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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 3  |  Page : 407-412

Short-term outcomes of the component separation technique for the repair of complex ventral hernia


General Surgery Department, Mansoura Faculty of Medicine University, Mansoura, Egypt

Date of Submission21-Jul-2018
Date of Acceptance04-Sep-2018
Date of Web Publication07-Jan-2019

Correspondence Address:
Dr. Amro ElHadidi
General Surgery Department, Mansoura Faculty of Medicine, Mansoura 35111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_156_18

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  Abstract 


Backgrounds The component separation technique is a well-known procedure for closure of a large abdominal wall defect. Primary reconstruction either alone or with synthetic mesh reinforcement provides physiological advantages. Our study evaluates this technique in terms of indications, operative outcomes, and postoperative results.
Patients and methods Fascial component separation was performed either alone or with mesh reinforcement for patients with large abdominal wall defects between January 2013 and December 2016.
Results A total of 40 patients, 15 (37.5%) men and 25 (62.5%) women were included in the study. The mean age of the patients was 53.8 years (range, 27–68 years). The mean body mass index (BMI) was 35.3 kg/m2 (range, 25.5–45.9 kg/m2). The mean defect size was 12.8 cm (range, 10–15 cm). The mean operative time was 152.5 min (range, 81–220.5 min), with the mean duration of hospital stay being 14 days (range, 9–19 days). Forty-five percent of patients needed mesh reinforcement. The mean follow-up period was 24 months. The total recurrence rate was 5% (2/40). No mortality or major intraoperative or postoperative complications were observed.
Conclusion The component separation technique provides a reliable, autologous reconstructive modality for treating large abdominal wall defects. Additionally, mesh reinforcement can decrease the recurrence rate without an increase in the rate of major intraoperative or postoperative complications.

Keywords: abdominal defects, component separation technique, mesh reinforcement, ventral hernia


How to cite this article:
ElHadidi A, Samir M, Abdelhalim M, Taha A, Noaman N, Dawoud I. Short-term outcomes of the component separation technique for the repair of complex ventral hernia. Benha Med J 2018;35:407-12

How to cite this URL:
ElHadidi A, Samir M, Abdelhalim M, Taha A, Noaman N, Dawoud I. Short-term outcomes of the component separation technique for the repair of complex ventral hernia. Benha Med J [serial online] 2018 [cited 2019 Dec 15];35:407-12. Available from: http://www.bmfj.eg.net/text.asp?2018/35/3/407/249415




  Introduction Top


A complex abdominal wall defect refers to abdominal defects that cannot be closed successfully by a simple ventral hernia repair. This could be due to various causes, such as a large size of the defect, presence of infection, and/or previous surgeries. Different surgical techniques need to be employed for the repair of such complex abdominal wall defects. The ultimate aim of each of these techniques is to maintain the fascial support integrity with unique protection of the abdominal viscera [1].

Both biological and prosthetic repair techniques for complex abdominal defects have been investigated in the literature. The component separation technique [2], partition technique [3], and Lindsay anterior rectus sheath flapping and its modification [4],[5] are some of the well-known biological methods for the repair of ventral defects.

The component separation technique involves the creation of a biological musculofascial sliding layer, thereby creating a new midline linea alba. Thus, the abdominal domain can be preserved without the risk of additional tension [6]. A modification of the component separation technique involves the use of a prosthetic mesh, thus providing additional reinforcement. However, it is imperative to take into consideration several local factors (e.g. multiple recurrences, previous infection, and the presence of wall sinuses and fistulae) and systemic comorbidities (e.g. smoking, diabetes mellitus, and hypertension) when deciding the repair strategy [7].

In spite that the rates of recurrence can be decreased significantly with the addition of a prosthetic material [8],[9], still high postoperative infection is a major disappointing finding associated with mesh reinforcement [6]. Thus, confusion exists regarding the preferred technique for the repair of complex defects.

In this study, we present our experience with the component separation technique on the patients admitted for the same, in our hospital. With this study, we aimed to evaluate the efficacy, short-term outcomes, and complications of component separation technique as a biological repair strategy for huge abdominal wall defects. In addition, we also tried to assess the advantage and disadvantages of mesh reinforcement.


