Endoscopic Component Separation in the Bariatric Patient

| January 21, 2013

This Month’s Featured Experts
Kashif A. Zuberi, MD, MRCSI
Johns Hopkins Bayview Medical Center, Baltimore MD
Department of Bariatric Surgery and the Johns Hopkins Comprehensive Hernia Center

Hien T. Nguyen, MD, FACS
Johns Hopkins Bayview Medical Center, Baltimore MD
Department of Bariatric Surgery and the Johns Hopkins Comprehensive Hernia Center

Michael Schweitzer, MD, FACS
Johns Hopkins Bayview Medical Center, Baltimore MD
Department of Bariatric Surgery and the Johns Hopkins Comprehensive Hernia Center

Funding: No funding was provided.

Financial disclosures: Drs. Zuberi and Nguyen report no conflits of interest relevant to the content of this article. Dr. Schweitzer has received a research grant from EnteroMedics Inc. (St. Paul, Minnesota) and a teaching Grant from Covidien (Mansfield, Massachusetts).

A Message from Column Editor Samuel Szomstein, MD, FACS

Dear Readers of Bariatric Times:
Happy New Year and welcome to the first installment of “The Hole in the Wall” for 2013.
This issue features my very dear friend and excellent surgeon Dr. Michael Schweitzer and his group from the Department of Bariatric Surgery and the John Hopkins Comprehensive Hernia Center at Johns Hopkins Bayview Medical Center, Baltimore Maryland. Dr. Schweitzer and his group share their technique in the novel approach of endoscopic component separation and provide an excellent literature review. Do you have any “pearls” or “tricks’ that you use in your daily practice related to abdominal wall defects?. Please e-mail it to szomsts@ccf.org, I would love to share it with our readers.

Once again, welcome to “The Hole in the Wall.” We hope you will enjoy this  column and we look forward to your questions, comments, and participation in future issues.

Sincerely,
Samuel Szomstein, MD, FACS

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Bariatric Times. 2013;10(1):22–24.

Introduction
Since its introduction, bariatric surgery has revolutionized the management of obesity in today’s increasing epidemic. There are approximately 100, 000 bariatric procedures performed annually in the United States. Patients with morbid obesity have a higher than normal intra-abdominal pressure, predisposing them to ventral hernias.[1] Datta et al[2] reported an eight-percent incidence of ventral hernias in patients presenting for a gastric bypass procedure.[1,2] Other studies indicate a 5-to-20-percent incidence after laparotomy at five years. Primary repair of these hernias is associated with a recurrence rate of 18 to 62 percent.[3] here is a higher rate of incisional hernias in open gastric bypass as compared to the laparoscopic procedure.[1]

Management of ventral hernias has also evolved from long open procedures with significant wound associated morbidity to a laparoscopic repair with lower inpatient stay and reduced wound-related complications.[3–6]

Until recently, large diameter (>10cm) defects were repaired with an open component separation technique to adequately close the defect and minimize recurrence. Endoscopic component separation has been shown to reduce the morbidity associated with complex ventral hernia repairs due to the elimination of large skin flaps and prevention of compromise of the blood supply to the anterior abdominal wall with subsequent reduced seroma/hematoma formation and wound infection.[4–8] Endoscopic component separation has been evaluated in mostly retrospective case series but has shown that the endoscopic method is neither more expensive or time consuming than the open technique.[5,7] There has been a trend toward reduced wound complications with equal efficacy and outcomes using the minimally invasive approach.[3–8]

Component Separation Technique
The open component separation technique for hernia repair allows for autologous tissue repair with approximation of the midline fascia in patients with complex hernias.[1] This requires dissection along the fascia and division of perforating vessels as encountered with release of the external oblique fascia. The wound flaps are large and almost invariably require some element of drainage due to seroma formation. Hematoma formation is common and can require a subsequent return to the operating room if the patient displays signs or symptoms of active blood loss. As a result, wound infection rates and wound complications after adequate repair of defects is still considerably high. The endoscopic component separation technique has been demonstrated in several studies to be associated with reduced wound morbidity.[3–6]

In our experience, component separation allows for a tensionless primary closure, which can be re-enforced with a dual layer mesh if a laparoscopic approach is preferred. Overall, the purpose is to reduce recurrence and offer a durable repair that allows symptom control and an adequate cosmetic finish. At our institution, the primary goal is to correct the anatomical defect to prevent any visceral injury and alleviate symptoms. We have observed these results so far and continue to follow our patients and gather data for a more objective view of this pattern in the future.

The endoscopic component separation procedure is performed in the following manner at our center: A 1-cm incision is made initially in the right upper quadrant at the costal margin at the anterior axillary line, and extended to the aponeurosis of the external oblique. This aponeurosis is then divided using electrocautery and blunt dissection is used to create space below this aponeurosis of the external oblique using a balloon dissector. The space is then insufflated to 15mmHg using a 10 to 12mm balloon Hasan trocar (see Figure 1). The appropriate plane is acknowledged by viewing the aponeurosis of the external oblique anteriorly and the muscle fibers of the internal oblique seen posteriorly.

