Ramirez component separation technique

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anatomy of the anterior abdominal wall

    1. Layered anatomy 

    The large area of the anterior abdominal wall from the xiphoid process and both costal arches to the pelvis demonstrates a characteristic layered anatomy: Skin covering the subcutaneous fatty tissue; superficial fascias; muscles and their fascias; and then an extraperitoneal fascia and the parietal peritoneum. 

    Particularly in the anterior wall inferior to the umbilicus the otherwise single-layered superficial fascia transitions into a double-layered structure (panniculus adiposus abdominis) comprising a superficial fatty layer (Camper fascia) and a deeper membranous layer (Scarpa fascia). The five abdominal muscles comprise: 

    • Three oblique muscles (1. external oblique, 2. internal oblique and 3. transversus abdominis) Two straight muscles (4. 
    •  rectus abdominis and the inconsistent 5. pyramidalis muscle). 

    a) Superficial muscle 

    It courses directly posterior to the superficial fascia in inferomedial direction to the large aponeurosis; both sides conjoining in the middle to the linea alba (white line). Its inferior margin constitutes the inguinal ligament from the anterior superior iliac spine to the pubic tubercle; medially, the inguinal ligament in turn gives off the lacunar and pectineal ligament (Cooper) respectively. 

    b) Middle muscle 

    The fibers course superomedially and conjoin with the fibers from 1. to the linea alba. 

    c) Deepest muscle 

    Transverse fibers, also conjoining with the linea alba. 

    • Both the anterior and posterior aspect of each of the three oblique abdominal muscles is covered by its own thin fascia, and 3. at its posterior aspect the strong transversalis fascia. It invests the abdominal cavity and cephalad becomes the diaphragmatic fascia and posteriorly the thoracolumbar fascia. Caudad it attaches to the iliac crest and becomes the endopelvic fascia. 
    • Long, straight, paired abdominal muscle divided by 3 – 4 transverse tendinous intersections ("six-pack") 
    • Triangular rudimentary muscle caudad and anterior to 4. between the pubic bone and linea alba. 

    2. Fascias and peritoneum 

    Muscles 4. and 5. are invested by the rectus sheath formed by the 3 oblique abdominal muscles 1.–3. The superior ¾ of 4. are completely invested by the rectus sheath, while the latter only covers the anterior aspect of the inferior ¼ below the arcuate line. The posterior aspect of 4. is only covered by the transversalis fascia and peritoneum. In its superior ¾ the anterior lamina of the rectus sheath is formed by 1. and half of 2., while the posterior lamina is formed by both 2. and 3. 

    Transversalis fascia and peritoneum are separated by the extraperitoneal space, the extent of which may markedly differ depending on the location. The retroperitoneal abdominal organs are found in the retroperitoneum. At the anterior abdominal wall the slender retroperitoneum often is known as the preperitoneal space (e.g., at the deep inguinal orifice). 

    The peritoneum (parietal serosa) invests the completely enclosed peritoneal cavity (exception: tube openings in women), and as visceral peritoneum it invests the intraperitoneal organs. Inferior to the umbilicus it forms three folds: 

    • The single median umbilical fold (obliterated urachus/allantoic stalk) 
    • The paired medial umbilical fold (former umbilical artery) 
    • The paired lateral umbilical fold (inferior epigastric vessels) 

    3. Innervation and blood supply 

    The anterior abdominal wall is innervated by the anterior branches of spinal nerves Th7 – Th11, Th12 (subcostal nerve) and L1 (iliohypogastric nerve and ilioinguinal nerve). 

    Its cephalic superficial blood supply comes from the internal thoracic artery (→ musculophrenic artery), while caudad the blood is supplied by the superficial epigastric artery and superficial circumflex iliac artery (both branches of the femoral artery). The deep layers are supplied cephalad by the superior epigastric artery (internal thoracic artery), laterally from the intercostal vessels and caudad from the inferior epigastric artery and deep circumflex iliac artery (both branches of the external iliac artery). Venous drainage is via the corresponding (eponymous) veins.

  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 07.05.2012
  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Marking the landmarks

    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

    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

    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

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  • Wound closure

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  • Applying the NPWT

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  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Intraoperative complications

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  • Postoperative complications

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  • Praxis für Chirurgie & Gefäßchirurgie

    Dr. Helmut Nigbur

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Literature search

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