Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction

doi:10.1016/j.amjsurg.2012.02.008

The American Journal of Surgery

Volume 204, Issue 5, November 2012, Pages 709-716

https://doi.org/10.1016/j.amjsurg.2012.02.008 Get rights and content

Abstract

Background

Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of transversus abdominis muscle release (TAR) for posterior component separation during major abdominal wall reconstructions.

Methods

Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5–1 cm underlying medial to the linea semilunaris to expose the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh.

Results

Between December 2006 and December 2009, we have used this technique successfully in 42 patients with massive ventral defects. Thirty-two (76.2%) patients had recurrent hernias. The average mesh size used was 1,201 ± 820 cm² (range, 600–2,700). Ten (23.8%) patients developed various wound complications requiring reoperation/debridement in 3 patients. At a median follow-up period of 26.1 months, there have been 2 (4.7%) recurrences.

Conclusions

Our novel technique for posterior component separation was associated with a low perioperative morbidity and a low recurrence rate. Overall, transversus abdominis muscle release may be an important addition to the armamentarium of surgeons undertaking major abdominal wall reconstructions.

Section snippets

Materials and Methods

We performed a retrospective review of all patients undergoing hernia repair at the specialized hernia repair center by a single surgeon (Y.W.N.). Patients who underwent abdominal wall reconstruction using retromuscular synthetic mesh repair with TAR were identified and reviewed.

Main outcome measures included patient demographics, body mass index, number of previous abdominal surgeries, number of recurrent hernias, and number of previous hernia repairs. Perioperative data included surgical time

Results

Between December of 2006 and December 2009, we used the TAR technique in 42 patients with complex ventral hernia defects. There were 32 (76%) women with a mean age of 52.1 years. The average body mass index was 39 ± 13 kg/m² (range, 23–69 kg/m²). The average defect size was 366 ± 120 cm² (range, 160–660 cm²). Thirty-two (76.2%) patients had recurrent hernias with an average number of previous repairs of 2.9 (range, 1–8). Thirty (71.4%) patients had chronically incarcerated hernias. Thirteen

Comments

The ideal surgical approach to the difficult ventral hernia repairs remains to be elucidated. Complex abdominal problems continue to present a significant technical challenge with high perioperative morbidity, frequent repair failures, and negative effects on patient quality of life.¹⁸ Similarly to others, we believe that the goal of any herniorrhaphy should be restoration of a functional abdominal wall with autologous tissue repair strengthened by reinforcement with a durable mesh.¹⁸ Our novel

Conclusions

Herein we presented our novel technique of abdominal wall reconstruction using a transversus abdominis muscle release. This approach is a modification of a posterior component separation and is an adjunct to the traditional retromuscular repair of Rives-Stoppa. It was associated with low perioperative morbidity and a low-recurrence rate in our challenging group of patients. The advantages of this approach include the ability for extensive lateral extension of the retromuscular plane beyond the

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Cited by (469)

