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Background Posterior Component Separation (PCS) is a surgical technique used in abdominal wall reconstruction. Understanding the relationship between the rectus abdominis and transversus abdominis muscles and the location of intercostal nerves is crucial for minimizing nerve injury during PCS. This cadaveric study aimed to investigate these anatomical relationships and propose practical guidelines for safer PCS procedures. Methods Eighteen fresh cadavers were dissected to assess the overlap or separation of the rectus abdominis and transversus abdominis muscles at seven abdominal levels. The distance of intercostal nerves from the lateral border of the rectus abdominis was measured. Results The study found that the muscles overlapped at the xiphoid and upper abdominal levels but began to separate below the 2/4 upper to umbilicus level. Intercostal nerves entered at varying distances from the lateral edge of the rectus abdominis, suggesting that levels above the 3/4 upper to umbilicus level are relatively safe for dissection. Conclusion The study recommends initiating the first incision for PCS between the subxiphoid and 2/4 upper to the umbilicus, based on observed muscle relationships and nerve distances. This practical approach enhances safety and simplifies decision-making during surgery. [ABSTRACT FROM AUTHOR]

Purpose: Given its potential advantages, open Transversus Abdominis Release (oTAR) has been proposed as a durable solution for complex AWR. However, its applicability in different scenarios remains uncertain. We aimed to analyze the current available evidence and determine surgical outcomes after oTAR. Methods: We performed a systematic electronic search on oTAR in PubMed/Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Postoperative morbidity and recurrence rates were included as primary endpoints and Quality of life (QoL) was included as secondary endpoint. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) between all studies. Results: A total of 22 studies with 4,910 patients undergoing oTAR were included for analysis. Mean hernia defect and mesh area were 394 (140–622) cm2 and 1065 (557–2206) cm2, respectively. Mean follow-up was 19.7 (1–32) months. The weighted pooled proportion of recurrence, overall morbidity, surgical site occurrences (SSO), surgical site infection (SSI), surgical site occurrences requiring procedural intervention (SSOPI), major morbidity and mortality were: 6% (95% CI, 3-10%), 34% (95% CI, 26-43%), 22% (95% CI, 16-29%), 11% (95% CI, 8-16%), 4% (95% CI, 3-7%), 6% (95% CI, 4-10%) and 1% (95% CI, 1-2%), respectively. A significant improvement in QoL after oTAR was reported among studies. Conclusion: Open TAR is an effective technique for complex ventral hernias as it is associated with low recurrence rate and a significant improvement in QoL. However, the relatively high morbidity rates observed emphasize the necessity of further patients' selection and optimization to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Posterior component separation with transversus abdominis release (TAR) is considered to be the optimal technique for large incisional ventral hernia repair. Endoscopic TAR (eTAR) that gets all the benefits of minimally invasive surgery (MIS) gives a possibility to enhance results of the treatment. The aim of our study was to make the comparison between open and endoscopic TAR procedures with an emphasis on frequency and severity of postoperative complications in comparable groups. Materials and methods: All patients had midline incisional hernia and underwent either open (open TAR group) or endoscopic (eTAR group) Rives-Stoppa repair in combination with bilateral transversus abdominis release in Moscow City Hospital №1 from January 2018 to December 2022. A propensity score matching (PSM) was used to make groups comparable. Postoperative complications were classified according to Clavien-Dindo Classification, and Comprehensive complication index was calculated. Results: We performed 133 open and endoscopic TAR separation for midline incisional hernia. After PSM analysis 51 patients were matched to each group. Overall surgical morbidity in the open TAR group (56.9%) was statistically significantly higher than in the eTAR group (29.4%) (p = 0.009). There were more severe complications (Clavien IIIa-V) in the open TAR group (11.8% vs. 0%, p = 0.027). Length of hospital stay after surgery was shorter in eTAR group (p < 0.001). The Comprehensive complication index in the open TAR group was significantly higher than in eTAR group, 8.7 (0–20.9) vs. 0 (0–8.7) (p = 0.011). Conclusion: Based on the data from our study, the entire MIS procedure including endoscopic TAR is a safe and optimal technique for surgery of midline incisional ventral hernia, requiring TAR separation in terms of reducing the rate of postoperative complications, their severity and hospital length of stay, compared to open TAR procedure. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to perform a systematic review and meta-analysis to summarize various approaches in performing minimally invasive posterior component separation (MIS PCS) and ascertain their safety and short-term outcomes. Methods: A systematic literature searches of major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify studies that provided perioperative characteristics and postoperative outcomes of MIS PCS. Primary outcomes for this study were: surgical site events (SSE), surgical site occurrence requiring procedural intervention (SSOPI), and overall complication rates. A random-effect meta-analysis was conducted which allows computation of 95% CIs using simple approximation and incorporates inverse variance method with logit transformation of proportions. Results: There were 14 studies that enrolled 850 participants that were included. The study identified rate of SSE, SSOPI, and overall rate of complications of all MIS TAR modifications to be 13.4%, 5.7%, and 19%, respectively. Conclusions: Our study provides important information on safety and short-term outcomes of MIS PCS. These data can be used as reference when counseling patients, calculating sample size for prospective trials, setting up targets for prospective audit of hernia centers. Standardization of reporting of preoperative characteristics and postoperative outcomes of patients undergoing MIS PCS and strict audit of the procedure through introduction of prospective national and international registries can facilitate improvement of safety of the MIS complex abdominal wall reconstruction, and help in identifying the safest and most cost-effective modification. [ABSTRACT FROM AUTHOR]

