Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
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Component seperation technique for the repair of very large ventral hernias
1. VENTRAL HERNIA REPAIR
BY
DR NIKHIL AMEERCHETTY
MS GENERAL SURGERY RESIDENT
email : nikhilameerchetty@gmail.com
2. Introduction
Protrusion Through The Anterior Abdominal Wall Fascia.
1. Spontaneous
2. Acquired
Incisional Hernias Account For 15% To 20% Of All Abdominal Wall Hernias
4 Million Laparotomies Performed Annually
2% To 30% Incidence Of Incisional Hernia,
150,000 Ventral Hernia Repairs Are Performed Each Year.
Rucinski J, Closure of the abdominal midline fascia,Am Surg 67:421–426, 2001.
7. Types
Open CST
Laproscopic CST
Endoscopic with open/laproscopic CST
Anterior CST
Posterior CST
All the above with or without mesh reinforcement
9. Abdominal Wall Reconstruction Utilizing the
Component Separation
Technique: Does Reinforcing Mesh Reduce
Recurrences?
J Scott Roth*, Dennis F Diaz, Margaret Plymale and Daniel L Davenport
Department of Surgery, University of Kentucky College of Medicine, Lexington, USA
10. Introduction
Incisional hernia Incidence 11-20% in patients undergoing laparotomy
Primary suture based repair - high incidence of recurrence.
Mesh for hernia repair improved recurrence rates .
Laparoscopic hernia repairs not suited for
1. Loss Of Abdominal Domain,
2. Infection
3. Abdominal Contamination.
Mudge M, Hughes (1985) Incisional hernia: a 10 year prospective study Br J Surg 72: 70-71.
Cengiz Y, Israelsson LA (1998) Incisional Hernia 2:175-177.
11. The Component Separation Technique (CST)
Ramirez and co-workers in 1990
Abdominal wall without the need for a synthetic mesh.
Autologous Tissue Transfer
Approximation Of The Rectus Abdominis Muscle Complex
Closure Of The Linea Alba Following Bilateral Release Of The External
Oblique Aponeurosis And Posterior Rectus Sheath.
12. Methods
Institutional Review Board approval
surgical database at the University of Kentucky 2004 - 2009.
Chi square test, Fisher’s exact test, or ANOVA .
14. Results
Total of 126 patients
Median follow-up 15.6 months (1-36 month range).
The overall recurrence rate was 20.6%.
Wound complications were seen in 46%
21. Conclusions
Wound complications following CST are increased in patients with
obesity.
Hernia recurrence rates are similar between primary, recurrent, and
multiply recurrent hernia repairs
Reinforcing CST hernia repairs with either biologic or synthetic mesh
has no proven advantage over an unreinforced repair.
WC, van den Tol MP, de Lange DC, Braaksma MM, et al.(2000) A comparison of suture repair with mesh repair for incisional hernia. N
Engl J Med 343: 392-398.
22.
23. Introduction
Very large incisional hernias defect of more than 10 cm .
The OCS gives an abdominal wall release of 10–15 cm on every side
24. Endoscopic component separation
The ECS can be combined with other open or laparoscopic
procedures
In 2007, Rosen et al.
Retrospective study of seven patients
The residual defect size 338 cm2 .
ECS enabled tension-free primary fascial reapproximation in all
patients.
25. Technique of ECS
A bilateral 15-mm skin incision below the costal margin
10-mm balloon dilator is inserted.
Blunt dissection between the external and internal oblique muscle.
Fascia of the external oblique muscle is vertically incised
26. Results
There was one superficial surgical site infection
No recurrences were identified.
27. STUDY
Harth and colleagues
Retrospective study
32 ECS to 22 OCS.
PARAMETRE ECS OCS
major wound morbidity (p=0.07) 19 % 41 %
recurrences rates (p=0.99) 27% 32%
Hospital length of stay (p=0.09) 8 11
28. STUDY
Bilateral ECS combined with an open sublay repair in 23 patients
Defect size of 210 cm2 .
The abdominal wall release on each side was 2–6 cm.
All patients received large-pore PP mesh.
Follow up 21 months
30. Statements
Level 3
The ECS is feasible with low morbidity
The ECS can be combined with lap IPOM, open IPOM, open sublay, and open onlay
technique in complex hernias
Abdominal wall release after ECS is less extensive than after OCS
There are fewer wound infections and wound healing problems after ECS compared to
OCS
Level 4
The question whether the lateral compartment should be augmented with mesh remains
unresolved.
31. Recommendations
Grade C
In large and very large ventral and incisional hernias, the ECS can
be considered in combination with open or laparoscopic mesh
techniques if the surgeon is able
32.
33. Methods
Medical records at Royal Liverpool Hospital from 2009 to 2012 were
reviewed.
Patients were classified by the Ventral Hernia Working Group
(VHWG) grading system.
Grade 1
Low risk
Grade 2
Comorbid
Grade 3
Potentially contaminated
Grade 4
Infected
No H/O wound infection Smoker Stoma present Infected mesh
Obese Previous wound infection Septic dihiscence
Diabetic Violation of
gastrointestinal tract
Immunosuppressed
34. Results
Twenty-three patients’ (15 males, 8 females) .
Median age 57 years (range20-76 years).
Median follow-up at the time of review was 17 months (range 2-48 months).
There were 13 grade III hernias and 10 grade IV hernias
Wound infection (13%), superficial wound dehiscence (22%), seroma formation (22%) and
stoma complications(9%).
Hernias have recurred in 3 patients (13%).
35.
36. Conclusions
Components separation and
reinforcement with biological mesh is a
successful technique in the grade III and
IV abdomen with acceptable rate of
recurrence and complications.
37.
38. Patients and methods
2006 and 2010,
Medical records analysed
Nine patients underwent the combination procedure.
Mean size of the transverse defect was 20 cm .
39.
40. Conclusion
Low recurrence rate in the short-term follow-up.
Increased occurrence of postoperative wound infections.
41.
42. Methods
75 patients over a 10-year period (2000 to 2010)
Adult patients (aged 18 to 75 years at the time of operation)
43.
44.
45.
46. Results
62% of recurrent hernias diagnosed within the first year
86% after a 2-year follow-up.
28% of recurrences were detected within 6 months
Hawn MT, Long-term follow-up . J Am Coll Surg 2010;210:
47. Conclusions
Literature review CST without mesh shows low recurrence rates -
underestimated
Author experience - high recurrence rate if follow up is more than a
year
Mesh augmentation will decrease recurrences,
48.
49. Methods
A single institutional retrospective review
42 patients ECS at a single institution by a single surgeon for ventral hernia repair with prosthesis
from 2010 to 2013.
17 patients open ventral hernia repair (OHR)
25 laparoscopic ventral hernia repair (LHR).
50.
51.
52.
53.
54.
55.
56. Conclusions
ECS with laparoscopic fascial re-approximation had
Shorter operative time
Estimated blood loss
Wound complications similar in both groups
Increase hernia recurrences post-operatively in the laparoscopic group.