An Evaluation of Tension Measurements During Myofascial Release for Hernia Repair

Abstract

Tension-free repairs have revolutionized the way we repair hernias. To help reduce undue tension when performing ventral hernia repair, multiple different techniques of myofascial releases have been described. The purpose of this project is to evaluate tension measurements for commonly performed myofascial releases in abdominal wall hernia repair. Patients undergoing myofascial release techniques for their ventral hernias were enrolled in a prospective Institutional Review Board-approved protocol to measure abdominal wall tension from June 1, 2011 to August 1, 2019. Abdominal wall tensions were measured using tensiometers before and after myofascial release techniques. Descriptive statistics were performed and data were analyzed. Thirty patients had tension measurements (5 anterior myofascial separation, 25 posterior myofascial separation with transversus abdominis release [TAR]). Average age was 60.1 years (range 29-81), 83% Caucasian, 53% female, and 42% recurrent hernias. The average hernia defect in patients undergoing anterior myofascial release was 117.3 cm2, and the average mesh size was 650 cm2. The reduction in tension after anterior release was 4.7 lbs (2.7 lbs vs 7.4 lbs). The average hernia defect in patients undergoing posterior myofascial release (TAR) was 183 cm2, and the average mesh size was 761.36 cm2. The reduction in tension after bilateral posterior rectus sheath incision was 2.55 lbs (5.01 lbs vs 7.56 lbs) with 0.66 lbs further reduction in tension after TAR (4.35 lbs vs 5.01). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair. Preliminary data show tension reductions associated with the different myofascial release techniques and, with further study, may be a useful intraoperative adjunct for decision making in hernia repair.

Will Quantifying Fascial Tension Change the Practice of Component Separations in Complex Abdominal Wall Reconstruction?

“…Miller and colleagues published their work on the quantification of anterior and posterior fascial release after posterior component separation (PCS) and transversus abdominis release (TAR) using a proprietary, sterilizable tensiometer on anesthetized patients with ventral hernia. To our knowledge, this is the largest study of its kind in our review . Their findings demonstrated that anterior fascial tension was most impacted by the retrorectus dissection.…”

“…To our knowledge, this is the largest study of its kind in our review. [2][3][4] Their findings demonstrated that anterior fascial tension was most impacted by the retrorectus dissection. This step contributed −82% of the total change in anterior fascial tension, compared with −18% from the incision of the internal oblique posterior lamella and 0% from the TAR.…”

Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release

“…Parikh et al and Tenzil et al performed tensiometry in small studies of patients undergoing retrorectus dissections and noted similar reductions in anterior fascial tension of −2.55 lb and −2.5 lb, respectively. Parikh et al evaluated a subset of 25 patients who underwent TAR and noted a modest reduction in anterior fascial tension (−0.66 lb). However, they did not evaluate the posterior lamella of the internal oblique release individually.…”

“…Data suggest that PCS with TAR reduces anterior fascial tension, but the contribution of each release to the advancement of both the anterior and posterior fasciae has not been well characterized. This has led surgeons to rely on subjective assessments of tension and fascial advancement, which can result in overtreatment through additional fascial releases and their associated morbidity, or undertreatment, with excessive tension leading to early posterior sheath breakdowns and bowel obstructions .…”

Is There Indication for the Use of Biological Mesh in Cancer Patients?

“…Only for patients in whom the fascial defect could not be closed (due to cardiological, pulmonary or surgical problems), we performed the inlay technique, requiring a bridging mesh. Obviously, radial tension on inelastic scar tissue increases the recurrence risk; paradoxically, in the bridging surgical procedure, a lower tension was observed compared with anterior component separations, but this tension works on an unclosing fascia and on the mesh without reinforcement [ 32 , 33 ].…”