Introduction: Incisional hernias with a defect width of more than10 cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. Methods: A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. Results: The standard PCSTAR can generally be used for a defect width of up to 15–17 cm. For defects greater than 17 cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0–97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. Summary: For a defect width greater than 17 cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia. [ABSTRACT FROM AUTHOR]

Background: Complex incisional hernia is still a debatable topic, with increasing incidence and an increased local and systemic postoperative morbidity and mortality. The size of the defect is a risk factor for both difficult closure and 30-day readmission due to complications. The main option for closure such defect is a mesh augmented component separation technique. The goal was to evaluate 30-day wound events and general complications including 90 days mortality. Material and methods: We present a retrospective study that includes patients from two different university hospitals who underwent open incisional hernia repair with anterior component or posterior component separation between January 2015 and December 2021. Only non-contaminated adult patients (over 18 years old) with postoperative primary or recurrent median abdominal wall defects larger than 6 cm and with complete fascial closure were included. Demographics (age, gender, Body Mass Index—BMI, American Society of Anesthesiologists Classification—ASA score), recurrence rank, and co-morbidities), operative details, patient outcomes complications were collected. A native abdomen/pelvis computerized tomography (CT) scan was performed preoperatively in all patients and the anatomy of the defect and volumetry (abdominal cavity volume, incisional hernia volume and peritoneal volume) were evaluated. One of the component separation technique was performed according to Carbonell's equation. Results: Two hundred and two patients (101 from each group) were included. The patients with posterior component separation were more comorbid and with larger defects. The procedure was longer with 80 min but overall length of hospital stay shorter (p < 0.001) for posterior component separation. Seroma, hematoma and skin necrosis were equally distributed for both group of patients and there was no direct relation to surgery (OR 0.887, 95% CI 0.370–2.125, p = 0.788; OR 1.50, 95% CI 0.677–3.33, p = 0.318 and OR 0.386, 95% CI 0.117–1.276, p = 0.119). Surgical Site Infection rate was increased for anterior component separation (p =0.004). Conclusion: Complex incisional hernia repair is a challenge given by a large amount of wound complications. Choosing between anterior and posterior component separation is still a source of significant debate. We were not able to depict significant different rates of complications between the procedures and we couldn't find any specific factor related to complications. [ABSTRACT FROM AUTHOR]

IntroductionIn recent years, Posterior Component Separation (PCS) with the Madrid modification (Madrid PCS) has emerged as a surgical technique. This modification is believed to enhance the dissection of anatomical structures, offering several advantages. The study aims to present a detailed description of this surgical technique and to analyse the outcomes in a large cohort of patients.Materials and MethodsThis study included all patients who underwent the repair of midline incisional hernias, with or without other abdominal wall defects. Data from patients at three different centres specialising in abdominal wall reconstruction was analysed. All patients underwent the Madrid PCS, and several variables, such as demographics, perioperative details, postoperative complications, and recurrences, were assessed.ResultsBetween January 2015 and June 2023, a total of 223 patients underwent the Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23–40). According to the EHS classification, 139 patients had a midline incisional hernia, and 84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150 (67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%) superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four (1.9%) recurrences were assessed by CT scan with an average follow-up of 23.9 months (range 6–74).ConclusionThe Madrid PCS appears to be safe and effective, yielding excellent long-term results despite the complexity of abdominal wall defects. A profound understanding of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to facilitating a complete retromuscular preperitoneal repair without incision of the transversus abdominis. The extensive abdominal wall retromuscular dissection obtained enables the placement of very large meshes with minimal fixation.

Abstract Background This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh. Methods Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study. Results The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level

Aim: This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias. Methods: A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double‐docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion. Results: Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra‐operative surgical complication occurred and follow‐up at 6 months showed no recurrence or mid‐term complication. Conclusion: Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing. [ABSTRACT FROM AUTHOR]

Purpose: The main objective was to assess the prevalence of hernia recurrence, wound complications (surgical site infections [SSI], seroma and hematoma) and mortality after anterior component separation (ACS) and posterior component separation via transversus abdominis muscle release (PCSTAR) in patients with complex incisional hernias. Summary background: The so-called complex IH is a serious medical and societal challenge due to its direct and indirect costs; it is also hampered by the use of different surgical techniques, different type of meshes, and different results heterogeneously reported and interpreted. According to actual data, the best approach seems to be a mesh reinforcement component separation procedure augmented or not with an adjuvant technique (preoperative progressive pneumoperitoneum and/or Botulin toxin type A infiltration). Methods: A systematic search of four databases (MEDLINE, PubMed, Web of Science, and Google Scholars) was conducted to identify studies reporting on outcomes of component separation techniques and which were published before December 2021. A systematic review and a meta-analysis of postoperative outcomes were performed. Results: Nineteen studies including 3412 patients (1709 with ACS and 1703 with PCSTAR) were selected. Pooled hernia recurrence rate after a minimum 1-year follow-up was evaluated at 5.15% (odds ratio [OR] 0.68; 95% confidence interval [CI] 0.5–0.9; p = 0.0175). Pooled surgical site infection rate was 10.6% (OR 1.32; 95% CI 1.06–1.65; p = 0.0119). Seroma and hematoma were estimated at 9.75% (OR 1.93; 95% CI 1.52–2.44; p = 0.0001) and 3.83% (OR 1.81; 95% CI 1.26–2.61; p = 0.0012), respectively. ACS was associated with increased wound morbidity, seroma and hematoma. PCSTAR displayed higher recurrence rate (4.27% vs 6.11%). Conclusions: PCSTAR was superior to ACS in terms of wound morbidity, surgical site infections, seroma and hematoma incidence. The procedure should be further evaluated in comparative head-to-head randomized controlled trials. [ABSTRACT FROM AUTHOR]

