Component separation technique for a very large abdominal wall hernia • 28 years male. • Abdominal distention since 1 month. • P/A- Large Ventral Hernia with widely gapping recti muscles, thinning of overlying skin, gross abdominal distention. • Past history: Ileostomy and Colostomy for megacolon with Crohn’s Colitis followed by closure of stoma.
Planned for Incisional hernia repair (component separation technique) with mesh
Step 1. Incision planning Skin incision is planned considering the size of the defect and the laxity of the overlying skin.
Step 2. Lateral dissection •
Extensive lateral dissection is done on both sides beyond the rectus muscle to expose the external oblique aponeurosis.
Step 3. Bilateral Lateral Incision on external oblique aponeurosis Long vertical incisions are placed on both sides starting from costal margin up to the pelvic bone inferiorly on both sides.
Step 4. Dissection between external and internal oblique muscles
• Extensive blunt dissection done in between the two muscles in an avascular plane to separate the components and gain 7-10 cm medial shift of the anterior component. • If necessary posterior incision on posterior rectus sheath can also be placed to further gain a shift of 3-4 cm.
Step 5. Midline mass closure with interrupted sutures Midline closure was done without tension with interrupted non absorbable no 1 sutures
Step 6. Overlay repair with Polypropelene mesh A large piece of polypropylene mesh (30 * 15 cm) is placed over the repair to have an adequate cover and overlap all around the defect and fixed to parities with sutures.
Step 7 Closure with negative suction drains Post-operative Course • • • •
Liquids were started on 2nd POD. Semisolid diet on 3rd POD and normal diet on 4th POD. Drains removed on 7th POD. Discharged on 7th POD.
Conclusion • Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. 10 cm on each side to cover the defect without tension. • An overlay mesh repair is performed to reinforce the mass closure • This technique can prevent intra-abdominal compartment syndrome and postoperative pain and can allow tension free repair of large hernias