Component separation technique (CST) provides a substantial amount of medial advancement of myofascial components of the abdominal wall and is useful in addressing large and complex hernia defects during open ventral hernia repair. Classic anterior CST is associated with high rates of surgical site occurrences and infection [1]. To reduce wound complications, endoscopic approach was developed [2]. Although endoscopic anterior CS (eACS) has lost popularity due to recent trend toward TAR for complex abdominal wall reconstruction cases [3], eACS result in a similar wound morbidity and recurrence rate as TAR [4]. eACS could be another option in the armamentarium to deal with complex ventral hernias.

Indications

  • Large ventral hernias (primary, incisional)

  • To close the abdominal wall primarily without mesh in contaminated fields.

    *Caution! CST without mesh reinforcement has high rates of hernia recurrence [5].

Contraindications

  • Noncompliant abdominal wall from previous repair/mesh

  • Concomitant TAR

  • Defects are disproportionally wider than longer (relative)

Preoperative Assessment

  • Same as previous chapter: “extraperitoneal ventral hernia repair.”

OT Setup and Patient’s Position

  • Supine position with both arms tacked in alongside the trunk of the patient.

  • Using ultrasound imaging, semilunar line lateral to the rectus abdominis muscle is identified and marked on the skin bilaterally.

Instrumentation Required

  • 0° telescope 10 mm

  • 30° telescope 5 mm

  • A cylindrical dissection balloon dissector—Spacemaker™ Pro Blunt Tip Trocar (Medtronic, New Haven, CT)

  • Atraumatic Graspers ( 2) 5 mm

  • Curved Scissors ( 1)] 5 mm

  • Suction/irrigation device

  • Hook electrocautery

Surgical Technique

Three options should be considered.

  1. 1.

    eACS first or median laparotomy first?

    • Some surgeons prefer to do eACS first to avoid contamination of lateral abdominal space from the midline wound [3] but others perform median laparotomy first to titrate the need for eACS [6]. The latter avoids overtreatment, for hernia width cannot be the only determinant; patient’s height, visceral fat amount, and abdominal wall compliance should be considered.

  2. 2.

    Depending on the place where the first port is placed; precostal [6] or inguinal approach [7].

    • Precostal approach: 13–15 cm away from the xiphoid depending on the patient’s height, and 4 cm above the costal arch.

    • Inguinal approach (Fig. 1): lower lateral quadrant of the abdomen, lateral to the previously marked semilunar line.

  3. 3.

    Depending on the location of the “endoscopic pocket”; subfascial [6] and subcutaneous [3] approach.

Fig. 1
The image of an exposed region of the human body. It has various tubes and medical equipment placed on the body. Two regions are marked and there are some other marks on the body as well.

Inguinal approach of eACS

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A Case of eACS for Large Midline Defect (Width 10 cm × Length 21 cm): eACS First, Inguinal and Subfascial Approach

  1. 1.

    Identify and mark the bilateral semilunar line (Fig. 2) under ultrasound guidance.

  2. 2.

    Create the lateral endoscopic pockets.

    • 12 mm incision is made in the lower quadrant of the abdomen, lateral to the semilunar line (Fig. 3)

    • Balloon dissector is introduced and advances below the aponeurosis of external oblique muscle then the balloon is inflated (Fig. 4).

    • The space is insufflated with CO2 and maintained at a pressure of 10 mmHg (Fig. 5).

  3. 3.

    Transection of the external oblique muscle (Fig. 6).

    • Additional 5 mm port is introduced at a position lateral and superior to the camera port.

    • The external oblique aponeurosis is incised laterally to the right semilunar line.

    • The external oblique aponeurosis is incised from inguinal ligament to 4–6 cm above the costal margin (Fig. 7).

  4. 4.

    Adhesiolysis and restoration of the linea alba (Fig. 8). the linea alba is reconstructed using continuous endo-laparoscopic intracorporeal suturing

  5. 5.

    Upon the restoration of the linea alba, a synthetic mesh is rolled and inserted in the surgical space and apposed to reinforce the abdominal wall (Fig. 9)

Fig. 2
The image of an exposed region of the human body. It has a small dent on the left side. Two regions are marked.

Bilateral semilunar line is identified and marked

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Fig. 3
The image of an exposed region of the human body. A small section of the region is opened using medical equipment. A line marks a region.

As in a standard inguinal hernia repair, the external oblique aponeurosis is incised and the space between external and internal oblique muscle was identified

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Fig. 4
2 images. Image 1 illustrates a section of the body. It has 2 holes. A tube-like thing is seen over one of the holes. Another end of the tube is a small cylindrical object that is filled with some content. Image 2 is a graphical picture. It has a cut-out section of the body with 2 pressure pump-like objects on either side.

Left: the Balloon dilatation is inserted in the subfascial space; Right: schematic of the balloon dilation within the lateral muscles

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Fig. 5
The image of an internal view of a surface. Few bright spots can be seen.

Overview of the space between the right external and internal oblique muscle after removal of the balloon and gas insufflation

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Fig. 6
The image of an internal view of a surface of an organ with a hollow space. A cylindrical object is on the upper part of the hollow space horizontally placed.

Incise the elevated external oblique aponeurosis

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Fig. 7
The image of an internal view of a surface of an organ with a hollow space.

Endoscopic view after release of external oblique muscle

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Fig. 8
The image illustrates an internal view of a surface. It has many thread-like structures throughout the surface from one end to the other horizontally.

The extracorporeal interrupted suture technique is used to close the fascial defect

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Fig. 9
The image illustrates an internal view of a surface with a hollow space. The space resembles some muscles of an internal organ.

IPOM reinforcement

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Here, below is a CT scan reconstruction of the abdominal wall before and after 1 year follow-up showing the excellent reconstruction and repair of the abdominal wall midline defect (Fig. 10).

Fig. 10
2 x-ray images of a section of the body. Image 1 has a region marked by an oval. The regions show a pattern. The label on top of the image reads preoperativ 3 D C T. Image 2 has a label A on it. Text on top of the image reads 1-year postop 3 D C T. 2 images have an arrow in between from left to right.

Left: preoperative 3D-CT image, yellow circle means hernia orifice. Right: 1-year postoperative 3D-CT image

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Complications and Management

  • Small bowel injury during adhesiolysis

  • Mesh infection

  • Seroma

  • Recurrence

    • same as the previous chapter: “laparoscopic IPOM and IPOM+.”

  • Lateral hernia

    • resulting from full-thickness injury to the linea semilunaris,

    • repair using TAR [8].

Postoperative Care

  • Standard Analgesia

  • Discharge the patient when the patient is able to ambulate

  • Reduce sports activities and carrying heavy weight for 2 weeks