Abstract Background Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation “PCS” with Transversus Abdominis Release “TAR” in the treatment of complex ventral-wall hernias (VHs). Methods This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; “TAR”. Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure. Results Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair. Conclusions Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups. Trail registration The study was registered on clicaltrials.gov “NCT04516031”.

Objective: We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice. Summary Background Data: Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain. Methods: Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain. Results: A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52–67], median body mass index was 32 kg/m2 (IQR: 28–36), median hernia width was 15 cm (IQR: 12–19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1–4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement. Conclusions: TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life. [ABSTRACT FROM AUTHOR]

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39–76) and Body mass index (BMI kg/m2) of 31.2 (24–45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6–30) and mean defect area was about 267.9 cm2. Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien–Dindo grade I–II) and one case (1.9%) major complication (Clavien–Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien–Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh. Methods: Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study. Results: The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh. Conclusion: Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117. [ABSTRACT FROM AUTHOR]

Enteroatmospheric fistula (EAF) is a rare and devastating surgical complication with significant management challenges. Abdominal wall reconstruction (AWR) at the time of definitive repair represents the major challenge in patients with large abdominal wall defects with associated loss of abdominal domain. Herein, we describe a case of EAF with significant loss of domain for which AWR was achieved using an innovative combined approach of preoperative botulinum toxin A (BTA), extensive transversus abdominal release (TAR), and abdominal reinforcement with biosynthetic mesh. This approach achieves primary abdominal closure, providing the option of a single definitive reconstructive procedure for EAF. Further studies with long-term follow-up are required to assess the long-term durability of this approach.

Background: Robotic transversus abdominis release (roboTAR) is a minimally invasive surgical approach for ventral hernia repairs that builds on the concepts developed by Rives and Stoppa. The Rives–Stoppa procedure incorporates Rives’ retromuscular repair and Stoppa’s concept of giant prosthetic reinforcement of the visceral sac (GPRVS).[1] In an effort to mitigate the limitations of the Rives–Stoppa procedure, Novitsky et al. developed the open transversus abdominis release (TAR). The TAR approach is favorable when repairing large ventral hernia defects, as it provides myofascial advancement to reconstitute linea alba, preserves the neurovascular bundles of the medial abdominal wall, and creates a large extraperitoneal space to allow for mesh reinforcement. Methods: The three main technical components of the roboTAR include the following: bottom-up, Novitsky method, and top-down approach. An understanding of the anatomy and technique involved in the three techniques is critical for performing roboTAR. Results: Within the authors’ practice, the average hernia defect size is 115 cm2. With a n = 200, approximately 1% of our patients has had a surgical site complication. Recurrences are rare and occur in very large complex hernias. The average operative time is approximately 400 min with an average length of stay being 1.2 days. This is consistent with others. Conclusion: Utilizing a minimally invasive approach, as seen in roboTAR, provides additional advantages, including shorter length of hospital stay, reduced wound morbidity, reduced postoperative pain, and expedited return to work and activities of daily living. This article is a comprehensive review of the pertinent anatomy, preoperative evaluation, operative technique, and the postoperative course of roboTAR.

Background: Complex ventral hernias (VHs) represent a real challenge to both general and plastic surgeons. This study aims to compare Sublay Mesh-Only Repair to Posterior Component Separation "PCS" with Transversus Abdominis Release "TAR" in the treatment of complex ventral-wall hernias (VHs).Methods: This a randomized, controlled, intervention, including two parallel groups: A; Sublay Mesh-Only Repair and Group B; "TAR". Consecutive patients of both genders aged between 18 and 65 years old with complex VHs presented at Mansoura University Hospitals including large-sized abdominal-wall hernia ≥ 10 cm in width, loss of domain ≥ 20%, multiple hernial defects, or recurrent hernias. Immuno-compromised patients, patients with liver impairment, or severe heart failure were considered an exclusion criterion. The primary outcome is the recurrence rate after 12-months following the procedure.Results: Fifty-six patients were recruited in this study. There was no significant difference between both groups regarding recurrence. However, there was significant differences between both groups regarding seroma favoring mesh-only repair.Conclusions: Although TAR may be associated with longer operative times and more blood losses, these were not found to be statistically significant. Postoperative complication, except for seroma, and recurrence rates were comparable in both groups. Trail registration The study was registered on clicaltrials.gov "NCT04516031". [ABSTRACT FROM AUTHOR]

