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

Abstract

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.

Stapled Fascial Closure vs. Continuous Hand-Sewn Suture: Experimental Study of the Abdominal Wall on Porcine Model and Human Cadaver

“…One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and hernia formation. A large incision inherently leads to greater tension during the closure of the fascial layers 18 , 21 . This heightened tension poses a substantial risk of fascial dehiscence, where the layers of the abdominal wall separate prematurely, favoring the development of incisional hernias.…”