Open Retromuscular Ventral Hernia Repair

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Chapter 5 Open Retromuscular Ventral Hernia Repair image

Yuri W. Novitsky, MD, FACS

1 Clinical Anatomy

image Retrorectus repair requires a thorough knowledge of the relative anatomy of the myofascial components of the abdominal wall.
image The rectus abdominis, a long, broad, strap-like muscle, is the principal vertical muscle of the anterior abdominal wall. Its origin is at the pubic symphysis and pubic crest. The muscle is inserted into the cartilages of the fifth, sixth, and seventh ribs. The rectus abdominis is three times as wide superiorly as it is inferiorly.
image The rectus abdominis is innervated by the thoracoabdominal nerves T7-T12. The main trunks of the intercostal nerves pass anteriorly from the intercostal spaces and run between the internal oblique and transversus abdominis muscles in a so-called neurovascular plane. The inferior intercostal, subcostal, and lumbar arteries accompany the nerves of this plane.
image In addition, the lateral cutaneous nerve branch of T12, as well as the ilioinguinal and iliohypogastric both enter the space between the internal oblique and transversus abdominis via the lateral border of the transversus muscle. These nerves, along with the ventral primary rami of the inferior six thoracoabdominal nerves (T7-11) innervate the anterolateral abdominal wall skin and musculature.
image The rectus sheath is the strong, incomplete fibrous compartment for the rectus abdominis muscle. It forms by the fusion and separation of the aponeurosis of the lateral abdominal muscles.
image At its lateral margin, the internal oblique aponeurosis splits into two layers, one passing anterior to the rectus muscle and the other passing posterior to it. The posterior layer joins with the aponeurosis of the transverse abdominis muscle to form the posterior wall of the rectus sheath. Muscle fibers of the transversus abdominis end in an aponeurosis, which contributes to the formation of the rectus sheath.
image The lateral abdominal wall consists of three flat muscles: external oblique, internal oblique, and transversus abdominis. The flat muscles cross each other similar to a three-ply corset that strengthens the abdominal wall and diminishes the risk of herniation between the muscle bundles. One important consideration for the retrorectus repair is the fact that in the upper third of the abdomen, the transversus abdominis extends medially beyond the overlying linea semilunaris as a primary muscular component not as fascia (Fig. 5-1).
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Figure 5-1

2 Preoperative Considerations

image Preoperative Imaging

image I recommend routine abdominal/pelvic computed tomography (CT) imaging. CT delineates all abdominal wall defects, assessment of the integrity of the remaining abdominal wall musculature, allows for detection of previous synthetic meshes and/or occult infection, and facilitates perioperative planning. I also mandate a screening colonoscopy in appropriate patients before undertaking major abdominal wall reconstructions.

image Preoperative Optimization

image Nutritional evaluation and counseling for obese patients is paramount, and weight loss surgery should be considered.
image Smoking cessation is mandatory
image Cardiac and pulmonary status should be assessed and optimized.

image Choosing the Type of Mesh

image Use a large, synthetic mesh with or without an antiadhesive barrier. I prefer a large (30 × 30 cm) macroporous, reduced-weight polypropylene mesh.
image Composite synthetic mesh with an antiadhesive barrier may need to be used if visceral exposure through fenestrations in the posterior layer is possible/likely.
image Biologic or biodegradable mesh should be considered in all contaminated and potentially contaminated fields. Synthetic mesh should be avoided in patients with a previous history of mesh infection, especially methicillin-resistant Staphyloccus aureus (MRSA). In addition, biologic meshes should be considered in patients with multiple comorbidities (morbid obesity, diabetes, systemic steroids or other form of immunosuppression, etc) and resultant increased risks of wound/mesh infections.

