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| POSTERIOR COMPONENT SEPARATION |
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| Year : 2022 | Volume
: 5
| Issue : 1 | Page : 26-29 |
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Open transversus abdominis release
Kelly Tunder, Yuri Novitsky
The Comprehensive Hernia Center, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| Date of Submission | 29-Jun-2021 |
| Date of Decision | 09-Sep-2021 |
| Date of Acceptance | 11-Dec-2021 |
| Date of Web Publication | 23-Feb-2022 |
Correspondence Address:
Dr. Kelly Tunder
Advocate Aurora Health, Milwaukee, WI.
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_45_21
The management of most complex abdominal wall hernias remains a significant challenge and the approaches to repair them have evolved. To address these challenges, the posterior component separation using the transversus abdominis muscle release (TAR) was developed. Through cadaveric research and better understanding of the anatomy of the transversus abdominis muscle, the first TAR transversus abdominis release was performed in 2006. In the numerous studies performed since, TAR continues to show low recurrence rates, limited significant wound morbidity, rare mesh complications, and low incidence of mesh explantation. The TAR approach has now been definitively proven to be a valuable technique for abdominal wall reconstruction and can address a wide variety of defects. Moreover, a proper performed TAR has been shown to have no deleterious effects on the abdominal trunk musculature and trunk/core function. A deep understanding of the anatomy, preoperative optimization and precise surgical technique is imperative to performing a TAR and ensuring the best outcome for the patient. Keywords: Abdominal wall reconstruction, hernia, transversus abdominis release
How to cite this article:
Tunder K, Novitsky Y. Open transversus abdominis release. Int J Abdom Wall Hernia Surg 2022;5:26-9 |
| Introduction | |  |
The management of most complex abdominal wall hernias remains a significant challenge and the approaches to repair them have evolved. Since the original description of the anterior component separation technique by Ramirez in 1990, several modifications have been proposed to this technique.[1] The Rives-Stoppa retromuscular dissection proved to be insufficient for large defects, because it limits the degree of myofascial advancement while also preventing the placement of large prosthetic meshes required for reliable overlap of the visceral sac. Further, the original “posterior” component separation was associated with transection of neurovascular bundles to recti muscles.[2] To address these shortfalls, the posterior component separation using the transversus abdominis muscle release (TAR) was developed. Through cadaveric research and better understanding of the anatomy of the transversus abdominis muscle, the first TAR was performed in 2006. It was first presented in 2009 at the World Hernia Congress but was received with skepticism. It was not until 2012, when the 42-patient experience of Novitsky was published,[3] that the TAR approach had attained its recognition as a reliable alternative to complex abdominal wall reconstruction (AWR).
Initially, the technique came with scrutiny, questioning the effect on the lateral abdominal wall and spine stabilization. On comparative radiologic analysis of the rectus muscle and oblique, it was observed that there was compensatory hypertrophy of the rectus muscle, internal and external oblique. Cutting the TA and restoring the normal anatomy and linea alba caused increases to the rectus muscle mass by 23%, external oblique by 10%, and internal oblique by 17% from baseline.[4] A dynamometry study revealed an improvement in core abdominal wall functionality six months after TAR reconstruction.[5] In addition, 21 patients who underwent TAR reported improved back pain and quality of life at six months postoperatively.[6]
This evidence proved the safety and efficacy of the approach, which was followed by a steady increase in the acceptance and utilization of TAR by the surgical community. In 2016, the outcomes of 428 patients who underwent TAR were reported.[7] Of the 347 patients (81%) with at least one-year follow-up, there were 13 (3.7%) recurrences. The low recurrence rate is convincing considering that the patients with TAR had hernias larger in size than those seen with anterior component separation in separate studies. This is due to consistent restoration of the linea alba/rectus muscle medialization and sublay mesh placement. In the numerous studies performed since these initial studies, TAR continues to show low recurrence rates, limited significant wound morbidity, rare mesh complications, and a low incidence of mesh explantation.[8]