Background: Component separation (CS) procedures have become an important part of surgeons' armamentarium. However, the exact criteria for training, procedure/mesh choice, as well as patient selection for CS remains undefined. Herein we aimed to identify trends in CS utilization between various cohorts of practicing surgeons.Study Design: Members of the Americas Hernia Society were queried using an online survey. Responders were stratified according to their experience, practice profile (private vs academic, general vs hernia surgery), and volume (low (< 10/year) vs high) of CS procedures. We used Chi-squared tests to evaluate significant associations between surgeon characteristics and outcomes.Results: 275 responses with overwhelming male preponderance (88%) were collected. The two most common self-identifiers were "general" (66%) and "hernia" (28%) surgeon. PCS was the most commonly (67%) used type of CS; endoscopic ACS was least common (3%). Low-volume surgeons were more likely to utilize the ACS (p < 0.05). Only 7% of respondents learned PCS during their residency, as compared to 36% that use ACS. 65% felt 0-10 cases was sufficient to become proficient in their preferred technique. 10 cm-wide defect was the most common indication for CS; 23% used it for 5-8 cm defects. Self-identified "hernia" and high-volume surgeons were more likely to use synthetic mesh in the setting of previous wound infections and/or contaminated field (p < 0.05). More general/low-volume surgeons use biologic mesh. Contraindications to elective CS varied widely in the cohort, and 9.5% would repair poorly optimized patients electively. Severe morbid obesity was the most feared comorbidity to preclude CS.Conclusion: The use of CS varies widely between surgeons. In this cohort, we discovered that PCS was the most commonly used technique, especially by hernia/high-volume surgeons. There are differences in mesh utilization between high-volume and low-volume surgeons, specifically in contaminated fields. Despite its prevalence, CS training, indications/contraindications, and patient selection must be better defined. [ABSTRACT FROM AUTHOR]

Purpose: While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience. Methods: We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence. Results: One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30 days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43 months. Conclusions: Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium. [ABSTRACT FROM AUTHOR]

Introduction: Among many other techniques for Abdominal Wall Reconstruction (AWR), posterior component separation with Transversus Abdominis Release (TAR), continues to gain popularity and it is increasingly used with promising long-term results. Our goal was to evaluate the influence of TAR with mesh retromuscular reinforcement on the intra-abdominal pressure (IAP) and respiratory function in a series of patients with complex incisional hernias (IH).Methods: Since November 2014 through February 2019, patients with TAR were identified in the Clinical Department of Surgery database and were retrospectively reviewed. Outcome measures include: demographics, pre- and perioperative details, preoperative and postoperative IAP and plateau pressure (PP).Results: One-hundred-and-one consecutive TAR procedures (19.7% from all incisional hernia repairs) were analyzed. Mean age was 63 years with a mean Body Mass Index (BMI) of 31.85 kg/m2 (25-51). Diabetes and Chronic Obstructive Pulmonary Disease (COPD) were the main major comorbidities. Mean hernia defect area was 247 cm2 (104-528 cm2).Conclusion: TAR is a safe and sound procedure with acceptable modifications of the IAP morbidity and recurrence rate when correctly performed on the right patient. [ABSTRACT FROM AUTHOR]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results—as well as reports from the literature—are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction. [ABSTRACT FROM AUTHOR]

The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14 cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the r‑TAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results—as well as reports from the literature—are encouraging. The r‑TAR is becoming the pinnacle procedure for abdominal wall reconstruction. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Transversus abdominis release (TAR) is the new revolution in hernia surgery and hernia surgeons are passionately doing it all over the world. With the increase in the popularity of TAR technique, there seems a decrease in anterior component separation technique (ACST) popularity. ACST despite gone modification such as endoscopic and perforator preserving method is seen as an inferior procedure to TAR. Is TAR better than ACST? What are its theoretical limitations? We have done a literature review to compare the postoperative outcomes and technicality of open ACST and open TAR procedure. METHODS: We performed a search in the database of PubMed, EMBASE, and Cochrane library for articles that have compared ACST with TAR procedure for postoperative outcomes and technical superiority. The search was limited to human studies and in the English language with cadaveric studies included. RESULTS: We found seven studies that have compared ACST and TAR for various outcomes. They are three systemic reviews with meta-analysis, one multicentric prospective randomized controlled trial, one prospective study, and two cadaveric studies. They have compared the surgical site infection and surgical site occurrence rates, recurrence rate, quality of life (QOL), and extent of mobilization of the rectus muscle. Most of the studies found no significant difference between ACST and TAR; however, the overall quality of the studies may be limited. CONCLUSION: Open ACST is comparable to open TAR procedure and has equally acceptable outcomes. In ACST, it seems to be essential to preserve the perforator vessels; however, altogether further studies are needed to gain more clarity in the daily decision-making process in the repair of complex ventral hernias.