3 Operative Steps

image Planning Incision

image A generous midline laparotomy is required.
image Elliptical incisions are used to incorporate previous scars, skin ulcerations, and/or defects. For most, and especially morbidly obese, patients with large midline hernias, I recommend excision of the umbilicus to minimize postoperative wound morbidity.
image Use an inverse “T” incision, if panniculectomy is contemplated.

image Lysis of Adhesions, Removal of Old Mesh

image Complete lysis of all visceral adhesions to the anterior abdominal and pelvic walls is performed. This is particularly important in cases where dissection lateral to the linea semilunaris is undertaken. Inter-loop adhesions are typically ignored.
image If possible, complete excision of all previously placed mesh is performed.

image Incision of the Posterior Rectus Sheath (Rives-Stoppa-Wantz Technique)

image To dissect the retromuscular space to the linea semilunaris, the posterior rectus sheath is incised sharply about 0.5 cm from its edge (Fig. 5-2, A). This typically is initiated at the level of the umbilicus. The retromuscular plane is then developed using a combination of blunt dissection and electrocautery. The lateral extent of this dissection is the linea semilunaris, confirmed by visualizing the junction between the posterior and anterior rectus sheaths (Fig. 5-2, B). Careful identification of the intercostal nerves and vessels is critical to maintaining an innervated functional abdominal wall (Fig. 5-2, C).
image Exposure of Cooper’s ligaments/pubis is shown in Figure 5-3. Inferiorly, the space or Retzius is entered to expose the pubis symphysis and both Cooper’s ligaments. This dissection is blunt in what is typically a bloodless plane. Since this area is below the arcuate line, posterior layer includes peritoneum and transversalis fascia only. Because both of these layers are very thin, fenestrations are not uncommon and should be repaired. Care should be taken to identify and preserve inferior epigastric vessels that course along the deep surface of the rectus muscles. The urinary bladder may be filled with saline to facilitate its identification and dissection. This is particularly prudent in patients with a previous history of pelvic surgery.
image Exposure of the subxiphoid space is shown in Figure 5-4. The retromuscular plane can be extended cephalad to the costal margin and to the retroxiphoid/retrosternal areas.
image image image image

Figure 5-2

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Figure 5-3

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Figure 5-4

image Lateralization of the Dissection Plane Beyond the Linea Semilunaris

image Traditional Rives-Stoppa-Wantz dissection is carried out to the lateral edge of the rectus sheath. However, such dissection is insufficient for some patients undergoing major abdominal wall reconstructions for three main reasons: (1) insufficient medial advancement of the posterior rectus sheath, (2) decreased potential for medialization of the rectus muscles, and (3) insufficient space for large prosthetic reinforcement.
image Three techniques for lateral extension of the retromuscular plane have been described. They are the preperitoneal, posterior component separation with intramuscular dissection, and the posterior component separation with transversus abdominis release (TAR). A description of each follows.

• Preperitoneal: The preperitoneal plane may be entered immediately at the medial border of the rectus sheath. Kocher clamps are placed on the edge of the posterior rectus fascia and peritoneum is incised. Alice clamps are then placed on the cut edge of the peritoneum and the plane is developed laterally using blunt dissection. Medial traction applied by the Alice clamps significantly facilitates the dissection. This technique has significant limitations, as it does not provide for any fascial release/advancement. In addition, peritoneal flap (especially its medial edge) is very tenuous in many patients and may tear easily. Such fenestrations should be repaired primarily or buttressed by underlying visceral fat and/or omentum. If complete exclusion of the peritoneal cavity is not possible, this plane should be bridged or buttressed with an absorbable, a biodegradable or a biologic mesh.
• The preperitoneal plane also can be entered from within the rectus sheath. Following a traditional retromuscular dissection (described above), the posterior rectus sheath is incised about 1 to 2 cm medial to the linea semilunaris. Once the plane is entered, the dissection is carried out as described above.
• Posterior component separation with intramuscular dissection (Fig. 5-5): Starting in the periumbilical area, the lateral edge of the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. This allows access to the plane between the internal oblique and transversus abdominis muscles. The dissection is carried out laterally using electrocautery. The main limitation of this technique is division of the neurovascular bundle to the abdominal musculature traversing this plane.
• Posterior component separation with transversus abdominis release (TAR): Starting in the upper third of the abdomen, about 0.5 cm medial to the anterior/posterior rectus sheath junction (linea semilunaris), the posterior rectus sheath is incised to expose the underlying transversus abdominis muscle (Fig. 5-6, A and B). The muscle is then divided along its entire medial edge using electrocautery. The use of a right-angled dissector significantly facilitates this release and minimizes injury to the underlying transversalis fascia and peritoneum. Transection of the medial edge of the transversus abdominis muscle allows for entrance to the space between the transversalis fascia and the lateral edge of the divided transversus abdominis muscle (Fig. 5-7). The retromuscular space is bluntly developed further laterally to as far as the lateral border of the psoas muscle to allow for a reinforcement of a visceral sac with a large mesh (Fig. 5-8). Also, if needed, this dissection may be extended superiorly above the costal margin and inferiorly to expose both myopectineal orifices (Fig. 5-9).

