Arnab Majumder, MD1, Luis Martin-Del-Campo, MD1, Heidi J Miller, MD2, Dina Podolsky, MD3, Hooman Soltanian, MD1, Yuri W Novitsky, MD, FACS3. 1University Hospitals Cleveland Medical Center, 2University of New Mexico, 3Columbia University
Background: Component separation during ventral hernia repair remains an integral step during abdominal wall reconstruction. Although a multitude of techniques have been described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR), are commonly utilized. However, the extent of myofascial medialization after ACS vs PCS has not been elucidated well to date. We aimed to conduct a comparative analysis of myofascial medialization of ACS vs PCS in an established cadaveric model.
Methods: Fifteen cadavers underwent both traditional ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Subsequent steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and posterior sheath release (PRR). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and subsequent retromuscular dissection (RMD). Medial advancement of anterior rectus fascia (ARF) was measured following application of 2.5lbs, 5.0lbs, and maximal tension to the fascial edge as a whole, and separately at upper, middle, and lower abdominal segments. Statistical analysis was performed with the Mann-Whitney U test. Values are represented as average myofascial medialization in centimeters.
Results: Following MLL an average of 5.0±0.9cm (range 3.4-6.0cm) of baseline myofascial medialization was obtained. Complete ACS via EOR provided a maximum of 8.8±1.2cm (range 6.3-10.4cm) of ARF advancement compared to 10.2±1.7cm (range 7.6-12.9cm) seen with PCS via TAR, p<0.05. In the upper and mid abdomen, we noted an increase in ARF advancement with PCS compared to ACS (8.1±1.4cm vs 6.7±1.6cm and 11.4±1.5 vs 9.6±1.4cm, respectively). In the lower abdomen we noted similar levels of advancement between ACS and PCS, 8.7±1.8cm vs 9.1±1.7cm.
Conclusions: Component separation via anterior and posterior approaches provide substantial myofascial advancement during ventral hernia repairs. In our cadaveric model, we noted significant increases in anterior fascial medialization after PCS vs ACS as a whole, especially in the upper and mid abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92356
Program Number: S032
Presentation Session: Complex Abdominal Wall Hernia
Presentation Type: Podium