Introduction: Posterior component separation (PCS) via transversus abdominis release (TAR) technique overcomes the pitfalls of traditionally described repairs. Aim: We evaluate the safety and efficacy of this approach and present the lessons we have learnt in our experience with a large series of complex ventral hernias. We also evaluate the importance of pre-operative optimisation and the value of a dedicated abdominal wall reconstruction (AWR) team in improving the surgical outcomes. Material and methods: A retrospective review of all patients undergoing TAR at a specialised hernia centre in the 2016–2019 period was performed. Pertinent data collected included patient demographics, peri-operative details and post-operative complications. Primary outcome variables were surgical site occurrences (SSO) and hernia recurrence. A multivariate regression model was developed to determine significant predictors of SSO. Results: In 92 consecutive patients, the mean age was 52 years with a mean body mass index of 27.9%. Major comorbidities included diabetes (41%), hypertension (23%), and chronic obstructive pulmonary disease (15%). The mean hernia defect was 13.2 cm and the average operative time was 232 minutes. Complete posterior sheath closure was achieved in 95.6% cases. There were 18 (19.5%) cases of SSO which were managed conservatively and no cases required mesh explanation. There were 2 (2.1%) recurrences which required a redo surgery. On multivariate analysis operative time (p value 0.047) was a significant predictor of SSO. Conclusions: AWR using the TAR approach offers a robust repair with low overall morbidity. A holistic pre-operative optimisation strategy and a dedicated AWR team can further improve surgical outcomes. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to describe the macroscopic features and histologic details observed after retromuscular abdominal wall reconstruction with the combination of an absorbable mesh and a permanent mesh.Methods: We have considered all patients that underwent abdominal wall reconstruction (AWR) with the combination of two meshes that required to be reoperated for any reason. Data was extracted from a prospective multicenter study from 2012 to 2019. Macroscopic evaluation of parietal adhesions and histological analysis were carried out in this group of patients.Results: Among 466 patients with AWR, we identified 26 patients that underwent a reoperation after abdominal wall reconstruction using absorbable and permanent mesh. In eight patients, the reoperation was related to abdominal wall issues: four patients were reoperated due to recurrence, three patients required an operation for chronic mesh infection and one patient for symptomatic bulging. A miscellanea of pathologies was the cause for reoperation in 18 patients. During the second surgical procedures made after a minimum of 3 months follow-up, a fibrous tissue between the permanent mesh covering and protecting the peritoneum was identified. This fibrous tissue facilitated blunt dissection between the permanent material and the peritoneum. Samples of this tissue were obtained for histological examination. No case of severe adhesions to the abdominal wall was seen. In four cases, the reoperation could be carried out laparoscopically with minimal adhesions from the previous procedure.Conclusions: The reoperations performed after the combination of absorbable and permanent meshes have shown that the absorbable mesh acts as a protective barrier and is replaced by a fibrous layer rich in collagen. In the cases requiring new hernia repair, the layer between peritoneum and permanent mesh could be dissected without special difficulty. Few intraperitoneal adhesions to the abdominal wall were observed, mainly filmy, easy to detach, facilitating reoperations.

Purpose: The closure of midline in abdominal wall incisional hernias is an essential principle. In some exceptional circumstances, despite adequate component separation techniques, this midline closure cannot be achieved. This study aims to review the results of using both anterior and component separation in these exceptional cases.Methods: We reviewed our experience using the combination of both anterior and posterior component separation in the attempt to close the midline. Our first step was to perform a TAR and a complete extensive dissection of the retromuscular preperitoneal plane developed laterally as far as the posterior axillary line. When the closure of midline was not possible, an external oblique release was made. A retromuscular preperitoneal reinforcement was made with the combination of an absorbable mesh and a 50 × 50 polypropylene mesh.Results: Twelve patients underwent anterior and posterior component separation. The mean hernia width was 23.5 ± 5. The majority were classified as severe complex incisional hernia and had previous attempts of repair. After a mean follow-up of 27 months (range 8-45), no case of recurrence was registered. Only one patient (8.33%) presented with an asymptomatic bulging in the follow-up. European Hernia Society's quality of life scores showed a significant improvement at 2 years postoperatively in the three domains: pain (p = 0.01), restrictions (p = 0.04) and cosmetic (p = 0.01).Conclusions: The combination of posterior and anterior component separation can effectively treat massive and challenging cases of abdominal wall reconstruction in which the primary midline closure is impossible to achieve despite appropriate optimization of surgery. [ABSTRACT FROM AUTHOR]

