Joshua S. Winder

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

Background: Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. Methods: The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. Results: The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. Conclusion: Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique

BACKGROUND Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution. METHODS We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence. RESULTS Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%). CONCLUSIONS Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.

Design strategies and applications of biomaterials and devices for Hernia repair

Hernia repair is one of the most commonly performed surgical procedures worldwide, with a multi-billion dollar global market. Implant design remains a critical challenge for the successful repair and prevention of recurrent hernias, and despite significant progress, there is no ideal mesh for every surgery. This review summarizes the evolution of prostheses design toward successful hernia repair beginning with a description of the anatomy of the disease and the classifications of hernias. Next, the major milestones in implant design are discussed. Commonly encountered complications and strategies to minimize these adverse effects are described, followed by a thorough description of the implant characteristics necessary for successful repair. Finally, available implants are categorized and their advantages and limitations are elucidated, including non-absorbable and absorbable (synthetic and biologically derived) prostheses, composite prostheses, and coated prostheses. This review not only summarizes the state of the art in hernia repair, but also suggests future research directions toward improved hernia repair utilizing novel materials and fabrication methods.

Comprehensive management of full-thickness luminal defects: The next frontier of gastrointestinal endoscopy.

Full thickness gastrointestinal defects such as perforations, leaks, and fistulae are a relatively common result of many of the endoscopic and surgical procedures performed in modern health care. As the number of these procedures increases, so too will the number of resultant defects. Historically, these were all treated by open surgical means with the associated morbidity and mortality. With the recent advent of advanced endoscopic techniques, these defects can be treated definitively while avoiding an open surgical procedure. Here we explore the various techniques and tools that are currently available for the treatment of gastrointestinal defects including through the scope clips, endoscopic suturing devices, over the scope clips, sealants, endoluminal stents, endoscopic suction devices, and fistula plugs. As fistulae represent the most recalcitrant of defects, we focus this editorial on a multimodal approach of treatment. This includes optimization of nutrition, treatment of infection, ablation of tracts, removal of foreign bodies, and treatment of distal obstructions. We believe that by addressing all of these factors at the time of attempted closure, the patient is optimized and has the best chance at long-term closure. However, even with all of these factors addressed, failure does occur and in those cases, endoscopic therapies may still play a role in that they allow the patient to avoid a definitive surgical therapy for a time while nutrition is optimized, and infections are addressed.

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release

IntroductionParastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration.MethodsA full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes.DiscussionThis repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

Reply: Posterior Component Separation with Transversus Abdominis Release

563e Reply: Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction Sir: We would like to thank our Italian colleagues for their thoughtful comments about our technical overview and for adding their modification of a similar method. We would like to make a few comments about their modification in comparison with the transversus abdominis release we described.1 First, one of the advantages of transversus abdominis release is the elimination of all skin flaps with the Dublin, Ireland).5 The size of this aid should provide for an overlap of a minimum of 6 cm. The two muscle bellies of the rectus muscle are then sutured with interrupted stitches on the midline, anchoring them to the underlying mesh and posterior sheath (Fig. 1). This maneuver allows the surgeon to obliterate dead spaces, minimizing fluid collection and mesh displacement. The anterior fascia is sutured with both interrupted and running sutures. Analogous to the previous layer, this suture should anchor the anterior fascia to the underlying rectus muscle (Fig. 2). The adipocutaneous excess is excised as in a common tummy-tuck procedure. Once the Scarpa fascia is synthesized, subcutaneous closure and intradermal suturing are performed. Our technique allows negligible scar overlapping (cutaneous and abdominal wall incisions), minimizing contaminations. The subcutaneous dissection allows an easier approximation of recti muscles and fascia, whereas the adipocutaneous excision produces a tight cutaneous layer that is able to effectively contain the underlying wall. DOI: 10.1097/PRS.0000000000002453

