Post on 27-Mar-2020
Abdominal Wall Reconstruction
Anterior and Posterior Component
Separation
Jin S. Yoo M.D.
Assistant Professor of Surgery
Duke University Medical Center
Jin.S. Yoo@duke.edu
Disclosures
Page 2
• The discussion will focus on hernias that are big
enough and/or warrant an AWR approach
NON-ELECTIVE
SMALL HERNIA
ELECTIVE
SMALL HERNIA
NON-ELECTIVE
LARGE HERNIA
ELECTIVE
LARGE HERNIA
AWR techniques
• External component separation (ECS)
- “Ramierz CS”
- can also be performed endoscopically
• Posterior component separation (PCS)
- “Transversus abdominis muscle release” (TAR)
- can also be performed laparoscopically or robotically
• Chemical component separation (CCS)
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AWR Techniques
External CS
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Open Anterior Component Separation
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SLIDE courtesy of Robert Martindale
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SLIDE courtesy of Robert Martindale
Page 9
SLIDE courtesy of Robert Martindale
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SLIDE courtesy of Robert Martindale
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Anterior CS VIDEO
AWR Techniques
Posterior CS
TARS
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Posterior Component Separation
• Minimizes subcutaneous
dissection
• Allows for wide overlap of
mesh in the
extraperitoneal position
• Difficult to perform
• Less pull (6-8 cm) than
Ramirez’s CST
Page 13Carbonell AM et al. . Hernia 2008; 12 (4); 359-62
Starts off as a Rives-Stoppa
rectrorectus repair…
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Gain access to retro-rectus space at midline
Dissect to linea semilunaris
Rosen MJ. Atlas of Abdominal Wall Reconstruction
Coverage of the defect at the midline which
provides space for wide mesh overlap
Rosen MJ. Atlas of Abdominal Wall Reconstruction
Ideal position for mesh with well vascularized
tissue on both sides
Rosen MJ. Atlas of Abdominal Wall Reconstruction
But if you need more (1) mesh
overlap or (2) tension off the
anterior rectus fascia closure,
then continue on with transversus
abdominis muscle release…
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Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Exposure of posterior sheath
Rosen MJ. Atlas of Abdominal Wall Reconstruction
Incision of the posterior rectus sheath
Anatomy of the posterior sheath and landmarks
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Rosen MJ. Atlas of Abdominal Wall Reconstruction
Transversus abdominis release
Exposure of transversus abdominis
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Development of preperitoneal space
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Completion of release and midline advancement
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Subxyphoid exposure
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Rosen MJ. Atlas of Abdominal Wall Reconstruction
Reapproximation of the posterior sheath
Rosen MJ. Atlas of Abdominal Wall Reconstruction
Mesh placement
Mesh fixation with transfacial sutures
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
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Posterior CS VIDEO
COURTESY OF Dr. Daniel Guerron
AWR Techniques
Chemical CS
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“Chemical” component separation
Botulinum toxin A
• Administered pre-op (1-4
weeks)
• Total dose 100 - 500 U
• 3-5 sites on each side
• Each muscular layer gets
injected
Page 37Soltanizadeh S et al. PRS Global Open 2017
“Chemical” component separation
Botulinum toxin A
Page 38Soltanizadeh S et al. PRS Global Open 2017
• Role as an adjunct for the larger hernias
Small medium large very large
• Role for patients who recurred after previous CS
• Limiting factor – how are you going to do it?
- cost of Botox ($9-20 per unit)
- ultrasound
- skill set – radiologist? surgeon?
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“Chemical” component separation
Botulinum toxin A
AWR Techniques
Laparoscopic / Robotic CS
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You can do it, but…
• There is a learning curve…
- start small… (don’t do the “ultimate robotic hernia repair you
eventually want to do” right off the bat)
• Only proven benefit right now is less wound Cx (due
to avoiding larger incision)
• Trouble with reimbursement
- lesson learned from laparoscopic external CST experience
• Will it catch on?
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Summary of all 4 AWR approaches
ECS PCS CCS LAP/ROBOTIC
Difficulty
(technical)
4 2 --- 1 (most difficult)
Difficulty
(physical)
2 1 (most difficult) --- 3
Mesh overlap 2 1 (most overlap) 2 ---
Mesh location Onlay,
Rectrorectus,
Sublay
Preperitoneal Onlay,
Sublay
Rectrorectus,
Preperitoneal,
Sublay
Amount of
release
1 (most release) 2 2/3 1/2
Repeatable ? ? YES ?
Cost 3 3 1 (most
expensive)
2
Reimbursement 1 1 3 (least likely to
be reimbursed)
2
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