| Preoperative Optimization | | |
As with any surgery, preoperative workup and optimization is key to performing a successful surgery. Initially, patients undergo a noncontrasted computed tomography (CT) scan of the abdomen and pelvis, which can help determine the operative approach, size of the hernia defect, and the location of previously placed mesh/tacks. Preoperative optimization is an integral part of the process for patients, as it leads to improved postoperative outcomes. Smoking cessation for four weeks or greater, adequate hyperglycemic control (HgBA1C<7.5%), and weight loss are important.[9] Patients with a BMI>35 are referred to bariatrics and nutritional counseling. It is not recommended to offer elective hernia surgery for patients with a BMI>40–45, as it can increase their postoperative complications, including mesh infection, and increase cost.[10],[11] Postoperatively, it has been proven that enhanced recovery after surgery (ERAS) pathways has improved patient outcomes and reduced length of stay.[12],[13]
| Operative Technique | | |
As a surgeon looks to gain more experience in AWR, it is important to have proper understanding of the anatomy and technical aspects of the procedure. We recommend attending a mini-fellowship, cadaver dissection, or work with a mentor when first starting to perform a TAR. It is important to understand one’s learning curve and be committed to additional proctoring and tracking outcomes. The procedure can become difficult, especially in the setting of a recurrent hernia with a previously placed mesh. In short, a midline incision is performed and the abdomen is entered. After the lysis of adhesions, the medial border of the rectus sheath is identified and the contralateral retrorectus plane is entered 0.5–1 cm lateral to the linea alba. The retrorectus plane is then created until the border of this dissection is the semilunar line [Figure 1]. The posterior lamella of the internal oblique (lateral aspect of the posterior rectus sheath) is incised 1–2 cm medial to the semilunar line, ensuring not to injure the neurovascular bundles. This will expose the underlying transversus abdominis (TA) muscle [Figure 2]. Once the TA is identified, it is transected by using the cautery with firm medial traction of the posterior sheath. The dissection is carried out both cranially and caudally. Then, the lateral aspect of the transected TA must be separated from the underlying transversalis fascia. A small amount of cautery is applied to the underside of the TA and the fascia is swept down. This allows the dissection to proceed in the pretransversalis plane instead of the thin preperitoneal plane [Figure 3]. The pretransversalis plane is dissected laterally to the posterior axillary line, extending superiorly above the costal margin. The space of Retzius and Bogros is dissected in the preperitoneal plane. The best way to ensure that the dissection is completed is to either visualize the lateral aspect of the psoas or ensure that the posterior layers are lying on the viscera. The contralateral dissection is performed in a similar fashion. All fenestrations in the posterior sheath are closed with 2-0 vicryl, and the posterior sheath is then closed with 2-0 vicryl in a running fashion [Figure 4]. The polypropylene mesh is placed as a sublay in the retromuscular space in a home plate fashion. Two 19F retrorectus drains are placed, and the linea alba is restored with #1 Maxon suture [Figure 5]. The redundant soft tissue is excised, a 15F subcutaneous drain is placed, and the skin is closed in layers [Figure 6].[14] | Figure 1: Retrorectus dissection with transversus abdominis muscle fibers visible
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 | Figure 2: Cut fibers of the transversus abdominis muscles just medial to the semilunar line and the neurovascular bundles
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 | Figure 3: Completing the transversus abdominis muscle release by dissecting laterally into the pretransversalis plane
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 | Figure 4: Closed posterior sheath demonstrating the cut edge of the transversus abdominis
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 | Figure 6: Soft tissue and skin closure with two retrorectus drains and one subcutaneous drain in place
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| Special Populations | | |
Several populations, including patients undergoing kidney transplant, patients who have had a previous open abdomen, patients who have previously undergone acute compartment syndrome, patients with parastomal hernias, and patients with massive defects, increase the technical difficulty of the operation. The TAR has proven to be a versatile option for managing complex abdominal wall defects in comorbid patient populations.
