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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 25-33

Is transversus abdominis muscle release sustainable for the reconstruction of peritoneal volumes? A retrospective computed tomography study

1 Department of Surgery, “Constantin Papilian” Emergency Military Hospital, Cluj-Napoca, Cluj County, Romania
2 Department of Radiology, “Constantin Papilian” Emergency Military Hospital, Cluj-Napoca, Cluj County, Romania
3 Department of Surgery, “Constantin Papilian” Emergency Military Hospital; Department of Surgery, “Iuliu Hatieganu”University of Medicine and Pharmacy, Cluj-Napoca, Cluj County, Romania

Date of Submission04-Nov-2019
Date of Decision05-Dec-2019
Date of Acceptance06-Jan-2020
Date of Web Publication17-Feb-2020

Correspondence Address:
Dr. Valentin Constantin Oprea
Department of Surgery, “Constantin Papilian” Emergency Military Hospital, No 22 Gral Traian Mosoiu Street, Cluj-Napoca, Cluj County
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_49_19

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BACKGROUND: Incisional hernia (IH) is the most frequent complication of laparotomy with an increasing incidence over time. A large amount of them present in complex forms with large defects or even loss of domain. There is still no consensus regarding the optimal surgical approach for this IHs. The posterior component separation with transversus abdominis release (TAR) alone or in combination with augmentation of the abdominal wall became the standard of repair in large IHs (LIH). No clear evidence that TAR alone can recreate the normal volume of the peritoneal cavity is available. We assessed if it is possible to reconstruct normal peritoneal volume (PV) by TAR.
MATERIALS AND METHODS: In this retrospective study, data from LIH patients with midline defects equal or larger than 10 cm width, and computed tomography scans available before and 1-week after TAR with complete fascial closure were analyzed. Hernia sac volume (HSV), abdominal cavity volume (ACV), and (PV = HSV + ACV) were evaluated before surgery. Peritoneal index (PI) was calculated as HSV/PV ratio. PV was measured at 7 days post-TAR (PVTAR). The compliance of the abdominal wall (Cab) was calculated as the ratio between the difference of the PV before surgery and after TAR and the difference between preoperative intra-abdominal pressure (IAP) and postoperative IAP.
RESULTS: 23 consecutive patients with a mean age of 64 years were included in the study. The mean value of the HSV was 3,775 cm3 and of the ACV 8377 cm3. PI varied between 0.22 and 0.4. A statistically insignificant difference was recorded between PV and PVTAR(P = 0.7). Patients with PI ≥0.3 had the volume of the peritoneal cavity lesser than patients with PI <0.3. The compliance of the abdominal wall was decreased for the patients with defects larger than 15 cm width and PI larger than 0.33. Urine output in the first postoperative day was smaller in the patients with PI larger than 0.3 with a statistically significant (P = 0.0002) difference and was highly correlated with the abdominal perfusion pressure (APP) and PI.
CONCLUSIONS: TAR is able to recreate normal PV in LIH patients with PI <0.3. When PI is larger than 0.33, a permissive intraabdominal hypertension develops for 24 h with the reduction of the APP and of the urine output. In this condition, the augmentation of the abdominal wall could be considered as an option by preoperative administration of pneumoperitoneum and/or Botulin toxin.

Keywords: Abdominal cavity volume, incisional hernia volume, intraabdominal hypertension, large incisional hernias, peritoneal index, transverse abdominal muscle release

How to cite this article:
Oprea VC, Rosian M, Mardale S, Grad O. Is transversus abdominis muscle release sustainable for the reconstruction of peritoneal volumes? A retrospective computed tomography study. Int J Abdom Wall Hernia Surg 2020;3:25-33

How to cite this URL:
Oprea VC, Rosian M, Mardale S, Grad O. Is transversus abdominis muscle release sustainable for the reconstruction of peritoneal volumes? A retrospective computed tomography study. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2022 Jan 19];3:25-33. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/1/25/278497

  Introduction Top

Despite considerable improvements and innovations in surgery, incisional hernia (IH) is still found after 11%–50% of laparotomies. It is one of the most frequent complications and a common indicator for reoperation.[1],[2] The costs involved in caring for this patient population are enormous (over USD 3 billion only in the USA) and constitute a real public health problem.[3]

Within this group, a specific subcategory of patients with large or very large IH (LIH) can be identified. Even though LIH incidence is underestimated, up to 40% of patients could be defined as large or with loss of domain (LOD) according to experts.[4],[5],[6] Most of these patients experience severe symptoms, a poor quality of life and surgical repair is commonly needed.[7]

The surgical management of IH associated with a patient's poor condition results in severe immediate complications (e.g., abdominal hypertension or compartment syndrome, respiratory failure), prolonged hospitalization (including intensive care), high reoperation rates and mortality. An optimized and proper surgical procedure choice is mandatory for a successful outcome.

