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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 42-47

Is the dissection of the abdominal wall still necessary in the treatment of W3 hernias?

1 Hamburg Hernia Center, Tabuk, Saudi Arabia
2 Hamburg Hernia Center, Tabuk, Saudi Arabia; University of Tabuk, Faculty of Medicine, Department of Surgery, Tabuk, Saudi Arabia
3 Klinik für Chirurgie-, Viszeral-, und Gefäßchirurgie, Vivantes Kilnikum Berlin-Spandau, Germany
4 Klinik für Allgemein-, Viszeral-, Transplant Chirurgie, Universitätsklinik Aachen, Germany

Date of Submission10-Aug-2021
Date of Decision28-Nov-2021
Date of Acceptance12-Dec-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Dr. Henning C Niebuhr
Hamburger Hernien Centrum, Eppendorfer Baum 8, 20249 Hamburg.
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_55_21

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Large incisional hernias are a permanent problem for surgeons in a growing number of operations. For the treatment of complex hernias, there are no internationally accepted evidence-based recommendations regarding the restoration of abdominal wall integrity. In this paper, we are reviewing the development of different component separations (CS) and other techniques used in treating such conditions. A literature review was carried out to describe some important techniques to treat giant hernias. After a detailed description of the CS and its important modifications, we are describing and discussing the relatively new fascial traction technique with its modification. With these reviews of the mentioned studies, we are questioning the extent to which the CS is still indicated in treating giant hernias and point out the importance of further comparison studies evaluating different techniques.

Keywords: Component separation, fasciotens, giant hernias, intraoperative fascial traction IFT, loss of domain, MILOS, TAR, techniques description

How to cite this article:
Niebuhr HC, Dag H, Malaibari Z, Köckerling F, Reinpold W, Helmedag M. Is the dissection of the abdominal wall still necessary in the treatment of W3 hernias?. Int J Abdom Wall Hernia Surg 2022;5:42-7

How to cite this URL:
Niebuhr HC, Dag H, Malaibari Z, Köckerling F, Reinpold W, Helmedag M. Is the dissection of the abdominal wall still necessary in the treatment of W3 hernias?. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2022 May 18];5:42-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/1/42/336221

  Introduction Top

Abdominal wall hernias are among the most common conditions requiring visceral and abdominal wall surgery. With a probability of about 20% 1 year after surgery, incisional hernia is a frequent late complication after laparotomy in visceral surgery and is one of the acquired abdominal wall defects.[1] Consequential conditions are limitations in physical resilience, in the intestinal and organ functions, pain, as well as cosmetic impairments, which have an immensely high socio-economic significance.[2]

Large incisional hernias are a permanent problem for surgeons in a growing number of operations on increasingly older and often obese patients. Hernia sizes of 10–25 cm transverse extension and up to 30 cm longitudinal extension are not uncommon. A particular problem with these complex hernias is the so-called loss-of-domain situation, in which a large part of the organs is no longer in the abdominal cavity but in the hernia sac.[2],[3]

According to the classification of the European Hernia Society (EHS), for complex W3 hernias, the hernia gap can no longer be closed without tension; therefore, complex reconstruction procedures and, if necessary, bridging with a mesh are required. For the treatment of complex hernias, there are no internationally accepted evidence-based recommendations regarding the restoration of abdominal wall integrity. Depending on the extent of the abdominal wall defect and the individual patient profile, different surgical procedures are used.

The concept of component separation (CS) is of great importance in the history of abdominal wall reconstruction [Figure 1]. As the complexity and extent of abdominal wall hernias pushed traditional surgical techniques to their limits, the development of a surgical technique to reduce tension through the lateral abdominal wall muscles by Albanese represented a milestone in the development of abdominal wall surgery.[4],[5] Ramirez et al.[6],[7] further developed this technique of classical anterior CS in the 1980s into a standard procedure for the treatment of very large abdominal wall and incisional hernias. In this procedure, the space between the external oblique muscle and the internal oblique muscle is dissected immediately lateral to the rectus compartment after extensive dissection of the subcutaneous tissue and bilateral dissection of the aponeurosis of the external oblique muscle. Subsequently, the rectus abdominis muscle is separated from its posterior rectus sheath, so that now the mobilization of the myofascial flap consisting of the ipsilateral part of the rectus muscle, the internal oblique muscle, and the transversus abdominis muscle (TAM) medially enables a tension-free closure.[8] A special feature of this procedure was the possibility of abdominal wall reconstruction without the need for alloplastic material. Unfortunately, however, this technique had high rates of recurrence and complications.[9],[10] These were due to a high risk of wound healing disorders (up to 48.2%) as well as an increased rate of hematoma and seroma up to skin necrosis[7],[11] caused by the extensive detachment of the subcutaneous tissue as well as the destruction of the perforating vessels of the rectus compartment. These disadvantages led to multiple modifications of this original technique.
Figure 1: Chronological overview of surgical therapy procedures for W3 hernias