| Common Pitfalls | | |
There are several pitfalls to be aware of when performing a TAR. One key technical aspect of the operation is to protect the linea semilunaris. Linea semilunaris injury can be caused by cutting the perforating neurovascular bundles at the lateral-most extent of the retrorectus dissection or the linea semilunaris is retracted medially as the surgeon attempts to incise the posterior lamella of the internal oblique. The injury leads to denervation of the rectus muscle, resulting in permanent abdominal wall laxity and an iatrogenic Spigelia More Detailsn hernia. This can be avoided by having a good understanding of the anatomy and keeping in mind the location of the linea semilunaris at all times.[15] Ensuring the release is far enough superiorly, inferiorly, and laterally to the psoas is a key component to the TAR. This ensures restoration of the visceral sac and overlap of the mesh. Staying in the pretransversalis plane as the dissection progresses laterally protects the posterior sheath from becoming too thin as compared with being in the preperitoneal plane. Small holes are fairly common in a complicated TAR and can be repaired with 2-0 vicryl. Larger holes that are not amenable to closure can be buttressed with nearby omentum, retroperitoneal fat or in dire cases of vicryl or biologic mesh. All holes in the posterior sheath must be closed; if not, an intraparietal hernia can occur. Obstructive findings in the postoperative patient must be investigated to ensure there is bowel herniated through the posterior sheath, causing an obstruction.[16] Patients undergoing transplant can be observed to be challenging due to their concurrent lifelong immunosuppression. Due to improvement of long-term survival in patients undergoing transplant, surgeons are witnessing more long-term complications such as incisional hernias, which are estimated to complicate up to 43% of patients undergoing orthotopic liver transplant.[17] Overall, 44 patients underwent a TAR and a retromuscular synthetic mesh was used in all cases with 93% achieving fascial closure. Postoperatively, there were five surgical site infections, four wound openings, one debridement, and one seroma drainage. They were followed for a median follow-up of 13 months, and there were 11 recurrences.[18] The TAR with a synthetic mesh is a great reconstructive option in select patients after abdominal visceral transplants.
| Conclusion | | |
The field of AWR has come a long way, due, in part, to the research done by Dr. Jean Rives and Dr. Rene Stoppa in the 1960s, the description of components separation by Dr. Ramirez, and finally our TAR procedure description. The TAR approach has now been definitively proven to be a valuable technique for AWR and can address a wide variety of defects. Moreover, a proper performed TAR has been shown to have no deleterious effects on the abdominal trunk musculature and trunk/core function. A deep understanding of the anatomy, preoperative optimization, and precise surgical technique is imperative to performing a TAR and ensuring the best outcome for the patient.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. Yuri Novitsky is an Associate Editor of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Associate Editor and their research groups.
| References | | |
| 1. | Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26.  |
| 2. | Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia 2008;12:359-62. |
| 3. | Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: A novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2012;204:709-16. |
| 4. | De Silva GS, Krpata DM, Hicks CW, Criss CN, Gao Y, Rosen MJ, et al. Comparative radiographic analysis of changes in the abdominal wall musculature morphology after open posterior component separation or bridging laparoscopic ventral hernia repair. J Am Coll Surg 2014;218:353-7. |
| 5. | Criss CN, Petro CC, Krpata DM, Seafler CM, Lai N, Fiutem J, et al. Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery 2014;156:176-82. |
| 6. | Haskins IN, Prabhu AS, Jensen KK, Tastaldi L, Krpata DM, Perez AJ, et al. Effect of transversus abdominis release on core stability: Short-term results from a single institution. Surgery 2019;165:412-6. |
| 7. | Novitsky YW. Hernia Surgery: Current Principles. New York: Springer; 2016. |
| 8. | Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB. Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 2016;264:226-32. |
| 9. | Slim K, Standaert D. Enhanced recovery after surgical repair of incisional hernias. Hernia 2020;24:3-8. |
| 10. | Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: Incidence, contributing factors, and treatment. Surg Infect (Larchmt) 2011;12:205-10. |
| 11. | Fischer JP, Wes AM, Wink JD, Nelson JA, Rohrbach JI, Braslow BM, et al. Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR). Hernia 2014;18:617-24. |
| 12. | Macedo FIB, Mittal VK. Does enhanced recovery pathways affect outcomes in open ventral hernia repair? Hernia 2017;21:817-8. |
| 13. | Jensen KK, Brondum TL, Harling H, Kehlet H, Jorgensen LN. Enhanced recovery after giant ventral hernia repair. Hernia 2016;20:249-56. |
| 14. | Wegdam JA, Thoolen JMM, Nienhuijs SW, de Bouvy N, de Vries Reilingh TS. Systematic review of transversus abdominis release in complex abdominal wall reconstruction. Hernia 2019;23:5-15. |
| 15. | Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): What are the real indications and where is the limit? Hernia 2020;24:333-40. |
| 16. | Kushner B, Holden S, Blatnik J. Surgical “error traps” of open posterior component separation-transversus abdominis release. Hernia 2021;25:1703-14. |
| 17. | de Goede B, Eker HH, Klitsie PJ, van Kempen BJ, Polak WG, Hop WC, et al. Incisional hernia after liver transplantation: Risk factors and health-related quality of life. Clin Transplant 2014;28:829-36. |
| 18. | Tastaldi L, Blatnik JA, Krpata DM, Petro CC, Fafaj A, Alkhatib H, et al. Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation. Hernia 2019;23:363-73. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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