In the last years, posterior component separation with transversus abdominis muscle release (TAR), alone or in combination with augmentation of the abdominal wall (progressive preoperative pneumoperitoneum (PPP) and/or Botulin toxin) became the standard of repair for LIH and was adopted routinely in several surgical centers.[8]

The effects of TAR on the abdominal wall muscles and on the abdominal wall function were investigated,[9],[10] but there is no evidence that TAR alone can recreate the normal volume of the peritoneal cavity. The primary objective of our study was to assess, by a computed tomography (CT) volumetric evaluation, if TAR is sustainable in reconstruction of the normal peritoneal volume (PV). The secondary objective was to identify if there is any valuable cut-off based on CT volumes for identification of abdominal wall augmentation indication before the surgery.

  Materials and Methods Top


All files of the IH patients admitted in the Department of Surgery of the Military Hospital Cluj-Napoca, between November 2014 and November 2018, were retrospectively analyzed. The study was approved by the Ethics Committee of the respective hospital. LIH was defined as a ventral IH with a fascial defect ≥10 cm width. The patients were included in the study based on the following pre-defined criteria: Midline IH defects ≥10 cm width, CT scan available before surgery and 1-week after the TAR with complete closure of the anterior fascia has been performed. Exclusion criteria were: Patients with preoperative local augmentation by PPP and/or Botulinum toxin, and patients with Class IV Ventral Hernia Working Group classification.[11] Patient consent was waived because the medical record review was retrospective and it was not feasible to obtain it.

Computed tomography protocol investigation

All preoperative CT scans were retrospectively re/reviewed by a surgeon and a radiologist. After the cross review, all inconsistencies of the measurements were eliminated. The length and the width of the defects were identified in their maximal dimensions and carefully measured. The width of the both rectus sheath has been also measured. Their sum divided by the width of the defect was the basis for TAR indication. The volume of the abdominal cavity volume (ACV) and of the hernia sac volume (HSV) (expressed in cm3) were calculated according to Tanaka et al. method.[12] The PV was obtained by adding up ACV and HSV. The peritoneal index (PI) was calculated as the ratio between IHV and PV. All the values were manually collected because there was no computer software; differences larger than ±10% between surgeon's and radiologist's measurements were reassessed until the agreement was obtained. The values were rounded to the nearest hundred or thousand.


Patients' baseline characteristics (age, sex, and onset of symptoms) were recorded in a database. Intraoperative findings (length and width of the defect) were also recorded and compared with the CT scan findings. The defect of most patients was equated with an ellipse, and the defect surface was calculated using the formula ½ length × ½ width × π. Intra-abdominal pressure (IAP) was measured by indirect evaluation through a urinary catheter[13] and was recorded before surgery and 24 h after TAR on the awakened patient. Intraabdominal hypertension (IAH) was defined as an IAP >12 mmHg.

The compliance of the abdominal wall (Cab) was indirectly calculated as the ratio between the difference of PVs before and after surgery (ΔV = PV – PVTAR) and the difference between preoperative IAP and postoperative IAP (ΔP = preoperative IAP– postoperative IAP) (Cab= ΔV/ΔP). As a direct measure of IAH, the abdominal perfusion pressure (APP) was calculated as the difference between mean arterial pressure and IAP preoperatively and in the first postoperative day. Urine output at 24 and 48 h was recorded.


The indication for TAR was established preoperatively using the formula 2RW: DW = 2:1, where RW was the rectus sheath width and DW is the defect width measured, both, on CT scan. All the procedures were performed under general anesthesia according to the technique described by Novitsky.[14],[15]

Statistical analysis

Data were tabulated as mean ± standard deviation (SD). Continuous variables were analyzed by ANOVA variance test followed by unpaired 2 tales Student's t-test assuming unequal variance, and the binary outcomes with the Chi-square test. Pearson correlation® was used with the regression equation. Multivariate logistic regression models were built with PI, IAP, PVTAR, Cab and APP as the outcomes of interest for the major determinants of severe postoperative complications, adjusting for identified confounders. In addition to the variables of interest, the following were included for adjustment: Age, rank of recurrence, severity of comorbidities score, BMI, length, width and area of the defect, ACV, IHV, PV, postoperative IAP, and pain. Probabilities smaller than 0.05 were considered as statistically significant. IBM SPSS Statistics Version 20.0, 2018, Chicago, IL, was used to perform the statistical analysis.

