anterior and posterior component separation wall anatomy with respect to...awr techniques •...
TRANSCRIPT
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Abdominal Wall Reconstruction
Anterior and Posterior Component
Separation
Jin S. Yoo M.D.
Assistant Professor of Surgery
Duke University Medical Center
Jin.S. [email protected]
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Disclosures
Page 2
• The discussion will focus on hernias that are big
enough and/or warrant an AWR approach
NON-ELECTIVE
SMALL HERNIA
ELECTIVE
SMALL HERNIA
NON-ELECTIVE
LARGE HERNIA
ELECTIVE
LARGE HERNIA
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AWR techniques
• External component separation (ECS)
- “Ramierz CS”
- can also be performed endoscopically
• Posterior component separation (PCS)
- “Transversus abdominis muscle release” (TAR)
- can also be performed laparoscopically or robotically
• Chemical component separation (CCS)
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AWR Techniques
External CS
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Open Anterior Component Separation
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Page 7
SLIDE courtesy of Robert Martindale
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Page 8
SLIDE courtesy of Robert Martindale
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Page 9
SLIDE courtesy of Robert Martindale
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Page 10
SLIDE courtesy of Robert Martindale
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Anterior CS VIDEO
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AWR Techniques
Posterior CS
TARS
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Posterior Component Separation
• Minimizes subcutaneous
dissection
• Allows for wide overlap of
mesh in the
extraperitoneal position
• Difficult to perform
• Less pull (6-8 cm) than
Ramirez’s CST
Page 13Carbonell AM et al. . Hernia 2008; 12 (4); 359-62
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Starts off as a Rives-Stoppa
rectrorectus repair…
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Gain access to retro-rectus space at midline
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Dissect to linea semilunaris
Rosen MJ. Atlas of Abdominal Wall Reconstruction
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Coverage of the defect at the midline which
provides space for wide mesh overlap
Rosen MJ. Atlas of Abdominal Wall Reconstruction
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Ideal position for mesh with well vascularized
tissue on both sides
Rosen MJ. Atlas of Abdominal Wall Reconstruction
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But if you need more (1) mesh
overlap or (2) tension off the
anterior rectus fascia closure,
then continue on with transversus
abdominis muscle release…
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Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Exposure of posterior sheath
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Incision of the posterior rectus sheath
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Anatomy of the posterior sheath and landmarks
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Transversus abdominis release
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Exposure of transversus abdominis
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Development of preperitoneal space
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Completion of release and midline advancement
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Subxyphoid exposure
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Reapproximation of the posterior sheath
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Mesh placement
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Mesh fixation with transfacial sutures
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Posterior CS VIDEO
COURTESY OF Dr. Daniel Guerron
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AWR Techniques
Chemical CS
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“Chemical” component separation
Botulinum toxin A
• Administered pre-op (1-4
weeks)
• Total dose 100 - 500 U
• 3-5 sites on each side
• Each muscular layer gets
injected
Page 37Soltanizadeh S et al. PRS Global Open 2017
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“Chemical” component separation
Botulinum toxin A
Page 38Soltanizadeh S et al. PRS Global Open 2017
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• Role as an adjunct for the larger hernias
Small medium large very large
• Role for patients who recurred after previous CS
• Limiting factor – how are you going to do it?
- cost of Botox ($9-20 per unit)
- ultrasound
- skill set – radiologist? surgeon?
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“Chemical” component separation
Botulinum toxin A
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AWR Techniques
Laparoscopic / Robotic CS
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You can do it, but…
• There is a learning curve…
- start small… (don’t do the “ultimate robotic hernia repair you
eventually want to do” right off the bat)
• Only proven benefit right now is less wound Cx (due
to avoiding larger incision)
• Trouble with reimbursement
- lesson learned from laparoscopic external CST experience
• Will it catch on?
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Summary of all 4 AWR approaches
ECS PCS CCS LAP/ROBOTIC
Difficulty
(technical)
4 2 --- 1 (most difficult)
Difficulty
(physical)
2 1 (most difficult) --- 3
Mesh overlap 2 1 (most overlap) 2 ---
Mesh location Onlay,
Rectrorectus,
Sublay
Preperitoneal Onlay,
Sublay
Rectrorectus,
Preperitoneal,
Sublay
Amount of
release
1 (most release) 2 2/3 1/2
Repeatable ? ? YES ?
Cost 3 3 1 (most
expensive)
2
Reimbursement 1 1 3 (least likely to
be reimbursed)
2
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