Endoscopic Component Separation

Published on 09/04/2015 by admin

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Last modified 09/04/2015

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Chapter 11 Endoscopic Component Separation image

Michael J. Rosen, MD, FACS

1 Clinical Anatomy

image The rectus muscle can be fairly wide, up to 8 to 10 cm, and therefore the initial cut down for the balloon dissector must be performed in the lateral abdominal wall to avoid inadvertently placing the balloon in the rectus sheath.
image Understanding the anatomic characteristics of the external and internal oblique muscles is critical to ensuring accurate placement of the balloon dissector when performing an endoscopic component separation. The external oblique is primarily fascialike on the lower to midabdomen and is more muscular laterally and cephalad. The internal oblique is primarily muscular except for the most medial 2 to 3 cm of fascia just before its insertion into the linea semilunaris.
image Clearly identifying the linea semilunaris is important to safely performing a component separation. Inadvertently transecting the linea semilunaris during a component separation will result in a full thickness defect of the lateral abdominal wall and a troublesome hernia to repair.
image The external oblique muscle inserts 5 to 7 cm above the costal margin and should be dissected off the ribs to maximize medialization.

2 Preoperative Considerations

1 Optimization of Comorbidities

image Abdominal wall reconstruction is a major surgical procedure requiring careful preoperative clearance. Smoking cessation is mandatory, weight loss is strongly encouraged, nutritional status is optimized, and cardiac status is stratified.

2 Anatomic Considerations

image Skin Considerations

image Skin ulcerations and peristomal excoriations are carefully prepared preoperatively to maximize healing potential. Because skin flaps are not raised in this technique, skin preservation is very important.
image The primary advantage of an endoscopic component separation is the elimination of lipocutaneous skin flaps. This reduces wound infections and flap ischemia. In cases where excess skin must be resected or skin flaps will be necessary to mobilize the skin to the midline, the endoscopic component separation should not be used. In these cases an open component separation or concomitant panniculectomy is performed as described in other chapters.

image Musculofascial Considerations

image Ideal characteristics for an endoscopic component separation include a relatively wide, well-preserved rectus muscle. With a wide rectus muscle, a large mesh typically can be placed in the retrorectus position as an underlay (as described in Chapter 5 without a skin flap).
image Component separation techniques have limitations. Large defects, >20 cm in width, and multiple recurrent hernias with fixed noncompliant abdominal walls often cannot be medialized with this technique. In addition, patients with transverse incisions should not be approached with an endoscopic technique.

image Reconstructive Considerations

image The surgeon should consider whether skin flaps will be necessary to place the mesh. The absence of skin flaps can create technical challenges in placing a large sheet of mesh as an underlay. If appropriate mesh placement requires large skin flaps, I perform an open technique.
image If the mesh must be placed in an intraperitoneal position without skin flaps and wide coverage, laparoscopic assistance is helpful as described in the following section.

3 Operative Steps

1 Equipment

image Equipment needs include a10-mm, 30-degree laparoscope; bilateral inguinal hernia balloon dissector (Covidien, Norwalk, CT); 30-mL balloon-tipped trocar (Covidien, Norwalk, CT); laparoscopic trocars; and an ultrasonic dissector or LigaSure™ device (Covidien, Norwalk, CT) (Fig. 11-1).
image Patients receive appropriate preoperative antibiotics and invasive monitoring as needed, and epidural catheters are routinely placed for postoperative pain control.
image

Figure 11-1

image Patient Positioning

image Patients are placed in the supine position with both arms abducted. Access to the posterior axillary line is important to place the lateral abdominal trocar during the endoscopic component separation and can be limited if the arm is tucked at the sides.

image Trocar Strategy

image Figure 11-2 shows trocar positioning, with lines showing the linea semilunaris, external oblique fascia, and costal margin
image The endoscopic component separation is typically performed first to avoid introducing any contamination from the midline wound into the lateral abdominal space. Given that these are closed spaces and no lymphatics are divided, drains are not routinely placed at the component separation sites.
image

Figure 11-2

image Endoscopic Component Separation Operative Steps

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