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 .

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.

3. ANATOMY

4. Treatment: Operative Repair
 Primary repair – recurrence rate of 10 – 50%
 Mesh repair - recurrence rate of 5-25%
 Wright BE, , Is laparoscopic hernia repair Am J Surg 184:505–508
 Anthony T, Factors affecting recurrence , World J Surg 24:95–100, 2000.

5. Choice of operation ?????

6. COMPONENT SEPARATION
TECHNIQUE

7. Types
 Open CST
 Laproscopic CST
 Endoscopic with open/laproscopic CST
 Anterior CST
 Posterior CST
 All the above with or without mesh reinforcement

8. TECHNIQUE OF COMPONENT SEPERATION
TECHNIQUE
D

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 .

13.  Operative Reports Reviewed
 Biologic Or Synthetic Mesh .
 Demographic Data
 Complications (Wound Infection, Wound Necrosis, Abscess, Seroma , Cellulitis)
 Recurrences. ( Physical Examination Or Abdominal CT Scan) .

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%

16. 25.5 16.7 27.3

19. 46.0 20.6

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.

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

29. Complications
 Hematoma 3
 Lateral abdominal wall bulging 3
 Superficial wound infection 1

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

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%).

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.

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 .

40. Conclusion
 Low recurrence rate in the short-term follow-up.
 Increased occurrence of postoperative wound infections.

42. Methods
 75 patients over a 10-year period (2000 to 2010)
 Adult patients (aged 18 to 75 years at the time of operation)

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,

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).

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.

57. Thank you