Endoscopic Component Separation November 2014

Philip Omotosho, MD Assistant Professor of Surgery

Duke University School of Medicine

External Oblique

Internal Oblique

Transverse Abdominus

Rectus Abdominus

Peritoneum Transversalis

Fascia

Abdominal Wall Anatomy

Open component separation Ramirez, OM. Et al

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Ramirez, OM. Et al. Plast Reconstr Surg. 1990; 86(3):519-26

Open component separation Ramirez, OM. Et al

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Ramirez, OM. Et al. Plast Reconstr Surg. 1990; 86(3):519-26

Endoscopic Component Separation

Rosen MJ, et al. Hernia (2007) 11:435–440

Endoscopic Component Separation Advantages

• Eliminate lipo-cutaneous flaps

– Reduce wound infections

– Reduce likelihood of flap ischemia

Endoscopic Component Separation

- 1 cm incision just inferior to costal margin lateral to the rectus abdominis

- Dissect subcutaneous tissues to expose external oblique aponeurosis

- External oblique aponeurosis grasped and sharply incised, fibers split in their natural orientation, exposing internal

oblique

- Potential space between int. and ext. obliques created using a bilateral lap inguinal dissecting balloon

- Structural balloon is placed, insufflated to 12 mmHg; 30 deg scope inserted and used as blunt dissector under

direct vision

- 2 additional ports (5 mm) are placed – one at level of umbilicus at post ax. line and another just above the inguinal

ligament, lateral to the rectus

- Intramuscular space completely dissected – just above costal margin to inguinal ligament, rectus muscle medially,

posterior axillary line laterally

- External oblique then released from costal margin to inguinal ligament (L-hook; coagulating scissors; other energy

source) Rosen MJ, et al. Hernia (2007) 11:435–440

• Large defects > 20 cm should probably not be approached with the endoscopic approach

• Avoid technique in fixed, non-compliant abdominal wall defects

• Medial advancement can be difficult to achieve with defects near xiphoid and suprapubic areas

• Avoid technique if large skin flaps already exist secondary to a very large hernia

• If exposure cannot be achieved laparoscpically to complete the cephalad portion of the release, skin incision can be enlarged, and using lighted retractors, the release can be completed open.

Endoscopic component separation Considerations

Rosen, MJ. Atlas of Abdominal Wall Reconstruction

• Perioperative

- Lovenox 40mg SQ??

- Ancef 2g IV

- SCDs

- Foley catheter

• Positioning

- both arms out

- mid-chest/abdomen prepped out wide laterally

- monitors on the patients right and left side (mobile to move

up toward the head and then down to the feet)

Endoscopic component separation Peri-operative Considerations

• Ports

- Spacemaker

- 5-mm bladeless ports

(x 2)

• Other instruments

- 10mm, 30-degree scope

- 5mm, 30-degree scope

- Hook cautery (or endo-scissors)

- Ligasure

- Army-navy retractors (or appendiceal retractors)

- Kocher clamp

Endoscopic component separation Instruments

Port Configuration

Rosen, MJ. Atlas of Abdominal Wall Reconstruction

Endoscopic Component Separation Steps

- 10-15 mm incision just inferior to costal margin lateral to the rectus abdominis

- Dissect subcutaneous tissues to expose external oblique aponeurosis

- External oblique aponeurosis grasped and sharply incised, fibers split in their natural orientation, exposing internal oblique

- Potential space between int. and ext. obliques created using a bilateral lap inguinal dissecting balloon

Endoscopic Component Separation Steps

- Structural balloon is placed, insufflated to 12 mmHg; 30 deg scope inserted and used as blunt dissector under direct vision

- 2 additional ports (5 mm) are placed – one at level of umbilicus at post ax. line and another just above the inguinal ligament, lateral to the rectus

- Intramuscular space completely dissected – just above costal margin to inguinal ligament, rectus muscle medially, posterior axillary line laterally

- External oblique then released from costal margin to inguinal ligament (L-hook; coagulating scissors; other energy source)

VIDEO – Balloon Dissection

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Endoscopic component separation View upon entry into space

• You should be in-between the EXT and INT OBL muscular space.

ROOF = EXT OBL (fatty)

MEDIAL = SEMILUNAR LINE

FLOOR = INT OBL (muscular)

VIDEO – Part 1

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