Tiffany C Cox, MD, Laurel J Blair, MD, Ciara R Huntington, MD, Vedra A Augenstein, MD, FACS, B. Todd Heniford, MD, FACS. Carolinas Medical Center
Introduction: Complex abdominal wall reconstruction requires a myriad of skills to tailor the method of repair. Familiarity with advanced surgical techniques for both open and laparoscopic methods is critical. Deciding when to perform open hernia repair and what type of myofascial release to perform to obtain midline closure requires good understanding of abdominal wall anatomy and can be well demonstrated in the TAR approach.
Case Description: A 66 year-old man with a history of diabetes mellitus, remote tobacco use, and a body mass index of 30 kg/m2 presented to our hernia referral center for evaluation of a complex ventral incisional hernia. The patient developed the hernia after undergoing a right hemicolectomy for reported perforated appendicitis in April 2013 at an outside facility. His recovery was complicated by extensive wound dehiscence requiring exploratory laparotomy, delayed primary closure of both fascia and skin necessitating the use of biologic mesh for eventual closure. On examination, the patient had an abdominal bulge and eventration of the mesh was noted on computed tomography with a defect size of 310cm2. Functionally, this was an abdominal wall hernia. After a thorough preoperative consultation, work up, and consent, the patient was taken to the operating room for open incisional hernia repair utilizing the TAR approach.
Description of TAR Procedure: After complete dissection of the excess skin and tissues overlying the hernia, the defect is visualized in its entirety. Entry into the retromuscular location is best accessed in the native tissue of the suprapubic region. Dissection into this avascular plane reveals the point of incision to expose the transversalis. The transversalis is then divided caudally into the space of Reitzus and continued cranially in the subxiphoid region above the falciform ligament. The divided transversalis is then bluntly dissected off the underlying fascia. These steps are repeated on the opposite side. Closure of the posterior sheath isolates abdominal contents from the mesh. The fascial defect is measured to select appropriate mesh size. Clamp placement in the midpoint of the mesh allows for a constant point of reference to avoid disproportionate mesh coverage during fixation. Complete mesh fixation is accomplished through a sequence of opposing counter-tension placement of transfascial sutures. Fascial closure commences in the subxiphoid region by marking out diastasis for incorporation in closure; intraoperative marking allows better cosmetic results while preventing rolling in of the fascia. Minimal subcutaneous flaps are created to allow advancement of skin midline. Talc is used for reduction in seroma formation. Interrupted deep dermal closure is performed with staple closure of the skin.
Discussion: The TAR repair is an elegant technique that is employed to gain midline approximation in complex hernias. Minimal subcutaneous dissection makes this component separation attractive when considering potential wound infections.
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