  Patients and methods Top


This is a prospective study carried out at the Mansoura University Hospital from January 2013 to December 2016. Adult patients, who were operated for huge primary and incisional hernia with a defect size of more than 10 cm in its transverse diameter, using the component separation technique (with or without mesh reinforcement), were included in the study. Patients with large ventral hernia with signs of infection, abdominal wall sinuses, or fistulae are excluded from the study. After a thorough explanation of the surgical procedure and the study, informed consent was obtained from all the participating patients. The study protocol was reviewed and approved by the institutional ethics committee.

Preoperative planning

Preoperative medical evaluation included recording a detailed history with special emphasis on the presence of associated comorbidities, details of any previous surgical procedures, along with a comprehensive physical examination.

Preoperative imaging of all patients was carried out by computed tomography of the abdomen and pelvis. This was primarily performed to assess the abdominal cavity and to measure the defect size. The defect size was defined as the maximum distance between the bilateral rectus abdominis sheath and expressed as the width of the fascial defect in centimeters.

All patients were admitted at least one night prior to the day of the surgery, as a part of optimal medical management to look for any systemic comorbidities. All the patients were administered a broad-spectrum antibiotic as a preoperative prophylactic measure for venous thromboembolism.

Surgical procedure

After adequate bowel preparation, the surgery was performed by a trained and qualified surgeon. The surgery was carried out under general anesthesia after ruling out any contraindications to the same. With the patient in supine position, the skin over the abdomen was disinfected with the help of povidone-iodine, and an adhesive drape was applied. As per the size of the defect and condition of the patient, appropriate incision was made. However, in most of the cases, the abdomen was entered with the help of a midline incision. Access to the abdominal cavity was gained with excision of any previous scars, if present. Meticulous adhesiolysis and complete dissection of the hernia sac were performed exposing the rectus muscles. An extensive skin flap mobilization was created, and the lateral border of the rectus muscle was located. At about 2 cm lateral to the rectus, the aponeurosis of the external oblique muscle was divided longitudinally, extending from the inguinal region to the costal margin. Lateral dissection was then carried out deep into the external oblique, allowing the creation of a sliding myofascial flap by bluntly dissecting the external oblique muscle from the underlying internal oblique muscle. This sliding myofascial flap consisted of internal oblique and transversus muscles.

In situations where dissection above the costal margin was needed, the lateral border of the rectus was released to allow these muscles to be mobilized from the chest wall and opposed in the new midline at the epigastrium. The midline was then closed by PDS 1-0 ([Figure 1]). When a synthetic mesh was deemed necessary, it was placed in the onlay position and secured with interrupted (0) prolene sutures to the aponeurotic edge of the external oblique muscle. Subcutaneous suction drains were then placed ([Figure 2]). Once homeostasis was achieved, layered skin closure was performed.
Figure 1 The creation of a new midline linea alba.

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Figure 2 Mesh placement in its onlay position after component separation technique.

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Postoperative course

A broad-spectrum antibiotic was administered to all patients for 5–7 days postoperatively. In the mean time, another dose of antibiotic was administered to the patients following the removal of any infected material. The patients were deprived of any oral administration till they pass flatus indicating return of bowl function. Along with this other routine postoperative care, methods like pulmonary toileting and venous thromboembolism prophylaxis were provided. In most of the cases, all stitches and drains were removed after 14 days of the surgery or when the drains produce less than 10 ml fluid/day for a minimum duration of 48 h. The patients were advised not to lift any heavy objects till 6 months postoperation and were under medical supervision for 7 and 14 days. After the discharge, the patients were advised to visit the surgeon at an interval of 1, 3, 6, and 12 months, and then at 6-month intervals. During the visit, the medico performed physical examination to diagnose recurrence or other postoperative complication. Imaging techniques (ultrasonography and/or computed tomography of the abdomen) were performed only if there is any serious concern.

Patient demographics, defect size, BMI, indications for surgery, associated comorbidities, details of previous surgeries (if any), operative details, duration of hospital stay, associated procedures, mesh placement, intraoperative and postoperative complications, and short-term outcomes (including infection and recurrence rate) were reported and analyzed.


