Optimizing complex abdominal wall reconstruction, “Extended Component separation Technique”
Mirsad Mujadzic, MD, Matthew Hughes, BS, Edmond Ritter, MD.
Medical College of Georgia, Augusta, GA, USA.
PURPOSE:The Component separation (CS) technique originally described by Ramirez, O. demonstrated significant efficacy in closing large abdominal hernia. Benefits of this technique are: a decreased rate of infection, avoiding mesh placement and providing dynamic support of abdominal wall. The original CS technique is associated with a relatively high hernia recurrence rate ranging from 10-45%, probably related to significant tension at the time of closure. We describe our approach and analyzed its complication rate to improve the efficacy of the closure of complex abdominal hernias.
Over 5 years (January 2005-January 2009) 33 patients underwent hernia repair using CS technique: 21 men and 12 women, aging from 28 to 79 years. Size of the fascial defect ranged from 4x12 to 30x 34 cm.
In our “Extended component separation technique,” the original CS technique described by Ramirez,O was extended with two techniques well established and described in literature:
a) Detachment of the rectus and pectoralis muscles from their costal cartilage attachments
b) Subperiostal lateral abdominal wall muscle mobilization from iliac crest (approach similar to iliac crest bone harvest)
Fascial edges were fortified using acellular dermal allograft/xenograft in a double layer. The first layer was placed as an underlay beneath the fascia and the second layer as an overlay above the fascia attached to the lateral external oblique
We used an incremental approach based on size of hernia:
Increment 1. For smaller hernia 3-6 cm: rectus posterior sheath release
Increment 2. Moderate size hernia 6-12 cm: external oblique mobilization
Increment 3. Large hernia 12-18 cm:
a. Superiorly located: Superior rectus -pectoralis major mobilization
b. Inferiorly located: Subperiosteal iliac crest lateral abdominal wall mobilization
Increment 4. Extra large hernias >18 cm: Superior rectus -pectoralis major mobilization and subperiosteal iliac crest lateral abdominal wall mobilization
Our approach was compared based on 4 parameters: ability to achieve direct fascia approximation, skin necrosis, infection rate and recurrence rate. Follow-up was between 1-5 years.
In all 33 patients we achieved direct fascial approximation. There were no hernia recurrences. Skin necrosis occured in 2 patients and infection in 3 patients.
Extended Component Separation technique is helpful in the management of complex abdominal hernia by decreasing the overall complication rate. Extension should be incremental based on hernia size. Acellular dermal allograft/xenograft onlay and underlay further reduced hernia recurrence.