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Ramirez component separation technique - general and visceral surgery
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Marking the landmarks
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
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
Incising the aponeurosis of the external oblique
Separating the external oblique muscle
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
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
Applying the NPWT