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Component separation in large midline hernia repair-there is an alternative.

Alex Karatassas1, O I Rodrigues2, K E Elistner2, A Jacobs2, J Read2, N Ibrahim2, J Saunders2. 1University of Adelaide Discipline of Surgery TQEH, 2Hernia Institute Australia

Introduction: Component separation (CS) involves division of the lateral abdominal muscles, allowing movement of a muscle section, restoring the midline and muscle function. CS is utilised to enable midline or near midline closure and minimise tension on the abdominal wall when closing large defects and in the case of Transversus Abdominus Release (TAR), the additional requirement to accommodate, within an interstitial plane, a large mesh (to dissipate the disruptive forces acting on the repair of the midline defect).

CS has recently come under criticism from sports and rehabilitation physicians who consider it debatable if the advantage of bringing the midline back is offset by the loss of function of one of the lateral muscles. In particular, the Transversus abdominus (TA) is important in core stability which provides spinal support and assists in respiration. Division may result in spinal and respiratory dysfunction long term.

Further, there is concern regarding formation of complex lateral hernias, donor site problems (haematoma, damaging neurovascular bundles leading to muscle atrophy and ischaemic skin flaps) as well as dehiscence of posterior layer of repair in TAR, resulting in early post op SBO.

Method: Botulinum A (BTA) was administered under ultrasound guidance, into the lateral 3 muscles, 2 weeks prior to hernia surgery in a series of 56 patients with major midline hernia. The mean hernia size was 11.6cm and 73% had previous repairs (70% involved mesh). 32% had loss of domain greater than 25%.

Results: 71% of the repairs were completed laparoscopically, and 29% required a hybrid approach with both laparoscopy and mini laparotomy. Only 16% of patients required limited single port anterior CS.

Discussion: This cohort of large hernias would require CS in nearly all cases. BTA administration enabled midline closure in 84% of cases without CS. 

When muscles detach from their insertion, as occurs in a hernia, they contract   eventually becoming fibrotic and shortened. When large defects are closed, this results in excessive tension on the repair.  BTA allows a period of gradual stretching of these muscles, improving plasticity and muscle compliance and avoiding CS.

The effects of BTA last 3-6 months. This decrease in abdominal wall tension in the post op period, may avoid the requirement for very large mesh.

Conclusion: BTA administration to the lateral oblique muscles facilitates midline repair and avoids CS in many patients with large midline hernias.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 94371

Program Number: S027

Presentation Session: Complex Abdominal Wall Hernia

Presentation Type: Podium

232

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