image The key component to the release is the division of the entire medial edge of the transversus abdominis muscle. The main function of the transversus is to act as a “corset” around the abdomen. The synergistic action of the transversus and the posterior fibers of the internal oblique produce hoop tension through the thoracolumbar fascia. By dividing the transversus abdominis, I am able to release the circumferential muscle tension and not only provide for expansion of the abdominal cavity but also afford significant medial advancement of the posterior rectus fascia (Fig. 5-10).
image

Figure 5-5

image image image image

Figure 5-6

image image

Figure 5-7

image

Figure 5-8

image

Figure 5-9

image

Figure 5-10

image Posterior Layer Reconstruction

image Once release is performed on both sides, the posterior rectus sheaths are reapproximated in the midline with a running monofilament suture (Fig. 5-11, A and B). Interrupted figure-of-8 sutures may be used if there is significant tension or pulmonary plateau pressures increase by 5 mm Hg or more.
image Fenestrations in the posterior fascia and/or peritoneum laterally are closed primarily or buttressed with native tissue (i.e., omentum), absorbable, biodegradable, or biologic mesh.
image Hemostasis is ensured.
image Copious antibiotic-laden pulse lavage of the newly created extraperitoneal space is performed.
image image

Figure 5-11

image Mesh Fixation

image The mesh is placed as a sublay in the retromuscular space (Fig. 5-12).
image The inferior edge of the mesh is secured to both Cooper’s ligament using 2 to 4 interrupted monofilament sutures. The mesh may be positioned to also reinforce both myopectineal orifices.
image Superiorly, the mesh could be placed in beyond the costal margin and in the retroxiphoid space. It is secured with interrupted sutures around the xiphoid process. Those sutures are placed 4 to 5 cm off the edge of the mesh to allow for large overlap, especially for subxiphoid defects. Similarly, even though the mesh edge may be significantly beyond the costal margin, fixation is performed below the margin to reduce the risks of lung injury.
image The mesh is then fixated circumferentially with full-thickness, transabdominal sutures using the Reverdin needle (Figs. 5-13 and 5-14, A and B).
image The mesh should be placed under appropriate “physiologic” tension. Laxity is of particular concern if biologic mesh is used because mesh “wrinkling” would lead to seromas, infections, and possible mesh degradation and/or weakening. The transfascial sutures should be placed under physiologic tension, so that when they are secured, they provide medialization of the rectus muscles. In doing so, the midline fascia is reapproximated while the mesh is taut, preventing wrinkling when closing the fascia. Alternatively, if the mesh is placed “tension free” and then the fascia is closed, the prosthetic will buckle.
image Drainage: Closed suction drains are placed ventral to the mesh. Subcutaneous drains are used selectively.
image

