7/2/2015

AWR: Endoscopic CST, Ramirez

CST, Stoppa
Stoppa,, Posterior CST:
A Decision Analysis

Michael J. Rosen MD, FACS

Professor of Surgery
Director, Cleveland Clinic Comprehensive
H
Hernia
i C
Center
t
Cleveland Clinic Foundation
Cleveland Ohio

Disclosures

Research Grants
- W. L. Gore
- LifeCell
- Davol

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Take Home Message

What at the basic tenets of AWR?
What are the basic technical aspects of
each approach?
Limitations and benefits of each
approach.
I do most things at least sometimes
I do one thing almost all the time
Why I do what I do.

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Not every patient has the

same definition of a 6 pack!

Ideal Ventral Hernia Repair

Minimal wound morbidity

Avoid extensive skin flaps
Large prosthetic mesh
Reconstruct midline
Reproducible

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Component Separation

What we really mean is:

try to reconstruct the midline
It does not always require a formal
component separation.
Do the least invasive/morbid procedure
to accomplish the goal.
One approach will not fit all defects.

What are the options for

reconstructing the midline?
Retro-
Retro-rectus Repair-
Repair- Rives
Rives--Stoppa
Stoppa--
Wantz
Open Component Separation
- Anterior Ramirez
Minimally Invasive Component
Separation
- Periumbilical Perforator Sparing
- Endoscopic component separation
- Posterior components separation

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Open Component Separation

Anterior Approach

Ramirez OM, et al. PRS. 1990.

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Component Separation
Rectus Muscle
- Upper 3 cm
- Middle 5 cm
- Lower 3 cm
External
Oblique
- Upper 2 cm
- Middle 4 cm
- Lower 2 cm

Ramirez OM, et al. PRS. 1990.

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Skin Flap Necrosis

Anterior Component
Separation
Pros Cons
Wide fascial Significant wound
advancement morbidity
Innervated / - Necrosis, ischemia,
vascularized repair infection, hematoma

Improved functional Non compliant abdominal

outcomes walls, not much
advancement
Closure of wide defects
with autologous tissue Durability?

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When I use it

If skin won
wontt come to midline
Will create a skin flap anyways
The hernia is so big that the lateral
extent of the hernia sac is at the
external oblique
If I dont want to use mesh, violate the
retro rectus plane, or think an onlay is
acceptable

Patient

62 year old female

s/p ovarian CA
resection
Planned Liver
resection and
primary closure of
hernia
On Avastin

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Defect--15x20 cm
Defect

Posterior Rectus Sheath Incision

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External Oblique Release

Fascia Closed

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Onlay PP

Completed

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Follow up 3 m

Periumbilical Perforator
Sparing

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Periumbilical Perforator
Sparing

Periumbilical Perforator
Sparing
Advantages Disadvantages
Preserve main blood Large dead space
supply Communicates with
Similar advancement midline wound
Low tech Seroma and abscess
Easy to perform rates may not change

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Minimally Invasive Component Separation

Endoscopic Technique

avr

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Endoscopic Component
Separation
Pros
Cons
Direct access to lateral
Requires laparoscopic
compartment skill set
Avoids subcutaneous Achieves 85% of open
flap release
Avoids division of No flaps, can be
abdominal wall difficult to place mesh
perforators Learning curve
Decreases complexity
of postoperative wound
infections

What have I learned from

Endoscopic CST? Good
1 Understand blood supply of anterior
1.
abdominal wall
2. Try and preserve blood supply to skin
and subcutaneous tissues
3. Understand and preserve innervation
of rectus muscle
4. If you preserve blood supply you will
reduce wound morbidity.

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What have I learned from

Endoscopic CST? Bad
Surgeons use it too often in cases that
do not require a component separation.
Those without advanced laparoscopic
skill set, will not adopt this approach.
Placement of mesh without a skin flap
is challenging for most surgeons.

Retro-Rectus Repair
Retro-
Rives--Stoppa
Rives
How I do it

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Rosen MJ. Atlas of Abdominal Wall Reconstruction

Elsevier

Rosen MJ. Atlas of Abdominal Wall Reconstruction

Elsevier

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Rosens Atlas of Abdominal Wall Reconstructions, 2011

Rosens Atlas of Abdominal Wall Reconstructions, 2011

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Retro rectus Repair

Pros Cons
Often good enough to Narrow/atrophied
get midline closure in rectus muscle limits
most hernias mesh overlap
Relatively Retrorectus space
straightforward obliterated
Large mesh Large hernias midline
Retro
Retro--muscular might not come
No skin flaps together

When I use it

For any hernia I can

As long as mesh coverage is wide
enough
Posterior sheath will close

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But What if I am doing a

Rives--Stoppa and I cant get
Rives
the Posterior Sheath Closed?
Make sure you go all the way to the
linea semilunaris.
You can use:
- Vicryl Mesh
- Omentum
Posterior Component Separation
- Preperitoneal Plane
- To Psoas
- Preserve Nerves

Transversus Abdominus Muscle

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Rosen MJ. Atlas of Abdominal Wall Reconstruction

Rosen MJ. Atlas of Abdominal Wall Reconstruction

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Rosen MJ. Atlas of Abdominal Wall Reconstruction

Rosen MJ. Atlas of Abdominal Wall Reconstruction

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Does Posterior Component

Separation Provide Equivalent
Myofascial Advancement?

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56 Open anterior CST versus 55 Posterior CST

Defect Size equivalent 531 cm2 versus 472 cm2

Myofascial advancement equivalent

50% reduction in wound morbidity

American Journal of Surgery March 2012

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Open Component Separation

Posterior Approach
Pros Cons
Takes advantage of Can violate abdominal
retromuscular wall neurovascular
dissection plane supply
Allows for Easy to get in wrong
medialization of both plane
posterior and anterior
Large dead space
components
created
Closure of defect
Technically challenging
Avoids subcutaneous
flap creation

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What happens to the muscles

after you perform these
releases and reconstruct the
abdominal wall?

N=50
25 TAR with midline reconstruction
25 Lap ventral NO midline reconstruction
Radiographic evaluation Pre v Post

JACS 2013

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Postop % change in Muscle

Area
Muscle TAR LVHR
Rectus +23% +3%
EAO +10% -4%
IAO +17% -2%
TA -18% 1%
P value <0.001 NS

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N=13
Preoperative and 6 months
Postoperative Biodex
HerQLes Score
TAR / PCST

Surgery 2014

Isokinetic Dynamometry

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Isometric Dynamometry

Test %Increase pvalue

Isokineticat60degrees/sec 23.8 0.008

Isometricat15degrees 35.8 0.03

Isometricat0degrees 43.3 0.026

Isometricat+15seconds 38.3 0.006

HerQLes 50 0.016

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MY own personal evolution

Laparoscopic Zealot
Exposure to reconstructive surgeons and
questioned the bridged repair
Open anterior component separation
advocate
Dissatisfied with wound morbidity
Endoscopic Component separation
Limited mesh placement options/ surgeon
adoption
Posterior component separation
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Conclusion

There is a wide spectrum of ventral

hernias
Understand all approaches to AWR
Pick which is best for your skill set,
your patient, and your objectives for
repair

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