Abdominal Wall Reconstruction

ABDOMINAL WALL
RECONSTRUCTION
PRESENTER: DR. RAHAB SAEED

POST GRADUATE TRAINEE
HAMDARD UNIVERSITY HOSPITAL
INTRODUCTION
Abdominal wall reconstruction has become a
frequently used term to describe hernia repairs
Many surgeons believe that abdominal wall

reconstruction involves the closure of the fascia at the
midline often with reinforcement using mesh
prosthetics.
INTACT ABDOMINAL WALL IS VITAL IN:
 It protects the internal organs.
Supports the spine and helps maintain an upright

posture.
Helps in urination, coughing , parturation or

defecation.
There are also suggestions that an absence of an intact

abdominal wall, fails to determine satiety, thus leading
to weight gain.
ANATOMY
ANATOMY
INDICATIONS
Indications may be structural defects or symptoms.
Prevention of obstruction or strangulation.
 Abdominal wall defects that eventually require

reconstruction include those arising from the removal
of cancer, management of severe infections and repair
of prior abdominal wounds.
CONTRAINDICATIONS
Inability to tolerate general anesthesia.
Uncontrolled diabetes mellitus.
Current smoking.
Extreme obesity.
TECHNIQUES
To achieve midline fascial closure, often components
of the abdominal wall must be separated to allow for
tension free repair.
Various component separation techniques have been

described.
COMPONENT SEPARATION TECHNIQUES
Component separation described by Ramirez.
Chevrel onlay technique.
“Rives-Stoppa” or retrorectus repair.
Intraperitoneal mesh repair.

RAMIREZ COMPONENT SEPARATION
This technique was described in 1990 by Ramirez and
colleagues.
 The component separation technique was originally

developed to allow closure of a wide midline
abdominal wall defect without the use of prosthetic
material.
This technique is based on lateral fasciotomies that
allow sliding of the muscular/fascia layers toward the
midline and subsequently enlargement of the
abdominal fascia surface, thus closing the defect
without tension.
STEPS
Midline vertical incision given along the hernial sac.
 Sac is identified, dissected, opened and ligated.
Flap in front of anterior rectus sheath is raised to

identify the external oblique aponeurosis
2-5 cm lateral to the lateral margin of the rectus sheath.
An incision is then made in the anterior rectus sheath

and the muscle is mobilized off from the posterior
sheath.
Longitudinal incision is made in the external oblique
aponeurosis below and beyond the hernial defect
usually from inguinal ligament up to 5 cm above the
costal margin.
External oblique muscle is then dissected off from the

internal oblique in an avascular plane between these
two muscles up to mid-axillary line.
By this separation technique rectus is advanced for 5

cm in upper abdomen; 7-10 cm in middle and 3 cm in
lower abdomen
Linea alba closure is done with interrupted non-
dissolvable stitches.
The skin flaps are closed in a layered closure after two

drains are left in the subcutaneous plane.
Remirez component separation
Bleichrodt evaluated this technique in 43 patients
with large ventral hernias.
 At a mean follow-up of 16 months the recurrence rate

was 32%.
Dumanian in 2009, evaluated 200 consecutive
abdominal wall ventral hernia repairs using CS from
1996 to 2007.
He found 23% recurrence rate with CS alone.
 33% recurrence rate with a biologic mesh used as an

underlay to the midline closure.
O% recurrence rate with a lightweight synthetic

POLYPROPYLENE MESH used as an underlay.
CHEVREL ONLAY METHOD
Chevrel in 1997 described 143 incisional hernia repairs
using this technique and had a reaurence rate of 4.8%.
This technique involves the standard midline incision

to lyse adhesions
Skin and subcutaneous flaps are developed as far as

possible in all directions to get healthy fascia.
Edges of the defect are then reapproximated into the
midline.
Relaxing incisions were given in the anterior rectus

sheath if there is a tension in closure.
They are done 2 cm away from the medial border of

each rectus.
The Lateral edges of these two flaps are rotated to the
midline with one overlapping the other.
A piece of polyester or polypropylene mesh that

extends for several cms (5 to 10) in all directions is
then placed as an onlay patch and fixed in place using
sutures.
Drains are placed and skin closed.

