Anatomical study comparing medialization after Rives-Stoppa, anterior component separation, and posterior component separation

Background

Large incisional hernias require medialization of the rectus abdominis muscles to facilitate tension-free closure. Medialization may be achieved by Rives-Stoppa, anterior component separation, or posterior component separation. This study aims to compare medialization achieved by these techniques in postmortem human specimens.

Methods

First, the Rives-Stoppa procedure was performed. Subsequently, anterior and posterior component separation were performed on one side in each specimen, with each specimen functioning as its own control. Medialization was measured at three levels of the linea alba with three 1-kg weights. Both medialization obtained in addition to initial medialization after opening the linea alba and total medialization were measured. Results are presented as median and interquartile range.

Results

A total of 13 postmortem human specimens were included (Rives-Stoppa n = 13, component separation n = 10). Additional medialization after Rives-Stoppa was 1.2 cm (IQR: 0.3–2.2) for the anterior rectus sheath and 2.2 cm (IQR: 1.6–3.0) for the posterior rectus sheath (total medialization: 3.9 and 4.5 cm). For the anterior rectus sheath, additional medialization was 2.6 cm (IQR: 1.2–3.6) after anterior component separation and 1.9 cm (IQR: 0.4–3.4) after posterior component separation (P = .125, total medialization: 6.5 and 5.7 cm). For the posterior rectus sheath, additional medialization was 3.0 cm (IQR: 2.2–3.7) after anterior component separation and 5.2 cm (IQR: 4.2–5.9) after posterior component separation (P < .001, total medialization: 5.8 and 9.4 cm).

Conclusion

Posterior component separation yielded significantly more medialization of the posterior rectus sheath compared with Rives-Stoppa and anterior component separation. Anterior component separation may provide marginally more medialization of the anterior rectus sheath.

Introduction

Incisional hernia (IH) remains a prevalent complication after abdominal surgery. The prevalence of IH ranges between 10% and 20% in the general patient population and may be well over 30% in high-risk patients.1, 2, 3 Moreover, recurrence rates after IH repair may be up to 37%.⁴ Therefore, IHs remain a surgical challenge and results in approximately 350,000 surgical procedures per year in the United States alone.⁵

IHs are associated with (severe) physical and aesthetic complaints.6, 7 In addition, repair of large and complex IHs is associated with high morbidity and recurrence rates.^6,8, 9, 10, 11, 12 Today, the objective of IH repair is tension-free fascial closure with mesh augmentation.11, 12, 13, 14 To achieve tension-free closure in wide IHs, additional medialization of the rectus abdominis muscles is required. A well-known technique to obtain medialization is the Rives-Stoppa procedure.15, 16 However, medialization achieved by this technique can be insufficient to close large defects. Therefore, component separation techniques may be used to obtain additional medialization.17, 18, 19

Two regularly applied component separation techniques are anterior and posterior component separation. The anterior component separation was first described by Ramirez et al.¹⁹ in 1990. The more recently developed posterior component separation or transverse abdominis release (TAR) was first described by Novitsky et al.¹⁸ in 2012. Both techniques are regularly performed to repair large IHs.6, 17, 20 However, data on the exact medialization potencies of these techniques is lacking. The total medialization distance that can potentially be achieved is vital to estimate the IH defect size that can be closed by a certain medialization technique. To date, no study has compared medialization obtained after anterior and posterior component separation techniques.

The extent of total medialization achieved is less suitable to compare different techniques in an experimental setting because it can be influenced by individual patient factors and might differ slightly between the abdominal sides.²¹ Therefore, we propose to use the extent of medialization achieved in addition to the initial medialization after opening the linea alba.

The objective of this study was to assess and compare medialization after Rives-Stoppa, anterior component separation, and posterior component separation in postmortem human specimens. The primary outcome measurement was the medialization achieved after Rives-Stoppa, anterior component separation, and posterior component separation in addition to the initial medialization after opening the linea alba. Secondary outcomes comprise total medialization after these three techniques.