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Rosen et al.[12] described the endoscopic anterior CS. They accessed the intermuscular space between external and internal oblique muscles lateral to the rectus abdominis muscle and below the costal margin. Like the inguinal TEP procedure, they did a blunt dissection using a balloon and a 10 mm 30° laparoscope to create their endoscopic space with 12 mmHg insufflation pressure. Using coagulation scissors, they released the external oblique from the costal margin to the inguinal ligament. They repeated the same procedure on the other side. This technique was followed by several modifications, such as releasing the internal oblique muscle described by Ng et al.[13] Jørgensen and co-workers[14] practiced and refined this technique.

The first posterior approach to CS was performed in 2007 by Milburn et al.[15] In a cadaveric study, they were able to show that a laparoscopic medial longitudinal release of the TAM resulted in the same release of the abdominal wall as the classic open anterior CS.

Another important modification of the original CS, which had been performed without positioning alloplastic material, was the placement of a mesh in the sense of the Rives operation.[16] The best position for this is the retromuscular/preperitoneal space.[17] However, midline closure in large hernias is often impossible without additional procedures. Posterior CS with TAR as described by Carbonell et al.[18] in 2008 was used to extend the operation to the lateral compartment of the abdominal wall and thus increase the mesh size [Figure 2]. The development of this technique was impressively described in 2019 by Reinpold[19] in this journal. After a longitudinal incision of the posterior rectus sheath and its complete separation from the rectus muscle, the posterior rectus sheath is then incised at its most lateral edge and the TAM is detached close to the linea semilunaris. This provides access to the space between the internal oblique muscle and the TAM, which can now be extended on both sides and function as an enlarged space for the positioning of the mesh. After suturing the posterior sheath, the mesh can now be placed in the retromuscular space and the anterior rectus sheath can be closed. It is true that this technique is a way of avoiding the wide subcutaneous epifascial mobilization. However, the dissection of the segmental nerves through the longitudinal incision of the posterior rectus sheath at the lateral edge of the rectus compartment leads to consecutive paralysis of the rectus muscle. Novitsky et al.[20] described a modification of posterior CS with TAR in 2012. By incising the posterior rectus sheath medial to the segmental nerves, these and their accompanying blood vessels could be identified and preserved.
Figure 2: A: External aponeurosis with anterior component separation acc. to Ramirez. B: Transversal aponeurosis with posterior component separation TAR. Sublay mesh position. With friendly permission of F. Köckerling

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Minimally invasive approaches represented the further development of the TAR technique.[21],[22],[23],[24],[25],[26],[27] For example, Belyansky et al.[21],[27] described the laparoscopic transperitoneal and endoscopic extraperitoneal TEP TAR technique. Reinpold et al.[28] have developed an endoscopic-assisted mini or less open (e-MILOS) TAR approach. Robotic-assisted TAR is another recent innovation in CS.[22],[23],[24],[25],[26],[27] Warren et al.[23] compared 103 standard laparoscopic ventral hernia repairs with 53 robotic-assisted TARs. Fascia closure was achieved more frequently with the robotic technique, but the duration of operation was significantly longer with the robot.

The incision of the transverse fascia medial to the semilunar line to avoid cutting all TAM fibers is another modification of the TAR procedure, the so-called “Madrid TAR modification” by Robin-Lersundi et al.[29]

Majumder et al.[30] quantified the medialization of the two rectus sheaths in a cadaver model using the individual steps of TAR. The authors concluded from their measurements that the TAR procedure allows effective reconstruction of very wide (≈20 cm) defects.

The modifications of the classical anterior CS technique resulted in a significant reduction of the epifascial wound area by avoiding the wide subcutaneous and epifascial preparation. The recurrence rate was also significantly reduced in the development of the surgical techniques. However, all these modifications are characterized by the fact that an abdominal muscle or its fascia is irreversibly separated and thus functionally inactivated. Long-term complications such as lateral abdominal wall weakness, postural defects, or bulging are thus made possible in the context of all CS techniques.

