ENDOSCOPIC SINGLE PORT “COMPONENTS SEPARATION TECHNIQUE” (CST) FOR ABDOMINAL INCISIONAL HERNIAS

The reconstruction of large midline abdominal wall defects, severely contaminated, in particular after a relaparotomy or after an abdominal prosthetic repair, continues to be a challenge to surgeon due to the technical difficulties, the relatively high recurrence rate and morbidity (1-2). In addition many patients with such a problem do need the surgical intervention for neoplasm or aortic diseases. In 1990 Ramirez (3) introduced a new procedure for the closure of the abdominal wall hernia, the "components separation technique (CST)". This technique is based on autogenous tissue reconstruction of the abdominal wall by bilateral separation and advancement of the muscular layers, to bridge the fascial gap without the use of prosthetic material. The limitations of this technique were complications of the skin and the subcutaneous tissue caused by the surgical interruption of the perforating vessels during the exposure of the oblique muscle (4-5). After Lowe et collegues (4) had demonstrated that the endoscopic assisted CST minimized tissue trauma and preserved blood supply of the skin. The aim of this contribution was to illustrate a new endoscopic approach for CST and evaluate the feasibility of this technique in a case of complicated large incisional hernia after section of a dual mesh. Metodo: We perform an endoscopically assisted CST, as described in other publications (4), but with a modification that consist in a single-port access and a gasless technique. The abdomen is entered via a midline laparotomy in order to treat the abdominal disease. Before the CST is endoscopically performed the adhesions between the ventral abdominal wall and the intra-abdominal viscera are cut. Preliminary, a skin incision of 1.5 cm is made 5 cm caudal to the arch of the ribs and 5 cm caudolateral to the midline (FIG 1). The operating 30° telescope (Storz SEPS Endoscope; Storz Tuttlingen, Germany), which has a lifting handle and a single 5-mm operating port, is inserted into the subcutaneous plane. The aponeurosis of the external oblique muscle is incised 1 to 2 cm lateral to the lateral border of the rectus abdominis muscle. The surgeon place one hand into the abdomen cavity to control the fascial border, but also during all the procedure to evaluate the release and to ensure the fascial integrity. The blunt dissection of the myoapeneurosis of the external oblique muscle is directed longitudinally over its full length with an hook under video-endoscopic control. The external oblique muscle is separated from the internal oblique muscle in the avascular plane between both muscles to the midaxillary line by blunt dissection with the scope, manually driven by means of trans-abdominal illumination (FIG 2). The separation is essential because the fibrous interconnections between both muscles prevent optimal medial shift of the rectus abdominis muscle. After a muscular flap is created by the releasing of the muscular layers providing abdominal wall mobilization necessary for a tension free closure of the midline fascia. Risultati: A 72 years old man had undergone a relaparotomy for a aortic aneurysm. He had a history of a previously dual mesh endoabdominal-repaired large incisional hernia. For the closure of such challenging defect he underwent at the end of the vascular procedure a bilateral endoscopically modified CST, with a successfully wound closure. The release produced an abdominal wall mobilization of 7-8 cm. The skin was closed without tension. No midline wound infection or dehiscence occurred in the early postoperative period. Conclusioni: The abdominal wall CST allows closure of ventral defects by transposition of the abdominal wall muscle. The CST is a useful procedure for the closure of large abdominal wall incisional hernia avoiding the use of mesh, in particular under contamination in which laparoscopic treatment or use of prosthetic material is contraindicated. The endoscopic CST produces the same results as the open conventional separation technique (6) and also preserved the blood supply preventing the postoperative wound complications (7). Although this procedure results in prolonged operative time, the use of a single port access with a gasless technique seems to decrease the operative time. From this initial experience with short follow-up no specific conclusions can be made, but we found that this method is safe and effective for the closure of large midline abdominal hernias when a primary closure open or laparoscopic is not feasible, as in patients previously treated.