Open Retromuscular Ventral Hernia Repair

Published on 09/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

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Chapter 5 Open Retromuscular Ventral Hernia Repair image

1 Clinical Anatomy

2 Preoperative Considerations

3 Operative Steps

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 Lateralization of the Dissection Plane Beyond the Linea Semilunaris

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.

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 Mesh Fixation

4 Postoperative Care

6 Pearls and Pitfalls

4 Technical Considerations