  Results Top


A total of 40 patients were enrolled in this study, which included 25 (62.5%) women and 15 (37.5%) men. The mean age of the patients was 53.8 years (range, 27–68 years). The mean BMI was 35.3 kg/m2 (range, 25.5–45.9 kg/m2).

Most of the patients had associated systemic medical comorbidities: hypertension in 37.5%, diabetes mellitus in 37.8%, chronic obstructive pulmonary disease in 22.5%, and hepatic cirrhosis in 22.5%. Ten (25%) patients had more than one comorbidity. Cirrhotic patients in the study were Child–Pugh class A, and no class B or C included. The indications for surgery were incisional hernia in 35 (87.5%) cases while the rest of the cases had primary ventral hernia

All abdominal defects in this study were midline defects with a fascial defect width of 10 cm or more (W3 according to the European Hernia Society classification) [10]. The mean defect size was 12.8 cm (range, 10–15 cm). Eighteen (45%) patients needed mesh reinforcement in addition to the component separation method. The mean duration of hospital stay was 14 days (range, 9–19 days). All patients had a follow-up of at least 6 months, with the mean period of follow-up being 24 months.

Surgical seroma was detected in seven (17.5%) patients, which was managed conservatively or treated successfully with simple aspiration and follow-up. Three (7.5%) patients eventually developed superficial skin necrosis, requiring bedside debridement and wound closure. Superficial wound infection occurred in eight (20%) out of the 40 patients, as determined by culture and sensitivity tests. These were fortunately managed conservatively and treated with an antibiotic. Two (5%) patients had fascial dehiscence without recurrence, which required operative interventions and follow-up.

Postoperative recurrence was reported in two (5%) cases that underwent component separation technique alone (without mesh reinforcement). One of these patients had chronic obstructive pulmonary disease and diabetes mellitus, while the second patient had hypertension, diabetes, and previous history of infected mesh repair. Detection of recurrence in these two cases was during 7 and 10 months, respectively. In both the cases, second admission and repair were successfully achieved. No other major intraoperative or postoperative complications occurred in this study ([Table 1]). There was no mortality reported till the follow-up period.
Table 1 Patients demographic (N=40)

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  Discussion Top


Despite the advancements in the field of surgery and the availability of prosthetic material, the repair of complex abdominal defects is a challenging task and is dependent on various factors including the surgeon’s experience, preoperative medical illness, and defect size. A wide variety of reconstructive techniques like the component separation technique, partition technique, and the Lindsay anterior rectus sheath flapping technique have been reported in the literature to control large abdominal wall defects [2],[3],[4],[5]. However, there has been no unanimous consensus on the best surgical technique of all.

One of these methods is the primary component separation technique introduced by Ramirez et al. [2]. The main indications of this technique include repair of large abdominal defects, recurrences, and reconstruction of giant omphaloceles. Contraindications include lack of good blood supply, considerable wall destruction, and contamination. The original technique did not involve the use of any kind of mesh reinforcement. However, with time, the technique underwent multiple modifications including the addition of a mesh wherever deemed necessary. Despite this, many studies have demonstrated benefits of the primary component separation technique in situations where the use of mesh is not considered ideal. These situations include the presence of contaminated wounds, fistulae, etc. [11].

Wherever possible, mesh reinforcement provides two major benefits like decreased recurrence rate and closure of larger defects. The recurrence rate after primary closure without mesh reinforcement ranges from 18 to 62%. However, with reinforcement, these rates have reported to be lowered significantly, up to 2 to 32% [8],[9],[12]. Component separation technique has also been reported to have associated with a higher rate of wound complications [13]. In our study, the recurrence rate was found to be 5% (2/40), which matches with the rates shown in the existing literature [14],[15],[16]. In comparison to these two cases of recurrence in patients treated with component separation technique alone, no recurrence was observed in the patients who underwent mesh reinforcement. Additionally, the patients who underwent mesh reinforcement (45%) did not demonstrate a higher rate of minor or major complications in our study. Onlay mesh placement was our preferred method with proper fixation of the mesh to the lateral margins, as the literature showed that most recurrences occurred at the lateral borders [14]. A study carried out in 2004 [15] comparing the different techniques of reconstruction using a synthetic mesh reported a higher number of postoperative complications with the onlay technique than the others. However, in our study, despite the fact that only the onlay technique was used for mesh reinforcement, it resulted in no major postoperative complication. This was in agreement with another study carried out by Ko et al. [16], which retrospectively evaluated the efficacy of component separation technique in 200 patients. Ko and his colleagues reported a zero recurrence rate with the use of a synthetic mesh, compared with that of primary repair (recurrence in 33.3% cases), thus highlighting the overall benefit of using a mesh for repair.