Background: The abdominal wall can be considered comprised of two compartments: an anterior and a posterior compartment. The anterior compartment includes the anterior rectus sheath and the rectus muscle. The posterior compartment comprises the posterior rectus sheath, the transversalis fascia, and the peritoneum. When a large defect in the anterior compartment has to be corrected, for example, a rectus diastasis or large incisional hernia, an action on the anterior compartment is necessary; therefore, an anterior component separation has to be considered. If a loss of substance is present in the posterior compartment, a trasversus abdominis release should be accomplished.Methods: We propose an original anterior compartment mobilisation, by a posterior approach. Dissection of the posterior rectus sheet proceeds until the linea semilunaris is reached. Incision of the anterior rectus sheath permits a mobilisation of the anterior compartment by a posterior approach. A mesh is placed in a sublay position. If the abdominal wall presents a loss of substance of the posterior compartment, a transversus abdominis release (TAR) can be performed in the same time.Results: No hernia recurrences, no wound infection, and no mesh infection have been reported.Conclusions: The anterior compartment mobilization permits mobilization towards the midline of rectus muscle and restoration of anterior compartment, with low morbidity rate; it can be easily associated to a large sublay mesh placement, it allows the preservation of the neurovascular bundles and rectus muscle trophism, and it can be associated with a concomitant TAR procedure for the restoration of the PC, if necessary. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of the study was to investigate the clinical utility of the transversus abdominis muscle release (TAR) procedure in complex abdominal wall reconstruction. MATERIALS AND METHODS: Retrospective study of 32 patients with complex abdominal wall defects admitted to Hangzhou First People's Hospital between January 2016 and December 2017. Clinical materials were collected and analyzed. RESULTS: Among 32 cases of large incisional hernias, there were 19 males (59.4%) and 13 females (40.6%). Mean age was 64.41 ± 12.11 years, body mass index was 30.00 ± 5.97 kg/m2, and mean width of the abdominal defect was 11.34 ± 1.82 cm. Twenty-four cases were midline incisional hernias with one case of planned incisional hernia after severe pancreatitis, and three cases were lateral. Five cases were recurrent incisional hernias. All patients underwent retromuscular mesh repair, with abdominal wall reconstruction using the TAR procedure. The operative time was 151.59 ± 28.64 min, and estimated blood loss was 118.12 ± 83.41 cm3. Length of hospital stay was 13.66 ± 2.72 days. Two cases had a superficial surgical site infection, five had Type II seroma, and one had intestinal obstruction. All postoperative complications resolved with nonsurgical therapy. No mesh infection, fistula, recurrence, or postoperative bulging was reported during follow-up. CONCLUSION: Posterior component separation through TAR is a reliable and effective technique for complex abdominal wall reconstruction. Long-term follow-up is needed to assess potential recurrence.

• Desmoid tumours are rare benign neoplasms with local invasion and recurrence. • A margin-free excision may be challenging for the surgeon. • If necessary, abdominal wall reconstruction can be required for rectus abdominis muscle tumours. • A multidisciplinary approach is necessary approaching this rare disease. Desmoid tumours are rare benign neoplasms with strong tendency to local invasion and recurrence. They usually rise from muscles and aponeurosis and could be challenging for medical treatment. We here report the case of a patient requiring the excision of part of the abdominal rectus muscle and an abdominal wall reconstruction. A 38 years old women referred to our institution complaining of a painful lump in the anterior abdominal wall. She underwent ultrasonography (US), magnetic resonance imaging (MRI) and a computed tomography (CT) biopsy who showed the presence of a desmoid tumour arising in the right abdominal rectus muscle. She underwent surgical excision of the mass and an abdominal wall reconstruction according to the posterior component separation technique, with a large polypropylene mesh reinforcement. The post-operative period was uneventful and at 6 months she shows no clinical nor radiological recurrence. Desmoid tumours are rare neoplasms rising in many anatomical spaces and requiring challenging decisions. A radical resection with free margins remains the principal determinant of outcome. Non-surgical approaches and adjuvant therapy may be useful for patients with unresectable lesions. The optimal treatment strategy for desmoid tumours still remains unclear. A multidisciplinary approach is always the best strategy to establish the correct treatment. [ABSTRACT FROM AUTHOR]

Background: Transversus abdominis release (TAR), as a type of posterior component separation, is a new myofascial release technique in complex ventral hernia repair. TAR preserves rectus muscle innervation, creates an immense retromuscular plane and allows bilaminar ingrowth of the mesh. The place of the TAR within the range of established anterior component separation techniques (CST) is unclear. Aim of this systematic literature review is to estimate the position of the TAR in the scope of ventral hernia repair techniques.Methods: MEDLINE, Embase, Pubmed and the Cochrane controlled trials register and Science citation index were searched using the following terms: 'posterior component separation', 'transversus abdominis release', 'ventral hernia repair', 'complex abdominal wall reconstruction'. To prevent duplication bias, only studies with a unique cohort of patients who underwent transversus abdominis release for complex abdominal wall reconstruction were eligible. Postoperative complications and recurrences had to be registered adequately. The rate of surgical site occurrences and recurrences of the TAR were compared with those after anterior CST, published earlier in two meta-analyses.Results: Five articles met our strict inclusion criteria, describing 646 TAR patients. Methodological quality per study was good. Mean hernia surface was 509 cm2 and 88% of the hernias were located in the midline. Preoperative risk stratification was distributed in low risk (10%), co-morbid (55%), potentially contaminated (32%) and infected (3%). Pooled calculations demonstrated a mean SSO rate of 15% after TAR (20-35% after anterior CST) and a mean 2-year hernia recurrence rate of 4% (13% after anterior CST). Mean hernia surface was 300 cm2 in anterior component separation studies.Conclusion: This review demonstrates that the transversus abdominis release is a good alternative for anterior CST in terms of SSO and recurrence, especially in very large midline ventral hernias. [ABSTRACT FROM AUTHOR]