RIVES-STOPPA-WANTZ
RETRORECTUS REPAIR
Rives described this technique in 1973 as a means of
placing a prosthetic.
Rives and his group published extensively on this

repair and Flament from this group recently, in 2002
reported a recurrence rate of 6. 7% in over a 1o-year
follow-up of 693 repairs.
The old incision is used and excess thinned-out skin
can be excised.
The sac is entered and all adhesions are completely

divided from the sac and from the peritoneal surface
in all directions.
The edge of the rectus sheath is opened on one side

and the muscle is dissected off from the posterior
rectus sheath to the lateral edge of the muscle
This is done on both sides and in classic Rives
approach, the posterior sheath is then closed to keep
the mesh away from the viscera.
The prosthesis used for repair of the hernia is

classically polyester since it is soft and supple and can
fit into the spaces more easily than heavyweight PPM.
A series of "'U" stitches is placed by placing the stitch

through the mesh and then up through the abdominal
waU using the Reverdin needle.
Each limb of the suture passes through the abdominal
wall separately but the two limbs of the “U“ stitch
come through the same skin puncture.
Twelve or more "'U" stitches are used and all the

sutures are tied on one side before the other side is
tied.
The rectus muscles and fascia are closed in the

midline to cover the prosthesis.
Drains are placed in the subcutaneous space and any
excess skin and fat are excised to give a good cosmetic
result.
INTRAPERITONEAL MESH REPAIR
This technique was developed in the 1990,s
In this technique expanded polytetrafluoroethylene

(ePTFE) mesh was used.
This mesh was placed intraperitoneally over the

viceras.
STEPS
After the incision is made, the hernia sac is entered
and adhesiolysis is done.
Skin and subcutaneous flaps are developed on both

sides back into good fascia and far enough laterally so
that the rectus muscles and fascia can be
approximated to cover the mesh after it has been
implanted.
One or more disposable visceral retractors were used.
The mesh is then placed in the abdominal cavity and

anchored with the fascia.
The rectus muscles and fascia are brought to the

midline and sutured to cover the mesh.
COMPLICATIONS
Seroma/haematoma formation.
Wound infection.
Recurrance.
Lateral bulging of the muscle if internal oblique
muscle is cut.
Paralytic ileus.
 Abdominal wall nerve injury.

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ABDOMINAL WALL

PRESENTER: DR. RAHAB SAEED

Many surgeons believe that abdominal wall

Supports the spine and helps maintain an upright

Helps in urination, coughing , parturation or

There are also suggestions that an absence of an intact

Prevention of obstruction or strangulation.

 Abdominal wall defects that eventually require

Various component separation techniques have been

Chevrel onlay technique.

“Rives-Stoppa” or retrorectus repair.

Intraperitoneal mesh repair.

 The component separation technique was originally

 Sac is identified, dissected, opened and ligated.

Flap in front of anterior rectus sheath is raised to

An incision is then made in the anterior rectus sheath

External oblique muscle is then dissected off from the

By this separation technique rectus is advanced for 5

The skin flaps are closed in a layered closure after two

 At a mean follow-up of 16 months the recurrence rate

He found 23% recurrence rate with CS alone.

 33% recurrence rate with a biologic mesh used as an

O% recurrence rate with a lightweight synthetic

This technique involves the standard midline incision

Skin and subcutaneous flaps are developed as far as

Relaxing incisions were given in the anterior rectus

They are done 2 cm away from the medial border of

A piece of polyester or polypropylene mesh that

Drains are placed and skin closed.

Rives and his group published extensively on this

The sac is entered and all adhesions are completely

The edge of the rectus sheath is opened on one side

The prosthesis used for repair of the hernia is

A series of "'U" stitches is placed by placing the stitch

Twelve or more "'U" stitches are used and all the

The rectus muscles and fascia are closed in the

In this technique expanded polytetrafluoroethylene

This mesh was placed intraperitoneally over the

Skin and subcutaneous flaps are developed on both

The mesh is then placed in the abdominal cavity and

The rectus muscles and fascia are brought to the

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