Ramirez component separation technique - general and visceral surgery

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date of publication: 06.05.2012
  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter  Berger

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  • Marking the landmarks

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    131-5

    Mark the landmarks with a skin marker before incising the skin. The landmarks include:

    • Costal arch
    • Symphysis pubis
    • Hernial orifice
    • Possible course of the skin incision
  • Skin incision

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    131-6

    After marking the landmarks and settling on the mesh size to be used, incise the skin from the xyphoid process to the symphysis pubis, taking down all scar tissue and excess skin.

  • Scar excision

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    131-7

    Carefully dissect the skin to be excised, including any subcutaneous tissue present, off the deeper tissue. This may be effected with dissecting scissors or by electrocautery. Special care must be taken not to injure any adherent intestinal loops.

  • Adhesiolysis

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    To free any adherent intestinal loops from the abdominal wall, perform lateral adhesiolysis either in parallel with the skin excision or after the latter has been completed. Here, too, the intestinal loops must be spared because otherwise the surgical field will be contaminated, thereby exposing the mesh implant to the risk of infection.

  • Freeing the posterior rectus sheath/peritoneum

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    After extensive adhesiolysis free the posterior lamina off the medial margin of the rectus sheath. This dissection runs from the costal arch or far (here 7 cm) along the posterior aspect of the xyphoid process to the retropubic space and should reach the lateral margins of the rectus sheath.

    Note: Opening up the retroxyphoidal space requires sharp dissection of the posterior lamina of the rectus sheath off the xyphoid process.
On both sides of the white line, the posterior lamina of the rectus sheath must then be transected transversely for 5 cm. This opens up the preperitoneal space. The preperitoneal fatty tissue appears in the “fatty triangle”. Also, see the article of incisional hernia repair with subfascial mesh augmentation

  • Freeing the subcutis

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    Now, free the subcutis off the aponeurosis of the external oblique far laterally, beyond the costal arch and down to the symphysis pubis. Carefully spare the vascular blood supply.

  • Incising the aponeurosis of the external oblique

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    After extensive exposure of the aponeurosis of the external oblique, split the aponeurosis cephalocaudad about 1 cm lateral to the lateral rectus sheath. Perform this step of the procedure cephalad far up to the costal arch and caudad to the inguinal ligament.

  • Separating the external oblique muscle

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    After splitting the aponeurosis of the external oblique, separate the external oblique muscle from the oblique muscle. Usually, this does not present any problems because it will be in an avascular region. To enable tension-free displacement of the rectus sheath and union with its contralateral counterpart, carry the dissection far laterally.

  • Closing the posterior rectus sheath/peritoneum

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    After identical dissection on both sides, starting caudad first close the peritoneum and transverse fascia up to the arcuate line with a running suture. Follow this with closure of the posterior laminas of the rectus sheath by inserting monofilament absorbable pulley stitches size 1.

  • Mesh augmentation

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    Once having sutured the laminas of the posterior rectus sheath with as little tension as possible, insert a Dynamesh® mesh to reduce the risk of recurrence. Cut the mesh to size and place it posterior to the rectus muscle, from the retroxyphoidal to the retropubic space. Usually, the mesh does not have to be secured in place. However, in the present case, the mesh was secured along its margins because two overlapping meshes had been implanted.

    Note: Always place the  DynaMesh®-CICAT such that the green reference lines run cephalocaudad.

  • Closing the anterior rectus sheath

  • Wound closure

  • Applying the NPWT