Force Comparison of Commercially Available Transfascial Suture Passers

Background. Transfascial suture passers (TSPs) are a commonly used surgical tool available in a wide array of tip configurations. We assessed the insertion force of various TSPs in an ex vivo porcine model. Methods. Uniform sections of porcine abdominal wall were secured to a 3D-printed platform. Nine TSPs were passed through the abdominal wall both without and with prolene suture under the following scenarios: abdominal wall only and abdominal wall plus underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion forces were recorded in Newton (N). Results. When passed without suture through the abdominal wall, smaller diameter TSPs required less insertional force (1.50 ± 0.17 N vs 9.68 ± 1.50 N [P = 0.00072]). Through composite mesh, the solid tipped TSPs required less force than hollow tipped ones (3.87 ± 0.25 N vs 7.88 ± 0.20 N [P = 0.00026]). Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty (Gore 2.95 ± 0.83 N vs Carter-Thomason 16.07 ± 2.10 N [P = .0005]) or with suture (Gore 8.37 ± 2.59 N vs Carter-Thomason 19.12 ± 1.10 N [P = .003]). Conclusions. Diameter plays the greatest role in the force required for TSP penetration. However, when passed through underlay mesh or while holding suture, distal tip shape, the mechanism of suture holding, and shaft diameter all contribute to the forces necessary for penetration. These factors should be considered when choosing a TSP for intraoperative use.

Colonoscopic-assisted percutaneous endoscopic gastrostomy tube placement

Percutaneous endoscopic gastrostomy (PEG) tube placement has become the mainstay for durable enteral access, eliminating the need for surgical gastrostomy [1, 2]. Placement requires a safe tract through the abdominal wall directly into the stomach. Colon interposition between the stomach and abdominal wall is uncommon, but precludes PEG tube placement [3]. In cases where the colon directly interferes with PEG tube placement, we have employed multimodal therapy by performing simultaneous colonoscopy, fluoroscopy, and upper endoscopy to permit PEG technique placement.

Open Parastomal Hernia Repair

Parastomal hernia formation, the presence of visceral contents protruding through an abdominal wall defect adjacent to an ostomy, represents a complex problem for the hernia surgeon. When compared to other types of ventral hernias, they occur at a higher rate, they are technically more difficult to repair, and they are associated with higher rates of surgical site occurrences and hernia recurrences. Recent reviews suggest that hernia formation complicates up to 50 % of stoma formation [1–6]. The presence of a parastomal hernia also increases the likelihood of a concomitant incisional hernia formation, which further complicates the repair of both hernias [7, 8]. Parastomal hernias have additional morbidity not associated with other hernias including poorly fitting stoma appliances, parastomal skin breakdown, stoma level obstruction, and pain which result in an overall negative impact on quality of life [9]. This chapter will provide an overview of the various types of open repair of parastomal hernias.

Common Bile Duct Stones: Health Care Problem and Incidence

Choledocholithiasis, or common bile duct (CBD) stones, are a common problem in the USA and Westernized cultures. Complications of choledocholithiasis can be serious, including biliary obstruction, gallstone pancreatitis, and cholangitis. The burden of the spectrum of diseases related to stones within the biliary tree is significant. Fortunately, with advances in diagnostic and therapeutic modalities, the mortality from these complications has declined over the past three decades. The gallbladder is the source of the majority of CBD stones in Westernized cultures. These are secondary stones, composed primarily of cholesterol. Populations at higher risk of gallstone formation (and therefore at risk of developing secondary CBD stones) including Native Americans, Mexican Americans, women, elderly patients, obese patients, those with certain chronic diseases (cirrhosis, cystic fibrosis, Sickle cell disease), patients experiencing rapid weight loss (bariatric surgery patients) and critically ill patients receiving total parenteral nutrition (TPN). Primary stones occur with greater prevalence in Southeast Asian populations. These stones, called brown stones, have a higher bilirubin content than cholesterol stones and are frequently infected. Retained stones are a subtype of secondary stones left in the biliary tree after cholecystectomy. Many retained stones pass spontaneously and are asymptomatic, though a proportion of patients with retained stones go on to develop CBD stone complications with signs and symptoms similar to patients with secondary CBD stones.