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Abdominal Wall Reconstruction:

Patch the tire or rebuild the car?

Michael J. Rosen MD, FACSAssociate Professor of Surgery

Chief, Division of Gastrointestinal and General SurgeryDirector, Case Comprehensive Hernia Center

Case Medical CenterCleveland OH

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Take Home Message

• We do not have the ideal ventral hernia repair yet.

• Mesh has not been the ultimate solution to this problem.

• Tension free repair might not be appropriate for the abdominal wall

• Is the linea alba a tendon?

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Approaches to Tendon Repair

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Objectives of a ventral hernia repair• Prevent hernia contents from protruding through

hernia orifice• Provide durable repair with low recurrence rate• Perform the procedure safely with minimal patient

morbidity• Reduce postoperative wound complications and

mesh infections• Reconstruct a functional dynamic abdominal wall,

with medialization of the rectus muscles

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Technical Objectives of Ventral Hernia Repair

• Gain access to the re-operative abdomen• Perform adhesiolysis without enterotomy• Expose entire hernia defect• Repair defect

– Tissue based repair– Mesh based repair– Combination

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Primary Repair

• Unacceptably high recurrence

– Burger JWA, et al 63% Ann Surg 240:4, 2004

– Anthony T, et al 54% World J Surg 24:95, 2000

– van der Linden FT, et al 49% Neth J Surg 40:127, 1988

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Suture vs Mesh Repair

Luijendijk et al. (Netherlands), 2000

Prospective randomized trial181 patients: suture vs mesh repairPrimary hernia (154) or first recurrence (27)Midline incisional hernia < 6cmSingle defect--no previous mesh3-year follow-up (physical examination)

NEJM 2000;343:392-NEJM 2000;343:392-397397

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Suture vs Mesh Repair

Suture Repair97 patientsMean defect size (20 cm2)Running #1 Prolene suture

Mesh Repair84 patientsMean defect size (24 cm2)Polypropylene mesh

NEJM 2000;343:392-NEJM 2000;343:392-397397

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Suture vs Mesh RepairRecurrence Rates

Suture repair : 46%Mesh repair : 23%

Defects < 10 cm2: Suture repair : 44%Mesh repair : 6%

ComplicationsSuture: Wound dehiscence (1)Mesh: SBO (1), infection (3), bleeding (1)

p=0.005*

NEJM 2000;343:392-NEJM 2000;343:392-397397

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We have not found the ideal solution to ventral hernia repair

• Prospective Randomized Trial

• Level 1 Evidence

• 6 cm defects

• 10 years

• Primary repair 62% Failure

• Mesh repair 32% Failure

Burger J. Ann Surg 240:4, 2004

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I. LaPlace’s LawII. Pascal’s Principle

Laplace’s LawLaplace’s Law

T=PT=P(intraperitoneal)(intraperitoneal)**rr(raduis)(raduis)/2h/2h(wall thickness)(wall thickness)

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Is there a better way to create a functional abdominal wall using minimally invasive hernia repair

techniques?

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Objectives of Functional Abdominal Wall Reconstruction

• Medialization of the Rectus Muscle

• Durable repair

• Minimal wound morbidity

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Outcomes ComponentOutcomes Component SeparationSeparation

Author Year N Defect cm2 Comps Recurrence

Ramirez 1990 11 216 0% 0%

Dibello 1996 35 225 11% 9%

Girotto 1999 33 140 27% 6%

Lowe 2000 30 240 40% 10%

deVries 2003 43 234 35% 30%

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Component Separation

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Component SeparationComponent Separation

Ramirez OM, et al. PRS. 1990.Ramirez OM, et al. PRS. 1990.

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Periumbilical Perforator Sparing

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Periumbilical Perforator Sparing

Advantages

• Preserve main blood supply

• Similar advancement• Low tech• Easy to perform

Disadvantages

• Large dead space• communicates with

midline wound• seroma and abscess

rates may not change

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Minimally Invasive Component Minimally Invasive Component SeparationSeparation

• Access the lateral compartment directlyAccess the lateral compartment directly

• Avoids large subcutaneous flap dissectionAvoids large subcutaneous flap dissection

• Avoids division of abdominal wall Avoids division of abdominal wall

perforatorsperforators

• Decreases complexity of postoperative Decreases complexity of postoperative

wound infectionswound infections

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avr

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Rosen et al. Am J Surg 2007

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Porcine ModelLaparoscopic versus Open CSM

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Porcine ModelLaparoscopic versus Open CSM

LaparoscopicLaparoscopic OpenOpen % Release% Release

5.35.3 5.65.6 95953.13.1 4.14.1 76764.04.0 5.35.3 7575

6.86.8 7.27.2 94944.04.0 5.55.5 7373

6.06.0 6.56.5 92925.35.3 6.06.0 8888

4.04.0 4.44.4 91916.26.2 7.57.5 8383

4.74.7 5.35.3 8989

Total Total ReleaseRelease 86%86%

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N=7N=7

Mean Defect Mean Defect 338 cm338 cm22

LOSLOS 5.4 days5.4 days

RecurrenceRecurrence 10%10%

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•What is the next step?

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Minimally invasive abdominal wall reconstruction

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Isolation of the External obliqueIsolation of the External oblique via balloon inflationvia balloon inflation

Balloon/ Instrument portBalloon/ Instrument port

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Cutting of the External Oblique

External obliqueExternal oblique

Insufflator / Insufflator / camera portcamera port

2 cm2 cm

Internal obliqueInternal oblique

Space created Space created by balloonby balloon

Instrument portInstrument port

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Following cutting of the External Oblique on each sidethe bowel is freed of adhesions.

Instrument portInstrument port

Insufflator / Insufflator / camera portcamera port

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A suture is passed through the A suture is passed through the right rectus.right rectus.

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The suture is handed off and pulledThe suture is handed off and pulledto below the left rectus muscleto below the left rectus muscle

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The suture is then pulled up throughThe suture is then pulled up throughthe left rectus muscle and out the samethe left rectus muscle and out the sameskin incision.skin incision.

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The suture is tied forcing the rectusThe suture is tied forcing the rectusmuscles together.muscles together.

Vertebra

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Vertebra

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The knot is pushed under the skin.The knot is pushed under the skin.

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Vertebra

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Vertebra

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Conclusions• There are many options for reconstructing the

abdominal wall.• The concept of bringing the rectus muscles

back together in most patients makes sense• Minimally invasive component separation is a

reasonable option and might be beneficial when used earlier in the treatment algorithm.

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Conclusions• Everyone does NOT need a functional dynamic

abdominal wall– Obese– Elderly

• Some people do DESERVE a functional dynamic abdominal wall– Young– Thin– Active, Manual Labor