

目的 总结并分析成分分离技术（component separation technique,CST）在腹壁切口疝中的治疗效果.方法 回顾性分析南京大学医学院附属鼓楼医院2011年1月至2012年6月对18例切口疝患者分组进行手术治疗.结果 18例患者均顺利完成手术.清洁切口疝行＂补片修补术＋腹壁CST＂的11例患者,术后恢复良好,未复发.污染切口疝行CST修补的7例患者,术后出现血肿1例,予对症处理后恢复良好;术后6个月复发1例.二组手术时间和住院时间比较差异均有统计学意义（t=2.34、2.67,P=0.034、0.017）,二组患者血肿发生率比较差异有统计学意义（P=0.39）.结论 对于清洁切口疝,补片修补是首选方法.对于巨大切口疝,最佳的治疗方式是补片修补联合CST.对于污染切口疝,CST是一种有效治疗手段.     

A single institutional comparison of endoscopic and open abdominal component separation

Background

The authors analyzed surgical factors and outcomes data in the largest single institutional study comparing endoscopic (ECS) and open component separation (OCS) in ventral hernia repairs (VHR).

Methods

A prospectively maintained database was reviewed, identifying 76 patients who underwent component separation for VHR with mesh from 2010 to 2013: 34 OCS and 42 ECS. Comparisons were made for demographics, surgical risk factors, and peri-operative outcomes. Wound complications and hernia occurrence post-operatively were reviewed. Risk analyses were performed to determine the association of pre-operative risk factors with surgical site occurrences.

Results

Twenty-five ECS patients underwent subsequent laparoscopic hernia repair, and 17 underwent open repair. Operative time for ECS was longer than OCS (334 vs. 239 min; P < 0.001); however, there was no difference in length of stay (4 days in both groups, P = 0.64) and estimated blood loss (ECS: 97 vs. OCS: 93 cc, P = 0.847). In a sub-analysis of ECS patients, those who underwent laparoscopic hernia repair had a 96 min shorter operative time (P < 0.001) and lower EBL (63 vs. 147 cc, P < 0.001) than open repair. Wound complications were 24 % in the ECS (n = 10) and 32 % in OCS group (n = 11). There was one midline hernia recurrence in the ECS group (mean follow-up of 8 months, range 0.5–34.5 months) and no hernia recurrences in the OCS group (mean follow-up 10 months, range 0.5–30 months). Three of the patients in the ECS group developed new lateral abdominal wall hernias post-operatively.

Conclusions

The ECS group had a significantly longer operative time than the OCS group. Post-operative wound complications were similar between ECS and OCS groups. Patients in the ECS group who underwent subsequent laparoscopic VHR had a shorter operative time and blood loss than open repair.     

应用组织结构分离技术重建腹壁巨大缺损

本文详细描述了腹壁中间缺损采用组织分离技术修补和重建的方法.分析了组织结构分离技术的解剖基础、手术原理、适应证及操作时的注意事项,并结合临床应用体会进行了讨论.