Quantifying fascial tension in ventral hernia repair and component separation

Levy, Alexandre; Bernstein, Jaime L.; Celie, Karel-Bart; Spector, Jason A.

doi:10.1007/s10029-020-02268-6

Cited by 6 publications

(7 citation statements)

References 21 publications

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“…Tension measurements were captured when the edge of the fascia reached the midpoint of the abdomen, which was marked by a suture plumb line (eFigure 2 in Supplement 1). Similar abdominal wall tensiometry has been described by other investigators …”

Section: Methodssupporting

confidence: 84%

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

Miller,

Ellis,

Petro

et al. 2023

JAMA Surg

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ImportancePosterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias.ObjectiveTo quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making.Design, Setting, and ParticipantsThis case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS.InterventionA proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR]).Main OutcomeThe primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR.ResultsThe study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were −53.27% (0.53%) and −98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of −82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of −17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of −3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of −58.78% (0.39%), and TAR with a change of −38.17% (0.39%).Conclusions and RelevanceIn this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.

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Section: Methodssupporting

confidence: 84%

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

Miller,

Ellis,

Petro

et al. 2023

JAMA Surg

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“…Hooke's law states that the force required to stretch a spring, elastic band or in this case the abdominal wall is directly proportional to the distance of that stretch. 21,22 Applied to the stoma location, as the distance of the stoma from a fixed bony point that is the costal margin increases, there will be higher force or tension on the stoma. Hence, the chance of stomal retraction and parastomal herniation should, logically, be less from an upper rather than a lower abdominal stoma trephine.…”

Section: Discussionmentioning

confidence: 99%

“…Stomas in the ostomy triangle in obese patients can be expected to be under higher tension than those in the upper abdominal zones, as supported by Hooke's law. Hooke's law states that the force required to stretch a spring, elastic band or in this case the abdominal wall is directly proportional to the distance of that stretch 21,22 . Applied to the stoma location, as the distance of the stoma from a fixed bony point that is the costal margin increases, there will be higher force or tension on the stoma.…”

Section: Discussionmentioning

confidence: 99%

Skin to origin of mesenteric artery study (STOMA): prospective study of distances between stoma location and proximal superior mesenteric artery

Cao

Farsi

Aljifri

et al. 2022

ANZ Journal of Surgery

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Background: Traditional siting of stomas, in the lower abdomen, has been guided by surgical dogma lacking evidence. In the lower abdomen, the combination of a thick and pendulous abdominal apron, can create a challenging and suboptimal site for a stoma. The anatomical determinant limiting delivery of a stoma to the abdominal skin is the distance of the SMA from the lower border of the pancreas. The aim of this cross-sectional study was to compare the distance between the traditional stoma site, and upper abdominal stoma sites, to both the superior mesenteric artery (SMA) origin and SMA at the inferior border of the pancreas on abdominal computed tomography (CT). Methods: A cross-sectional study at a single academic university hospital of adult patients who underwent abdominal CT in Australia. Results: Two hundred and thirteen patients were included. Stoma sites in the upper abdomen were 57-76 mm shorter to the origin of the SMA and inferior border of the pancreas than those positioned at the traditional stoma site (P < 0.001). The mean panniculus thickness in the upper abdomen was 10 mm thinner than in the lower abdomen and increased with increasing BMI (P < 0.001). The ratio between the distance from the xiphisternum to umbilicus, and the umbilicus to pubic symphysis, was 1.10; this ratio increased with increasing BMI. Conclusion:The distance of the SMA to the skin is always shorter in the upper abdomen compared to the traditional stoma site. Consideration should be given to placing stomas in the upper abdomen, particularly in overweight or obese patients.

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“…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 ].…”

Section: Discussionmentioning

confidence: 99%

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

Patrone

Leongito²,

Giacomo³

et al. 2022

JCM

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Up to 28% of all patients who undergo open surgery will develop a ventral hernia (VH) in the post-operative period. VH surgery is a debated topic in the literature, especially in oncological patients due to complex management. We searched in the surgical database of the Hepatobiliary Unit of the National Cancer Institute of Naples “G. Pascale Foundation” for all patients who underwent abdominal surgery for malignancy from January 2010 to December 2018. Our surgical approach and our choice of mesh for VH repair was planned case-by-case. We selected 57 patients that fulfilled our inclusion criteria, and we divided them into two groups: biological versus synthetic prosthesis. Anterior component separation was used in 31 patients (54.4%) vs. bridging procedure in 26 (45.6%). In 41 cases (71.9%), we used a biological mesh while a synthetic one was adopted in the remaining patients. Of our patients, 57% were male (33 male vs. 24 female) with a median age of 65 and a mean BMI of 30.8. We collected ventral hernia defects from 35 cm2 to 600 cm2 (mean 205.2 cm2); 30-day complications were present in 24 patients (42.1%), no 30-day mortality was reported, and 21 patients had a recurrence of pathology during study follow-up. This study confirms VH recurrence risk is not related with the type of mesh but is strongly related with BMI and type of surgery also in oncological patients.

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Quantifying fascial tension in ventral hernia repair and component separation

Cited by 6 publications

References 21 publications

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

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

Skin to origin of mesenteric artery study (STOMA): prospective study of distances between stoma location and proximal superior mesenteric artery

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

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