Eucker et al.[31] pursued the idea of avoiding component separation to preserve the integrity of the lateral abdominal wall in the treatment of W3 hernias when he performed intraoperative vertical fascia traction for the first time in Basel to achieve direct closure of a complex hernia. For the success of the procedure, a complete muscular relaxation during the approximately 30 min of traction is required. The first results of the treatment of 10 patients were published by Eucker et al.[31] in 2017. The hernias of all 10 patients treated in this way were successfully closed. No recurrences were observed in the median follow-up of 21 months (range 7–36 months).[31] However, the disadvantage of this procedure is that the force that can be applied to the fascia must be correctly assessed subjectively. The risk of tissue damage due to the tearing out of sutures or clamps in the case of excessive traction or the risk of insufficient tractions forces must thus be accepted. The lack of standards entailed certain dangers and made it seem necessary to quantify the traction force.

At the same time, the first results of a perioperative traction of the abdominal wall in the treatment of laparostoma patients with the fasciotens® Abdomen device were obtained. This innovative technique to avoid abdominal wall retraction in open abdomen not only antagonizes the retraction but also helps to recover already retracted (“frozen”) fascia.[32],[33],[34],[35]

This technique now made it possible to quantify the drag force applied to the fascia perioperatively in a standardized way. Traction forces of 7–8 kg were applied perioperatively for hours to the fascia to prevent fascial retraction in the treatment of open abdomen.

In the first intraoperative treatments of W3 hernias using fasciotens®Abdomen published by Niebuhr et al.,[36] traction forces of more than 10 kg were required. This need for quantification led to the development of the new fasciotens® Hernia device, which allows quantification of drag forces of up to 20 kg. It has been specially developed for the requirements of the treatment of complex hernias. Intraoperatively, after adhesiolysis and preparation of the fascia sheets, polyfiles suture material (six per fascia edge as U-suture) is sutured into the fascia of each side. These are then clamped diagonally into the retention frame of fasciotens® Hernia. Traction forces of up to 20 kg can then be chosen via a traction controller. More than 50 intraoperative applications have shown that traction forces of 12–14 kg are sufficient. In addition, the traction sutures are regularly retightened during the traction phase of 30 min to adapt the fascia in the direction of the midline [Figure 3].
Figure 3: Schematic illustration of the use of fasciotens® Hernia

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  Results Top

The evaluation of the first 21 patients treated with this technique showed, with a mean initial hernia width of 17.3 cm, an average and significant gain in length of the fascia of 9.8 cm through an intraoperative traction of 32.5 min on average. In a morbid patient collective (7 × ASA II, 14 × ASA III), intermediate VAC therapy was used only in three subcutaneous wound healing problems. One patient had to be closed again surgically for small fascia dehiscence (5 cm), with healing without complications.[36] In 20 out of 21 patients, closure could be performed without problems; one patient received bridging of the anterior fascial sheet. Despite the impressive average initial hernia width of 17.3 cm (8.5–44 cm), only one patient required an additional anterior CS, and one patient underwent TAR to enlarge the space for the mesh. None of the patients treated with intraoperative traction in the meantime experienced a method-specific complication.

Very promising is still unpublished data of 50 patients with a medium hernia width of 16.1 cm showing a closure rate of 90% after 30 min of intraoperative fascia traction [Figure 4].
Figure 4: Intraoperative gain of fascia during the traction period of 30 min. First the initial situation of a 16 cm hernia gap is shown. The fascia gap after 15 and 30 min prior to closure is depicted

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  Discussion Top

Due to the novelty of the intraoperative traction method, long-term results are not yet available. Eucker et al. report only one recurrent hernia in a total of 33 operated patients in a follow-up of up to 8 years (data not yet published). The results of the above-mentioned observational study as well as more than 50 successful applications of an intraoperative fascia traction show that intraoperative fascial traction is a promising new method for the therapy of complex hernias. Whether the reduction of the wound area and the more economical preparation compared with the established techniques of CS can reduce the complication rate, shown in further studies. However, the evaluation of 50 patients treated with fascia traction showed reoperation rate of 6%, which is clearly lower than applying any kind of CS techniques.[37],[38],[39],[40]

Regarding the attempt to minimize the access trauma, the length of the skin incision can now be limited to the diameter of the hernia gap according to the principles of the MILOS procedure.

The traction of the fascia can nevertheless be carried out over the entire length by using the transcutaneous crossed traction, which was recently used for the first times.

Reinpold[19] concluded in his article in this journal that all large and very large midline, lateral, or combined abdominal wall defects cannot be closed without TAR. Further studies need to show whether an extended space for mesh positioning will still be required for successful and recurrence-free midline closure of large, complex W3 hernias with loss-of-domain. In addition to the observational study presented, a prospective randomized study comparing the fascial traction procedure with the different forms of CS is in progress.

Financial support and sponsorship


Conflicts of interest

Prof. Ferdinand Köckerling is an Associate Editor, Prof. Henning C. Niebuhr and Prof. Wolfgang Reinpold are Editorial Board members 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 them and their research groups.

  References Top

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