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation
2024, American Journal of Surgery
While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear.
A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years).
Of 219 patients who underwent VHR with CST, 114 patients (52.1 %) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p = 0.002) and COPD was positively associated with seroma development (OR 20.1, p = 0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p = 0.766).
VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.
The evolution of incisional hernia repair in Spain. A comparative analysis of results from the EVEREG Registry
2024, Cirugia Espanola
El objetivo del estudio fue comprobar la utilidad del registro EVEREG para evaluar la evolución del tratamiento quirúrgico de la hernia incisional y sus resultados en España, comparando los datos de dos períodos de estudio.
Análisis retrospectivo comparativo de las hernias operadas entre 2011 y 2015 (primer período) y entre 2017 y 2022 (segundo período) usando los datos recopilados en el registro EVEREG.
Se detectaron diferencias estadísticamente significativas en la cohorte más reciente en: disminución de abordaje mínimamente invasivo (11,7% vs. 8,2%; p < 0,001); incremento de varones intervenidos de urgencia (31,7% vs. 41,2%; p = 0,017); incremento de las reparaciones de hernias de trócar (16% vs. 26,2%; p < 0,0001); reducción de reparaciones sin malla (2,8% vs. 1,5%; p< 0,0001); aumento de técnicas retromusculares (36,4% vs. 52,4%; p < 0,001) en la cirugía abierta con malla.
En la cirugía electiva disminuyó la estancia media (4,9 vs. 3,8 días; p < 0,0001), el porcentaje de complicaciones (27,9% vs. 24,0%; p < 0,0001), reintervenciones (3,5% vs. 1,4%; p < 0,0001) y mortalidad (0,6% vs. 0,2%; p = 0,002).
A largo plazo se produjo una disminución de recurrencias a los 12 meses (20,7% vs. 14,5%; p < 0,0001) y del dolor (13,7% vs. 2,5%; p < 0,0001) e infección crónicos (9,1% vs. 14,5%; p < 0,0001) a los seis meses.
Se ha producido una importante mejora de los resultados en el tratamiento de la hernia incisional en los últimos años. El registro es una herramienta fundamental para comprobar la evolución del tratamiento de las hernias y permite discernir los principales puntos para implementar mejoras y evaluar los resultados de estas.
The aim of this study was to assess the utility of the EVEREG registry in evaluating the evolution of surgical treatment for incisional hernia and its outcomes in Spain by comparing data from two study periods.
A retrospective comparative analysis of hernia surgeries performed between 2011 and 2015 (first period) and between 2017 and 2022 (second period) was conducted using data collected from the EVEREG registry.
Statistically significant differences were observed in the second cohort, including: a decrease in minimally invasive procedures (11.7% vs 8.2%; P < .001), an increase in emergency surgeries for males (31.7% vs 41.2%; P = .017), an increase in trocar hernia repairs (16% vs 26.2%; P < .0001), a reduction in suture repairs (2.8% vs 1.5%; P < .0001), and an increase in retromuscular techniques (36.4% vs 52.4%; P < .001) in open surgery with mesh.
In elective surgery, there was a decrease in the average length of stay (4.9 vs 3.8 days; P < .0001), the percentage of complications (27.9% vs 24.0%; P < .0001), reoperations (3.5% vs 1.4%; P < .0001), and mortality (0.6% vs 0.2%; P = .002).
Long-term outcomes included a decrease in recurrences after 12 months (20.7% vs 14.5%; P < .0001) and in chronic pain (13.7% vs 2.5%; P < .0001) and chronic infections (9.1% vs 14.5%; P < .0001) after 6 months.
In recent years, there has been a significant improvement in the outcomes of incisional hernia treatment. The registry serves as a fundamental tool for assessing the evolution of hernia treatment and enables the identification of key areas for improvement and the evaluation of treatment outcomes.
Rectus to defect ratio for estimating the complexity of ventral hernia repair: Is it reliable for robotic surgery?
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The rectus to defect ratio (RDR) has been previously described as a metric which enables surgeons to estimate the need to perform additional myofascial release (AMR), in addition to open Rives-Stoppa retro-muscular hernia repair. We sought to validate this measurement specifically for patients undergoing robotic totally extraperitoneal (eTEP) hernia repair.
A retrospective chart review of 188 patients who underwent robotic ventral hernia repair via eTEP approach. RDR on preoperative CT was compared to the final operation rendered. The primary endpoint was the RDR's ability to predict the need for TAR to achieve fascial closure.
Of 188 patients, 154 were repaired with rectus myofascial release, while 34 also required TAR. There was a linear decrease in the need for TAR with increasing RDR. RDR 1–1.49 (n = 12) required TAR in 66.7 % of cases, RDR 1.5–1.99 (n = 25) in 43.8 %, RDR 2–2.49 (n = 31) in 29 %, and RDR >2.5 (n = 151) in just 5.8 %
The RDR accurately predicts the need for TAR to achieve fascial closure during robotic eTEP ventral hernia repair. An RDR >2.5 portends fascial closure without TAR 94.2 % of cases.
Intraoperative complications of robotic-assisted extended totally extraperitoneal (eTEP) ventral hernia retromuscular repairs with mesh: a systematic literature review and narrative synthesis
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Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis
2024, Annals of Plastic Surgery
Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias
2024, Hernia

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Clinical scienceTransversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction

Abstract

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Comments

Conclusions

Surg Clin North Am

J Am Coll Surg

Surgery

J Gastrointest Surg

Am J Surg

Incisional hernia: a 10 year prospective study of incidence and attitudes

Br J Surg

Surgical treatment of incisional hernia

Br J Surg

Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias

Eur J Surg

Retrorectus polyester mesh repair for midline ventral hernias

Hernia

Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia

Ann Surg

Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia

Br J Surg

Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a randomized controlled trial

World J Surg

Have outcomes of incisional hernia repair improved with time?A population-based analysis

Ann Surg

Clinical science
Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction