Abstract
An incisional hernia occurs in 11 % to 18.7 % of patients, within 10 years after laparotomy. Morbidity of reconstruction is high and long term results are poor with recurrence rates varying from 32 - 63 % after 10 years of follow-up. Oscar Ramirez described good results by using the
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Components Separation Method (CSM): non-mesh functional repair in which the external and internal oblique abdominal muscles are separated, allowing large abdominal defects to be closed primarily. All peri-operative measures, as well as technical details of the CSM and possible pitfalls are outlined. In eight human cadavers the CSM was performed and translation of the rectus abdominis muscle was measured. The hypothesis that rotation of separate tissue layers of the abdominal wall, largely accounts for the translation effect of the CSM was rejected. Release of the external oblique muscle produces more benefit than release of the posterior rectus sheath. In a 6 year period, 95 patients were treated with a mean defect-size of 230 cm2. After a median follow-up of 48 months we discovered 15 recurrences (15.7%), of which 13 patients were asymptomatic. We found 1 recurrence (3.8%) in patients with mesh augmentation and 14 (20%) in patients without mesh augmentation (p=0.036). Patients with massive abdominal wall defects can be treated by means of the CSM with good long term results. The additional use of mesh in the pre-fascial retromuscular space, seems to lower the recurrence rate without more restrictions in daily life activities. Detailed analysis of contaminated large abdominal wall hernias showed that they can be closed in one-stage procedures by the CSM with a low recurrence rate but considerable morbidity. In a prospective study we evaluated lung function, physical performance and quality of life before and six months after performing the CSM. Reconstruction by means of the CSM seems not to impair respiratory function on the long term and might improve physical performance and quality of life. Sustained reduction of perfusion of the muscular components of the abdominal wall in the postoperative phase might be an important factor in the origin of fascial dehiscence or incisional hernia formation in patients with increased intra-abdominal pressure (IAP). In 10 patients planned for laparoscopic cholecystectomy, we investigated the relation between IAP and tissue perfusion in the rectus abdominis muscle. Mean rectus pO2 decreases with rising IAP (p=0.015) and this impaired perfusion seems to be exclusively based on elevation of intra abdominal pressure. Prolonged raised IAP and subsequent impaired perfusion of the rectus muscles seems a risk factor for the development of incisional hernia. In a review we stated that treatment of large abdominal wall defects is not yet standardized. This is not surprising as there are so many variables which have to be respected including aetiology, size and site of the defect, duration of existence and idiosyncrasies of the patient, making controlled studies almost impossible and together with the wide spectrum of therapies, it is doubtful whether this will allow large trials to prove the superiority of one of the techniques over another.
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