Abdominal wall reconstruction with mesh and components separation

Abstract

Incisional hernias in the abdominal wall are a by-product of multiple previous laparotomies. Unfortunately, the incidence of incisional hernias has risen, as we have progressed with new surgical techniques in the treatment of abdominal pathologies. Many methods have been attempted in the past to achieve a better and more durable repair, namely using components separation to bring the fascia into the midline, and reinforce incisional hernias with different mesh materials. The authors review the recent literature regarding the efficacy of these synthetic materials and biomaterials in incisional hernia repair, as well as share their experience in treating complex abdominal wall defects using components separation and biologic mesh.

Keywords: biologic mesh; components separation; ventral hernia.

Figure 1

Subcutaneous lateral dissection through a 3 cm wide tunnel up to the linea semilunaris.

Figure 2

Subcutaneous tunnels dissected 2 cm lateral to linea semilunaris to allow the incision in the fascia as a part of the components separations.

Figure 3

Completion of the ventral hernia repair with application of the mesh under the fascia with wide overlapping of the fascia, closure of the fascia at the midline and components separations.

Figure 4

A 48-year-old patient with a history of multiple laparotomies and recurrent ventral hernia after two failed hernia repairs. (A) Components separation performed prior to minimally invasive components separation with preservation of the perforators to the skin. (B) Insertion of the porcine acellular dermal matrix (PADM) under the fascia with wide fascia overlap. (C) Closure of the fascia at midline over the PADM.

Figure 5

(A) A 50-year-old man with a history of recurrent ventral hernia exhibits loss of domain after gastric bypass and a repair of a ventral hernia with Marlex mesh. (B) Wide defect of the fascia with loss of domain. (C) Closure of the fascia after components separation and bridging with the porcine acellular dermal matrix (PADM). (D) Open wound with exposure of the PADM after dehiscence of the skin incision and after treatment with wound VAC for 3 weeks. (E) Wound with granulation tissue and decrease in size after 8 weeks of treatment with wound VAC. (F) Closed wound after treatment with split-thickness skin graft.