Endoscopic Component Separation November Philip Omotosho, MD Assistant Professor of Surgery Duke University School of Medicine

Transcription

1 Endoscopic Component Separation November 2014 Philip Omotosho, MD Assistant Professor of Surgery Duke University School of Medicine

2 Abdominal Wall Anatomy External Oblique Rectus Abdominus Internal Oblique Transverse Abdominus Transversalis Fascia Peritoneum

3 Open component separation Ramirez, OM. Et al Ramirez, OM. Et al. Plast Reconstr Surg. 1990; 86(3): Page 3

4 Open component separation Ramirez, OM. Et al Ramirez, OM. Et al. Plast Reconstr Surg. 1990; 86(3): Page 4

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9 Endoscopic Component Separation Rosen MJ, et al. Hernia (2007) 11:

10 Endoscopic Component Separation Advantages Eliminate lipo-cutaneous flaps Reduce wound infections Reduce likelihood of flap ischemia

11 Endoscopic Component Separation - 1 cm incision just inferior to costal margin lateral to the rectus abdominis - Dissect subcutaneous tissues to expose external oblique aponeurosis - External oblique aponeurosis grasped and sharply incised, fibers split in their natural orientation, exposing internal oblique - Potential space between int. and ext. obliques created using a bilateral lap inguinal dissecting balloon - Structural balloon is placed, insufflated to 12 mmhg; 30 deg scope inserted and used as blunt dissector under direct vision - 2 additional ports (5 mm) are placed one at level of umbilicus at post ax. line and another just above the inguinal ligament, lateral to the rectus - Intramuscular space completely dissected just above costal margin to inguinal ligament, rectus muscle medially, posterior axillary line laterally - External oblique then released from costal margin to inguinal ligament (L-hook; coagulating scissors; other energy source) Rosen MJ, et al. Hernia (2007) 11:

12 Endoscopic component separation Considerations Large defects > 20 cm should probably not be approached with the endoscopic approach Avoid technique in fixed, non-compliant abdominal wall defects Medial advancement can be difficult to achieve with defects near xiphoid and suprapubic areas Avoid technique if large skin flaps already exist secondary to a very large hernia If exposure cannot be achieved laparoscpically to complete the cephalad portion of the release, skin incision can be enlarged, and using lighted retractors, the release can be completed open. Rosen, MJ. Atlas of Abdominal Wall Reconstruction

13 Endoscopic component separation Peri-operative Considerations Perioperative - Lovenox 40mg SQ?? - Ancef 2g IV - SCDs - Foley catheter Positioning - both arms out - mid-chest/abdomen prepped out wide laterally - monitors on the patients right and left side (mobile to move up toward the head and then down to the feet)

14 Endoscopic component separation Instruments Ports - Spacemaker - 5-mm bladeless ports (x 2) Other instruments - 10mm, 30-degree scope - 5mm, 30-degree scope - Hook cautery (or endo-scissors) - Ligasure - Army-navy retractors (or appendiceal retractors) - Kocher clamp

15 Port Configuration Rosen, MJ. Atlas of Abdominal Wall Reconstruction

16 Endoscopic Component Separation Steps mm incision just inferior to costal margin lateral to the rectus abdominis - Dissect subcutaneous tissues to expose external oblique aponeurosis - External oblique aponeurosis grasped and sharply incised, fibers split in their natural orientation, exposing internal oblique - Potential space between int. and ext. obliques created using a bilateral lap inguinal dissecting balloon

17 Endoscopic Component Separation Steps - Structural balloon is placed, insufflated to 12 mmhg; 30 deg scope inserted and used as blunt dissector under direct vision - 2 additional ports (5 mm) are placed one at level of umbilicus at post ax. line and another just above the inguinal ligament, lateral to the rectus - Intramuscular space completely dissected just above costal margin to inguinal ligament, rectus muscle medially, posterior axillary line laterally - External oblique then released from costal margin to inguinal ligament (L-hook; coagulating scissors; other energy source)

18 Page 18 VIDEO Balloon Dissection

19 Endoscopic component separation View upon entry into space You should be in-between the EXT and INT OBL muscular space. ROOF = EXT OBL (fatty) MEDIAL = SEMILUNAR LINE FLOOR = INT OBL (muscular)

20 Page 20 VIDEO Part 1

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