In our study, history of multiple recurrences with infection along with associated medical problems was noted in two patients who had recurrences and had the likely responsible factors. The association between preoperative morbidity in the form of huge defect size, previous surgeries, infection, multiple associated ailments and postoperative results, and probability of recurrence are well established [17]. Furthermore, when repair is associated with other intra-abdominal operations, there may be a sixfold increase in postoperative morbidity [17].

Preoperative computed tomography scan of the abdomen and measurement of the abdominopelvic cavity with hernia sac volume is used in complex incisional hernia [18],[19]. In the current study, abdominopelvic computed tomography was a routine preoperative investigation carried out to assess the defect size and associated pathology. However, in our experience, intraoperative measurement after complete dissection of the hernia sac might be a superior method and more compatible with the original technique [2],[3]. The mean defect size in this study was 12.8 cm and is in concordance with other studies [19],[20],[21]. This proves that a defect size may be a dependent factor associated with high postoperative complication rate [7],[20],[21].

Regarding postoperative complications, we found that 17.5% of patients developed wound seroma in spite of the routine use of drains. This could likely be due to extensive skin flap dissection and high BMI, both factors are clearly associated with postoperative complications [22],[23]. With simple observation and reassurance, most patients recovered without seroma aspiration. Wound infection occurred in eight patients (20% of cases) in this study which was treated conservatively. We attribute these complications to the high number of patients with preoperative morbidities and high BMIs.The Ventral Hernia Working Group recommends the use of permanent prosthetic mesh for patients with no history of abdominal wall contamination, whereas in patients with present or past history of wall contamination, the group recommends placement of a biologic mesh [24]. Several studies have investigated the safety of a synthetic mesh in clean and contaminated cases [25],[26],[27],[28],[29]. In this study, however, no mesh was applied in patients with documented previous abdominal wall infection.

In the present day, another modification of the original component separation method for complex abdominal wall reconstruction is an endoscopically performed minimally invasive surgery. Although it is technically more demanding, a retrospective, comparative study [30] showed that the minimally invasive procedure resulted in lesser wound complications, and thus, a shorter hospital stay. Our study, however, did not evaluate the effectiveness of the minimally invasive procedure.

However, there are several limitations of this study. First, the exact original technique of component separation was used without any additional biological modification. Moreover, the unavailability of biological mesh in our locality to replace the synthetic mesh might have proved detrimental in certain cases especially the infected one. Second, there was also a lack of precise parameter to determine the use of prosthetic mesh. However, in our opinion, along with the defect size, a lax and weak abdominal wall muscle with redundancy of the skin plays an important role in this decision. Moreover, the short follow-up period in certain cases cannot be overlooked.


  Conclusion Top


Large abdominal wall defects can be safely and effectively closed by the component separation technique, with or without mesh reinforcement. Mesh reinforcement must be used in larger abdominal wall defects to decrease the recurrence rate, and at no risk of an increased rate of major postoperative complications. Preoperative evaluation of defect size, optimization of any current medical comorbidity, and clear parameters for mesh repair are of paramount importance. For better patient care, a conjoint multidisciplinary team must be involved. Our approach in this study was very conservative and remained close to the original report; it is our hope that there will be further upgrading of the research on this topic with more comparative results, which also address the shortcomings noted in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Awad ZT, Puri V, Leblanc K, Stoppa R, Fitzgibbons RJ, Iqbal A, Filipi CJ. Mechanisms of ventral hernia recurrence after mesh repair and a new proposed classification. J Am Coll Surgeons 2005; 201:132–140.  Back to cited text no. 14
    
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