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- Title
Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release.
- Authors
Miller, Benjamin T.; Ellis, Ryan C.; Petro, Clayton C.; Krpata, David M.; Prabhu, Ajita S.; Beffa, Lucas R. A.; Huang, Li-Ching; Tu, Chao; Rosen, Michael J.
- Abstract
This case series assesses the changes in tension on the anterior and posterior fascial elements of the abdominal wall associated with each retromuscular release during a posterior components separation with a transversus abdominis release. Key Points: Question: What are the associations of each retromuscular release with anterior and posterior fascial tension changes in patients undergoing a posterior components separation (PCS) with transversus abdominis release (TAR)? Findings: This case series of abdominal wall tensiometry in 100 patients undergoing PCS with TAR found that retrorectus dissection was associated with the greatest change in anterior fascial tension change (−82%). The TAR technique was not associated with anterior fascial tension change but was associated with a −38% change in posterior fascial tension. Meaning: The findings of this study suggest that posterior but not anterior fascial advancement in abdominal wall reconstruction may be achieved with a TAR procedure. Importance: Posterior components separation (PCS) is a commonly used myofascial release technique in ventral hernia repairs. The contribution of each release with anterior and posterior fascial advancement has not yet been characterized in patients with ventral hernias. Objective: To quantitatively assess the changes in tension on the anterior and posterior fascial elements of the abdominal wall during PCS to inform surgeons regarding the technical contribution of each step with those changes, which may help to guide intraoperative decision-making. Design, Setting, and Participants: This case series enrolled patients from December 2, 2021, to August 2, 2022, and was conducted at the Cleveland Clinic Center for Abdominal Core Health. The participants included adult patients with European Hernia Society classification M1 to M5 ventral hernias undergoing abdominal wall reconstruction with PCS. Intervention: A proprietary, sterilizable tensiometer measured the force needed to bring the fascial edge of the abdominal wall to the midline after each step of a PCS (retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release [TAR]). Main Outcome: The primary study outcome was the percentage change in tension on the anterior and posterior fascia associated with each step of PCS with TAR. Results: The study included 100 patients (median [IQR] age, 60 [54-68] years; 52 [52%] male). The median (IQR) hernia width was 13.0 (10.0-15.2) cm. After complete PCS, the mean (SD) percentage changes in tension on the anterior and posterior fascia were −53.27% (0.53%) and −98.47% (0.08%), respectively. Of the total change in anterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of −82.56% (0.68%), incision of the posterior lamella of the internal oblique with a change of −17.67% (0.41%), and TAR with no change. Of the total change in posterior fascial tension, retrorectus dissection was associated with a mean (SD) percentage change of −3.04% (2.42%), incision of the posterior lamella of the internal oblique with a change of −58.78% (0.39%), and TAR with a change of −38.17% (0.39%). Conclusions and Relevance: In this case series, retrorectus dissection but not TAR was associated with reduced tension on the anterior fascia, suggesting that it should be performed if anterior fascial advancement is needed. Dividing the posterior lamella of the internal oblique aponeurosis and TAR was associated with reduced tension on the posterior fascia, suggesting that it should be performed for posterior fascial advancement.
- Publication
JAMA Surgery, 2023, Vol 158, Issue 12, p1321
- ISSN
2168-6254
- Publication type
Article
- DOI
10.1001/jamasurg.2023.4847