Figure 5-12

image

Figure 5-13

image image image image

Figure 5-14

image Reconstruction of the Linea Alba

image The anterior rectus sheaths are then reapproximated in the midline to restore the linea alba. A running, slowly absorbable suture is used. Alternatively, interrupted figure-of-8 stitches can be used, especially when there is a potential predisposition to the abdominal compartment syndrome.
image In rare instances when the anterior rectus sheath cannot be reapproximated, external oblique fascia release (open or endoscopic) may be performed. However, it is important to not combine the anterior external oblique release with a transversus abdominus release. If both muscle layers are released, the lateral abdominal wall can become destabilized.

4 Postoperative Care

image General

image Intraoperative hemodynamics and airway pressures affect postoperative care. Overnight intensive care unit admission is recommended for patients undergoing major abdominal wall reconstructions. Long operative times and prolonged exposure of the abdominal cavity to room air lead to significant insensible losses and predispose to large fluid shifts. As a result, patients undergoing complex abdominal wall reconstructions often remain intubated overnight. In addition, those patients with poor pulmonary reserve and/or significant increase in plateau airway pressures are kept paralyzed for 24 to 48 hours postoperatively.
image The drains are kept in place until the output is <20 mL per day.
image When a biologic graft is used, the drains are left in place for at least 2 weeks, regardless of the output.
image Antibiotics are continued for up to 24 hours, unless otherwise indicated.
image Aggressive deep vein thrombosis prophylaxis is mandatory. I do not use systemic anticoagulation and/or caval filters, unless specifically indicated. Ambulation is avoided until the second postoperative day.
image Abdominal binders are used in the early postoperative period. Beyond the first week, their use is liberalized at the patient’s discretion.

image Pain Management

image Epidural catheters are strongly recommended. Epidural catheters are maintained until patients are tolerating a diet and have full return of bowel function. In addition, scheduled (not prn) intravenous diazepam (Valium) is given for muscle relaxation and spasm prevention.

image Diet

image Routine nasogastric tube decompression is reserved for patients with intestinal resections, significant intestinal manipulations, and prolonged adhesiolysis. Diet advancement is very conservative in order to avoid early postoperative bloating, retching, and vomiting, which may lead to pulmonary complications, as well as disruption of the repair. As a result, diets are not advanced until return of bowel function occurs.

5 Outcomes

image Retromuscular (Rives-Stoppa-Wantz) repair has been shown to result in an effective repair of most ventral hernias. Recurrence rates of 3% to 6% at mid- to long-term follow-ups have been reported. In fact, in 2004, given its superior track record, this approach was proclaimed to be the gold standard for open ventral hernia repair by the American Hernia Society.
image The posterior component separation and retromuscular repair has the following advantages: (1) it is relatively easy to adopt, (2) it is applicable in a broad range of patients, (3) the creation of skin flaps is avoided, and (4) the risk of lateral laxity/bulging is low.

An additional advantage is that sublay mesh placement allows for giant prosthetic reinforcement of the visceral sac and for proper mesh placement and sufficient mesh overlap for repair of hernias in difficult locations including the subxiphoid, suprapubic, flank, and parastomal areas.

image It may also be the best space for a biologic graft positioning to maximize the environment for graft integration and regeneration via superior blood supply.

6 Pearls and Pitfalls

1 Anatomy

image Neurovascular bundles supplying rectus muscles run in between transversus abdominis and internal oblique muscles and traverse posterior rectus sheath near the linea semilunaris, entering rectus muscle at its lateral edge. Care should be taken to identify and preserve these nerve bundles during the retrorectus dissection to prevent denervation of the rectus muscles
image The transversus abdominis muscle is the “corset” of the abdomen and is the muscle mostly responsible for intraabdominal pressure. It extends more medially than both internal and external obliques. These anatomic features allow for TAR in posterior component separation.