  Results Top

Of 327 IH patients identified during the study period, 98 (27%) underwent TAR and 23 patients (7%) fulfilled the criteria for inclusion in the study. Mean age ± SD was 64.47 ± 7.98 years and the onset of symptoms ranged between 12 and 148 months (62.17 ± 37.4). Demographic characteristics are shown in [Table 1].
Table 1: Demographic data of the studied patients

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IAP was low in 6 patients (6 mmHg), moderate in 10 patients (7–8 mmHg), and close to normal values in 7 patients (9–10 mmHg). The mean value was 7.6 ± 1.24 mmHg.

The dimensions of abdominal wall defect measured on CT scan are listed in [Table 2]. No statistically significant difference was observed between intraoperative data and CT findings (Student's t-test; P = 0.83 data not shown). Pre and postoperative values of IAP and of the abdominal volumes are also shown in [Table 2].
Table 2: The values expressed as mean±standard deviation for the computed tomography scan evaluation of the abdominal wall defect and for the pre- and post-operative intra-abdominal pressure and volumes of abdomen

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Univariate analysis of the entire cohort with the PI as a reference, showed no correlation with the dimensions of the defect length, width or surface. A high negative correlation was found with the preoperative IAP at the 0.01 level of significance (Pearson r = −0.809 and r2 linear = 0.654) [Figure 1]. Also PI was negatively correlated with PVTAR(Pearson r = −0.512; r2 linear = 0.654; P = 0.006) and with ACV (Pearson r = −0.627; r2 linear = 0.623; P < 0.001). When IAP was the reference, a significantly statistical difference between preoperative and postoperative was found P = 0.004. Asignificant negative correlation for 2 tailed at a level of 0.01 was found between postoperative IAP and ACV, preoperative IAP and PVTAR[Table 3].
Figure 1: Correlation between preoperative intra-abdominal pressure and peritoneal index (x-axis represents the value of peritoneal index)

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Table 3: The univariate analysis shows some significant correlations * for peritoneal index and postoperative intra-abdominal pressure

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[Table 4] details the results of multivariate logistic regression models. After adjustment, PI and postoperative IAP were shown to be independently associated with increased odds for higher values of width, area, ACV, HSV, and PV.
Table 4: Multivariate logistic regression results

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The mean postoperative PV increased to 11,015.82 ± 2,184.44 cm3 (ranges: 7,013–14,211 cm3). There was no statistic difference between preoperative PV and PVTAR(Student's t-test: P = 0.076; F-test: P = 0.739).

The values of the abdominal wall compliance ranged between −133 and −18 cm3/mmHg with a mean value of −133.51 ± 69.51 cm3/mmHg. It was highly associated with IHV (odds ratio [OR] = 2.7; 95% confidence interval [CI] = 1.35–4.19; P = 0.019), and ΔV (OR = 4.28; 95% CI = 1.24–14.7; P = 0.0001).

Most of the PVTAR values were close to the PI of 0.3. A high negative correlation between PI and PVTAR was observed [Figure 2].
Figure 2: Correlation between PVTARand the peritoneal index. The critical value for PVTARis for a peritoneal index of 0.3. The equation of regression confirms the correlation (y = 1.14E + 1.85E3 × x) (x-axis represents the value of peritoneal index and y-axis the peritoneal volume after transversus abdominis release)

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According to histogram distribution of the PI, 57% of the patients had values ranging between 0.3 and 0.34. Related to these values, we considered that a PI equal with 0.3 could be an arbitrary range to compare, so the patients were divided into two groups: Group 1 with PI between 0.2 and 0.29 (7 patients) and Group 2 with PI ≥0.3 (16 patients). Demographic characteristics were similar between groups [Table 5].
Table 5: Comparison of groups characteristics mean±standard deviation

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When the PV and PVTAR were compared, a significant difference was recorded in group 2 (Student's t-test P = 0.041) and no difference in group 1 (P = 0.3). The difference between PV and PVTAR(ΔP representing the necessary volume after TAR for completing PV) and the difference between pre-and postoperatively IAP was statistically significant between groups for both values [Table 5].