Purpose: Posterior component separation (PCS) via the transversus abdominis release (TAR) procedure continues to gain popularity. However, neither the physiologic basis nor the extent of myofascial medialization after TAR is established. We aimed to assess both anterior and posterior rectus fascia (AF and PF) medialization following each step of the TAR procedure.Methods: Ten fresh cadavers underwent PCS via TAR. Steps included midline laparotomy (MLL), retrorectus dissection (RRD), incision of the posterior rectus sheath (IPL), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Medial advancement of AF and PF was measured following application of 2.5, 5.0 lb, and maximal tension to the fascial edge. Values are represented as mean advancement past midline in centimeters.Results: MLL allowed advancement of 2.5, 3.7, and 4.9 cm. RRD provided advancement of 4.1, 5.9, and 7.6 cm for AF and 4.4, 6.2, and 7.5 cm for PF. IPL provided advancement of 4.2, 6.1, and 8.0 cm for AF and 4.6, 6.6, and 8.3 cm for PF. TAD provided advancement of 4.5, 6.6, and 8.6 cm for AF and 5.3, 7.5, and 9.5 cm for PF. RMD provided advancement of 5.5, 7.9, and 9.9 cm for AF and 6.9, 9.6, and 11.2 cm for PF. Overall, the complete TAR procedure provided AF advancement of 102% and PF advancement of 129%, over baseline.Conclusions: The TAR procedure provides for substantial medial advancement of both anterior and posterior myofascial components of the abdominal wall. Retromuscular dissection deep to the divided transversus abdominis muscle appears to be the key step of the procedure, allowing for effective reconstruction of very wide (≈ 20 cm) defects. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to compare the outcomes of posterior component separation and transversus abdominis release (PCSTAR) with the open anterior component separation (OACS) technique. OACS, first described by Ramirez et al. (Plast Reconstr Surg 86(3):519-526, 1990), has become an established technique for local myofascial advancement in abdominal hernia surgery. PCSTAR, described by Novitsky et al. (Am J Surg 204(5):709-716, 2012), is being used more frequently and is rapidly becoming the technique of choice in complex ventral hernia repair.Methods: Analysis was conducted according to PRISMA guidelines. A systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on midline ventral hernia repair were reviewed. Studies describing PCSTAR were selected and compared to matched studies describing OACS. Meta-analysis was used to compare outcomes between the two-pooled groups.Results: Seven studies describing 281 cases of PCSTAR for midline incisional hernia using a retromuscular mesh placement were identified. Six comparable studies describing 285 cases of OACS and retromuscular mesh placement were identified from the same search. Pooled analysis demonstrated a hernia recurrence rate of 5.7% (3.0-8.5) for PCSTAR and 9.5% (4.0-14.9) for OACS. Comparative analysis demonstrated no significant difference between hernia recurrence rate (p = 0.23). The use of bridging mesh was not significantly reduced by the use of PCSTAR (3.1%) when compared to ACS (7.5%) (p = 0.22). No significant difference was found in wound complication rates between PCSTAR and OACS, respectively, 'superficial' 10.9 vs 21.6% (p = 0.15); and 'deep' 9.5 vs 12.7% (p = 0.53).Conclusions: These data suggest PCSTAR have comparable outcomes to OACS. This analysis is limited by the lack of comparative studies and heterogenicity in the OACS group. [ABSTRACT FROM AUTHOR]

Background Abdominal wall reconstruction after huge incisional hernias considered one of challenges that face surgeons, component separations, either anterior component separation (ACS) or posterior component separation (PCS) with transversus abdominus release (TAR), are novel and less expensive solutions for this problem. Aim This prospective randomized trial compares the results of ACS procedure versus PCS with TAR in repair of incisional hernias. Patients and methods This study included 40 patients who underwent surgical repair for midline incisional hernias with defects larger than 5 cm in width between March 2016 and October 2017 at Ain Shams University Hospitals. Patients were randomly assigned to surgical procedures. Patients in group Ι (n=20) underwent ACS, and patients in group II (n=20) underwent PCS with TAR. Results In group Ι (ACS), wound morbidity significantly exceeded that in group II (PCS with TAR) such that 10 (50%) patients in group I developed surgical wound infection compared with four (20%) patients in group II. Regarding wound dehiscence, seven patients in group I had this sequel, whereas two patients in group II had wound dehiscence. Hernia recurrence occurred in seven (35%) patients in group I, but only one (5%) patient in group II developed this. Conclusion PCS with TAR provides equivalent myofascial advancement with significantly less wound morbidity and recurrence rate when compared with ACS. [ABSTRACT FROM AUTHOR]

Background: Transversus abdominis release (TAR) is a safe, effective strategy to repair complex ventral incisional hernia (VIH); however, open TAR (o-TAR) often necessitates prolonged hospitalization. Robot-assisted TAR (r-TAR) may benefit short-term outcomes and shorten convalescence. This study compares 90-day outcomes of o-TAR and r-TAR for VIH repair.Methods: A single-center, retrospective review of patients who underwent o-TAR or r-TAR for VIH from 2015 to 2016 was conducted. Patient and hernia characteristics, operative data, and 90-day outcomes were compared. The primary outcome was hospital length of stay, and secondary metrics were morbidity, surgical site events, and readmission.Results: Overall, 102 patients were identified (76 o-TAR and 26 r-TAR). Patients were comparable regarding age, gender, body mass index, and the presence of co-morbidities. Diabetes was more common in the open group (22.3 vs. 0%, P = 0.01). Most VIH defects were midline (89.5 vs. 83%, P = 0.47) and recurrent (52.6 vs. 58.3%, P = 0.65). Hernia characteristics were similar regarding mean defect size (260 ± 209 vs. 235 ± 107 cm2, P = 0.55), mesh removal, and type/size mesh implanted. Average operative time was longer in the r-TAR cohort (287 ± 121 vs. 365 ± 78 min, P < 0.01) despite most receiving mesh fixation with fibrin sealant alone (18.4 vs. 91.7%, P < 0.01). r-TAR trended toward lower morbidity (39.2 vs. 19.2%, P = 0.09), less severe complications, and similar rates of surgical site events and readmission (6.6 vs. 7.7%, P = 1.00). In addition, r-TAR resulted in a significantly shorter median hospital length of stay compared to o-TAR (6 days, 95% CI 5.9-8.3 vs. 3 days, 95% CI 3.2-4.3).Conclusions: In select patients, the robotic surgical platform facilitates a safe, minimally invasive approach to complex abdominal wall reconstruction, specifically TAR. Robot-assisted TAR for VIH offers the short-term benefits of low morbidity and decreased hospital length of stay compared to open TAR. [ABSTRACT FROM AUTHOR]