2 Preoperative Considerations

image Smoking cessation is mandatory. Abdominal wall reconstructions in smokers carry a high risk of wound morbidity and repair failures.
image Abdominal imaging (CT) should be performed routinely.
image Both synthetic and biologic meshes can be used in complex repairs even if component release has been performed. Mesh choices should be based on the multitude of patient factors and surgeon preferences and is more completely covered in Chapter 19.

3 Intraoperative Considerations

image Complete lysis of visceral adhesions to the abdominal wall is performed to facilitate fascial advancement and to avoid subsequent intestinal injuries during component release.
image Removal of ALL previous meshes is essential to allow optimum prosthetic integration and reduce postoperative infectious complications.

4 Technical Considerations

image In many patients, retromuscular dissection to the extent of the lateral edge of both rectus sheaths may be sufficient.
image Release of the posterior rectus sheath (posterior component separation) could be achieved with or without transversus abdominis muscle release. Posterior component separations should NOT be combined with any type of the anterior release. Traditional retrorectus dissection, on the other hand, could be an excellent adjunct to the anterior (external oblique) release to allow for sublay mesh placement.
image Fenestrations in the transversalis fascia should be repaired.
image If posterior rectus sheaths cannot be re-approximated, omentum, remnants of the hernia sac, or an absorbable mesh can be used to “bridge” the gap.
image Complete exclusion of the abdominal viscera is essential to both avoid intestinal herniations/strangulations through defects in the posterior layer of reconstruction and to avoid intestinal exposure to uncoated synthetic meshes.
image The mesh should be sized to provide significant reinforcement of the whole visceral sac. Typically, at least a 30 × 30 cm synthetic or a 20 × 20 cm biologic mesh is used.
image Mesh fixation is performed with a wide lateral overlap. Full-thickness transabdominal sutures are used to fixate the mesh and to provide physiologic tension across the entire abdominal wall. “Tension-free” repair of the abdominal wall is not adequate if preservation of the abdominal wall function is intended.
image Fixated biologic mesh should be taut without bucking/wrinkling.
image Follow pulmonary plateau pressures to minimize risks of postoperative abdominal hypertension and respiratory failures. In cases of significant (>5 mmHg) intraoperative plateau pressures elevation, fascial bridging, postoperative mechanical ventilation, and/or paralytics may be employed.

5 Postoperative Care

image Aggressive pain management, including epidural and intravenous antispasmodic agents, is mandatory.
image Advance diet slowly.
image Keep drains until output is <20 mL per day, especially when a biologic mesh used.

Selected References

Carbonell A.M., Cobb W.S., Chen S.M. Posterior components separation during retromuscular hernia repair. Hernia. 2008;12(4):359-362.

Conze J., Prescher A., Klinge U., et al. Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the “fatty triangle. Hernia. 2004;8(3):255-259.

Hammond D.L., Ackerman L., Holdsworth R., Elzey B. Effects of spinal nerve ligation on immunohistochemically identified neurons in the L4 and L5 dorsal root ganglia of the rat. J Comp Neurol. 2004;475(4):575-589.

Iqbal C.W., Pham T.H., Joseph A., et al. Long-term outcome of 254 complex incisional hernia repairs using the modified Rives-Stoppa technique. World J Surg. 2007;31(12):2398-2404.

Novitsky Y.W., Porter J.R., Rucho Z.C., et al. Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias. J Am Coll Surg. 2006;203(3):283-289.

Rives J., Pire J.C., Flament J.B., et al. [Treatment of large eventrations. New therapeutic indications apropos of 322 cases]. Chirurgie. 1985;111(3):215-225.

Rosen MJ, Fatima J, Sarr MG: Repair of abdominal wall hernias with restoration of abdominal wall function. J Gastrointest Surg 14(1):175–185.

Stoppa R.E. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13(5):545-554.

Wirhed R. Athletic Ability & the Anatomy of Motion. Wolfe Medical Publications Ltd; 1984.

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