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Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Jorge Daes1, Joshua S Winder2, Eric M Pauli3

  • 1Clinica Portoazul, Barranquilla, Colombia.

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|March 25, 2020
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Summary

Simultaneous anterior and posterior component separation for abdominal wall reconstruction is feasible. Cadaver studies and patient CT scans show minimal muscle displacement and minimal changes in muscle mass after the procedure.

Keywords:
abdominal wall reconstructionbridged repaircompensatory hypertrophycomponent separationsmidline closureventral hernia

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Area of Science:

  • Surgical Anatomy
  • Abdominal Wall Reconstruction
  • Minimally Invasive Surgery

Background:

  • Abdominal wall reconstruction often requires complex techniques to restore integrity.
  • Simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is generally considered contraindicated.
  • Understanding the anatomical and functional consequences of combined ACS and PCS-TAR is crucial for surgical decision-making.

Purpose of the Study:

  • To evaluate the anatomical feasibility and potential consequences of combining ipsilateral endoscopic ACS with PCS-transversus abdominis release (TAR).
  • To assess the reinforcement of the abdominal wall layers and muscle displacement after the combined procedure.
  • To analyze long-term changes in muscle mass and displacement in patients who underwent PCS-TAR.

Main Methods:

  • Performed ipsilateral endoscopic ACS combined with endoscopic or open PCS-TAR in 5 fresh cadaver models.
  • Examined the reinforcement of the semilunar line and lateral abdominal wall by internal oblique (IO) and transversus abdominis (TA) muscles.
  • Reviewed CT scans at 1 month and 1 year post-PCS-TAR in 17 patients (30 PCS-TARs) to assess TA displacement and muscle mass changes.

Main Results:

  • Cadaver models demonstrated that the abdominal wall remained well-reinforced by two muscle layers (IO and TA) after combined ACS and PCS-TAR.
  • Myofascial releases were a median of 4 cm apart, and significant lateral displacement of the TA muscle was minimal (<1 cm) and localized.
  • Patient CT scans showed minimal changes in muscle mass over time, with compensatory hypertrophy observed in other abdominal muscles following successful midline restoration.

Conclusions:

  • The combination of simultaneous ipsilateral anterior component separation and posterior component separation (PCS-transversus abdominis release) is anatomically feasible and provides adequate abdominal wall reinforcement.
  • While theoretically possible to add ACS to PCS-TAR for challenging reconstructions, surgeons are advised to opt for simpler, bridged repairs to avoid potential morbidity associated with complex combined procedures.
  • Successful midline restoration after PCS-TAR is associated with beneficial compensatory muscular changes, enhancing core physiology and quality of life.