Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model

Arnab Majumder, Luis A. Martin-del-Campo, Heidi J. Miller, Dina Podolsky, Hooman Soltanian, Yuri W. Novitsky

Research output: Contribution to journalArticle

Abstract

Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters. Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. Graphic Abstract: [Figure not available: see fulltext.].

Original languageEnglish (US)
JournalSurgical endoscopy
DOIs
StateAccepted/In press - Jan 1 2019

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Herniorrhaphy
Fascia
Abdominal Muscles
Abdomen
Dissection
Muscles
Laparotomy
Ventral Hernia
Elasticity
Cadaver

Keywords

  • Component separation
  • External oblique release
  • Myofascial advancement
  • Transversus abdominis release
  • Ventral hernia repair

ASJC Scopus subject areas

  • Surgery

Cite this

Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model. / Majumder, Arnab; Martin-del-Campo, Luis A.; Miller, Heidi J.; Podolsky, Dina; Soltanian, Hooman; Novitsky, Yuri W.

In: Surgical endoscopy, 01.01.2019.

Research output: Contribution to journalArticle

Majumder, Arnab ; Martin-del-Campo, Luis A. ; Miller, Heidi J. ; Podolsky, Dina ; Soltanian, Hooman ; Novitsky, Yuri W. / Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model. In: Surgical endoscopy. 2019.
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title = "Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model",
abstract = "Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters. Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. Graphic Abstract: [Figure not available: see fulltext.].",
keywords = "Component separation, External oblique release, Myofascial advancement, Transversus abdominis release, Ventral hernia repair",
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T1 - Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model

AU - Majumder, Arnab

AU - Martin-del-Campo, Luis A.

AU - Miller, Heidi J.

AU - Podolsky, Dina

AU - Soltanian, Hooman

AU - Novitsky, Yuri W.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters. Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. Graphic Abstract: [Figure not available: see fulltext.].

AB - Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters. Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. Graphic Abstract: [Figure not available: see fulltext.].

KW - Component separation

KW - External oblique release

KW - Myofascial advancement

KW - Transversus abdominis release

KW - Ventral hernia repair

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