Five-millimeter trocars are placed into the operative field. Blunt dissection is then used to free up the areolar tissue below the aponeurosis of the external oblique to the mid axillary line, starting from the inguinal ligament and extending past the subcostal margin. The aponeurosis of the external oblique is then divided approximately 3cm lateral to the semilunar line starting from the inguinal ligament and extending up past the costal margin by approximately 3 to 4cm using L-hook electrocautery (see Figure 2). This allows 6 to 7cm of fascial release on each side, which can be seen under insufflation. A similar approach is then performed on the opposite side. Care is taken not to injure the visualized perforators on both sides. The abdominal cavity is then entered through a left upper quadrant incision using a Visiport technique. The abdomen is then insufflated and the herniated contents are carefully reduced.  The fascial defect is reapproximated primarily using a large slow absorbing monofilament suture on a Carter-Thomason suture passer device. This is performed with multiple interrupted figure-of-eight sutures along the length of the defect. The fascia is able to be re-approximated in a tension-free manner due to the prior release of the external oblique aponeurosis. The mesh of choice is placed over the primary fascial repair in an underlay fashion. The mesh is positioned in such a way to allow at least 3 to 5cm underlay from the fascial edge. Transfascial sutures are placed 4cm apart. The mesh is then tacked to the anterior abdominal wall using absorbable tacks in a double-crown technique.

Considerations
One concern after performing a laparoscopic ventral hernia repair is that primary closure of the defect can lead to excessive skin externally. Usually this can be handled by excision and primary repair especially if the skin is excoriated or thin, or scarred from previous operations and may necrose. Most of the time this is not managed at the initial operation, but rather observed over time. The patient can also be managed by referral to plastic surgery as needed. Patients with obesity may not show a significant change in skin appearance initially as the sac can be deep to the skin and primary closure of the defect will not result in significant excessive skin. Ideally, the goal of the ventral hernia repair is closure of the abnormal anatomic defect, not cosmesis. Patients with obesity are given advice and counseling regarding a bariatric procedure for weight loss, and cosmetic or body contouring procedures can be considered in the future if so desired by the patient.

Performing an endoscopic component separation in lieu of a patient undergoing an abdominoplasty or body contouring procedure would be unnecessary as large skin flaps would be required regardless, and most ventral hernias are repaired as an open procedure at this time. On the other hand, if the procedure requires less skin removal and large flaps are not necessarily required—the endoscopic component separation could be performed after the abdominoplasty has been completed and the new re-alignment of the abdominal wall components is established, provided the dissection planes where the component separation is to be undertaken is not violated.

Conclusion
Several series evaluating the open component separation technique and the endoscopic or laparoscopic component separation technique have demonstrated significant reduction in wound related morbidities. Albright et al[4] and Giurgius et al[5] reviewed the experience at the University of Kentucky and found a comparable hospital length of stay and operative time with reduced wound complications (p=0.03).[4,5] Parker et al[6] demonstrated the added benefit of laparoscopic component separation when laparoscopic ventral hernia repair is undertaken for complex ventral hernias.[6] Harth et al[7] reviewed their institutions experience with endoscopic component separation and found that the overall direct cost was similar to the open technique.[7] Although most bariatric procedures are performed with a minimally invasive approach, open bariatric procedures are still necessary in patients who are not appropriate candidates for a laparoscopic approach. The incidence of incisional or ventral hernias after this major abdominal operation is higher in this patient subgroup. Repair of these hernias is usually undertaken after considerable weight loss has been achieved or in conjunction with plastic and reconstructive surgery for body contouring. The addition of a minimally invasive approach to component separation in large defects allows for primary closure of the defect with mesh reinforcement and reduction in hernia recurrence and wound complications.

References
1.    Raghavendra SR, Gentileschi P, Kini SU. Management of ventral hernias in bariatric surgery. Surg Obes Relat Dis. 2011;7:110–116.
2.    Datta T, Eid G, Nahmias N, Dallal RM. Management of ventral hernias during laparoscopic gastric bypass. Surg Obes Relat Dis. 2008;4:754–758.
3.    Malik K, Bowers SP, et al. A case series of laparoscopic components separation and rectus medicalization with laparoscopic ventral hernia repair. J Laproendosc Adv Surg Tech. 2009;19(5):607–610.
4.    Albright E, Diaz D, Davenport D, Roth JS. The component separation technique for hernia repair: a comparision of open and endoscopic techniques. Am Surg. 2011;77(7):839–843.
5.    Giurgius M, Bendure L, Davenport DL, Roth JS. The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia. 2012;16:47–51.
6.    Parker M, Bray JM, et al. Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair.  J Laproendosc Adv Surg Tech. 2011;21(5):405–410.
7.    Harth KC, Rose J, et al. Open versus endoscopic component separation: a cost comparison. Surg Endosc. 2011;25:2865–2870.
8.    Tong WMY, Hope W, et al. Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation. Ann Plast Surg. 2011;66c: 551–556.

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