Purpose: Parastomal hernias are challenging to manage, and an optimal repair has yet to be defined. An open, modified, retromuscular Sugarbaker technique has recently been described in the literature as a technically feasible approach to parastomal hernia repair. This study evaluates our initial institutional experience with parastomal hernia repair with the aforementioned technique with respect to safety and durability.Methods: All patients who underwent an open, modified retromuscular Sugarbaker parastomal hernia repair from 2014 through 2016 at our institution were identified. Patient characteristics, hernia variables, operative details, and 30-day and medium-term outcomes were abstracted from the Americas Hernia Society Quality Collaborative database. Outcomes of interest included 30-day wound morbidity, mesh-related complications, and hernia recurrence.Results: Thirty-eight patients met inclusion criteria. 20 (53%) patients presented to our institution for management of a recurrent parastomal hernia. 35 (92%) patients had a concurrent midline incisional hernia with a mean total hernia width of 15.1 cm and mean defect size of 353 cm2. Thirty-day wound morbidity rate was 13%. At a mean of follow-up of 13 months (range 4-30), the hernia recurrence rate was 11%. Three patients (8%) experienced mesh erosion into the stoma bowel, leading to stoma necrosis, bowel obstruction, and/or perforation which required reoperation at day 8, 12, and 120 days, respectively.Conclusions: The outcomes of the retromuscular Sugarbaker technique for the management of parastomal hernias have been disappointing at our institution, with a concerning rate of serious mesh-related complications. This operation, as originally described, needs further study before widespread adoption with a particular focus on the technique of mesh placement, the most appropriate mesh selection, and the long-term rate of mesh erosion. [ABSTRACT FROM AUTHOR]

Introduction: Posterior component separation herniorrhaphy via transversus abdominis release (TAR) permits midline reapproximation of large fascial defects. To date, no report delineates the reduction in tensile force to reapproximate midline fascia following TAR. We hypothesized that open and laparoscopic TAR would provide similar reductions in midline reapproximation forces in a porcine model.Methods: Under general anesthesia, a 20-cm midline laparotomy was created and bilateral lipocutaneous flaps were raised to expose the anterior rectus sheath. Five stainless steel hooks were placed at 1-cm intervals lateral to the midline at three locations: 5 cm above, at, and 5 cm below the umbilicus bilaterally. Baseline force measurements were taken by pulling each lateral point to midline. Laparoscopic TAR was performed unilaterally by incising the parietal peritoneum and transversus muscle lateral to the linea semilunaris. Open TAR was performed contralaterally, and force measurements were repeated. Comparisons were made to baseline and between the groups.Results: Following laparoscopic TAR, 87 % (13/15) of points showed significant reduction compared to baseline forces, whereas only 20 % (3/15) of open TAR points had significant force reductions. Compared to open TAR, three locations favored the laparoscopic approach [1 cm lateral to midline, 5 cm above the umbilicus (p = 0.04; 95 % CI 0.78-1.00), 2 cm lateral to midline at the umbilicus (p = 0.04; 95 % CI 0.80-1.00), and 1 cm lateral to midline 5 cm below the umbilicus (p = 0.05; 95 % CI 0.79-1.00)]. The mean length of TAR was longer for laparoscopic than open at 27.29 versus 19.55 cm (p < 0.0001; 95 % CI 6.46-9.02).Conclusions: Open TAR reduced midline tensile force at few locations, suggesting that the mechanism by which TAR facilitates herniorraphy may not solely be through reductions in linea alba tensile forces. At specific locations, laparoscopic TAR provides superior reduction in midline closure force compared to open TAR, likely as a result of a longer muscle release. [ABSTRACT FROM AUTHOR]

Abdominal wall reconstruction techniques have evolved significantly over the last fifty years and continue to do so at an increasing pace. Beginning with open incisional hernia repair with bilateral rectus myofascial release, multiple techniques to offset tension at the midline by exploring options of layered myofascial release have been described. This article reviews the history, technique, advancements, and future of myofascial release in abdominal wall reconstruction leading from the open Rives-Stoppa repair to the robotic-assisted iteration of the transversus abdominis release., (Copyright © 2023 AEC. Published by Elsevier España, S.L.U. All rights reserved.)