The compliance in the patients with PI larger than 0.3 was smaller than for the patients with PI <0.3 and the difference was statistically significant (P = 0.0075). In the univariate analysis factors that influenced the compliance in patients with PI larger than 0.3 were postoperative IAP, ΔV, and ΔP. When multivariate logistic was applied age, onset, length, width, area, ACV, PI, and preoperative IAP were added as risk factors for decreased compliance [Table 6].
Table 6: Risk factors for decreased abdominal compliance

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The most decreased values of the Cab were encountered in patients with PI >0.33. If the difference of the volumes to replace was larger than 1,000 ml the risk to have a postoperative IAP larger than 16 mmHg is ninefold increased compared with volumes smaller than 1000 ml (OR 9.00; 95% CI = 1.51–53.4; P = 0.0156).

The mean preoperative APP in group 1 was 82.85 ± 3.8 mmHG and in the Group 2, 80.12 ± 6.02 mmHg (P = 0.885). Mean values were decreased postoperatively in both groups and the difference was statistically significant (76.85 ± 4.7 mmHg vs. 69.81 ± 6.42 mmHg, P = 0.0168). APP was negatively highly correlated with the PI in patients of Group 2 for both univariate and multivariate logistic regression (r = −0.724, r2 = 0.524, P = 0.002, OR = 4.84, 95% CI = 1.08–21.58, P = 0.038). The value of the PI has no influence on the APP in group 1 (OR = 1.00, 95% CI = 0.017–57.31, P = 1.00). In Group 2, 11 patients with PI larger than 0.33 developed APP lower than 70 mmHg compared with 5 with PI ranging between 0.3 and 0.33 who did not (OR 4.84, 95% CI = 1.08–21.58, P = 0.037) and the difference was statistically significant (Χ2 = 4.5, P = 0.02).

No difficulties to close the abdominal wall were encountered. The mean urinary output for 24 h from the end of the operation was decreased with an average of 815 ml for patients with PI ≥0.3 (P = 0.0002). For the patients of Group 2, the 24-h urinary output was strongly influenced by the PI, postoperative IAP, and postoperative APP in both univariate and multivariate analysis [Table 5]. After 48 h no difference was found between groups (P = 0.813).

  Discussion Top

IH remains an unfortunate event for many patients after laparotomy. With an increasing incidence ranging from 10% to 63% in high-risk patients, IH is the most common complication after abdominal surgery.[1],[2] Despite a large amount of innovation in surgical techniques and technologies, prosthetic materials and more insides into the mechanisms of IH, the short-and long-term outcomes remain poor. Obesity, smoking, and aging population with multiple associated comorbidities are the main factors contributing to the increased incidence and unsatisfactory results of such repairs.[11]

A large number of IH are complicated cases, which include large defects or even LOD. The European Hernia society defines LIH as defects with a width >10 cm.[4] For LOD no acceptable definition exists yet. In a recent systematic review, Parker et al. reported six different definitions for “LOD” which vary and are not interchangeable.[16] They concluded that expert consensus is necessary to standardize this important concept for hernia surgeons, but the best definition is probably a volumetric one. In our study, LOD was considered a chronic large irreducible hernia with a large defect and a large sac in which a significant portion of the abdominal viscera is residing outside the abdominal cavity.

Historically, physical examination was considered acceptable for diagnosing LIH, but nowadays clinical diagnosis alone may result in an inappropriate surgical management. CT is recommended as the standard procedure not only for diagnosis but also for abdominal wall evaluation and for the selection of repair method.[17],[18] This statement is also the conclusion of our study because postoperative IAP is correlated with almost all CT scan evaluated parameters.

However, a recent systematic review suggested that out of 158 studies (31 randomized controlled trials, 32 cohort studies, and 95 retrospective studies with 31,874 patients), only 12% used preoperative imaging for IH characterization.[19] According to this report, only 511 patients (2%) benefit from a CT scan evaluation. Furthermore, in most studies reporting imaging technique use, not all patients had benefit of it (only 4% used it for all subjects preoperatively).

CT scan is mandatory for labeling protocol of the abdominal wall[20] but also for the volumetric evaluation of the IH and abdominal cavity, especially when there is a large difference between the abdominal cavity and content (hernia volume that needs to be restored).[12]

The physiologic function of transversus abdominis muscle is the main target during posterior component separation. It is viewed as the “corset” which maintains the IAP and provides hoop tension through the thoracolumbar fascia.[14],[15],[17] The subsequent mobilization of the underlying fascia after its release removes the “tone” of the lateral wall resulting in a larger expansion of the abdominal girth with medial advancement of the rectus complex, especially in patients with wide abdominal defects.[17]

The impact of TAR has been little studied and only related to core function.[9],[10] To our knowledge, there is no study on the capability of TAR to increase the abdominal capacity without or with minimal consequences upon normal physiology. According to Majumder et al., on a cadaveric study, after a complete TAR with large retro-muscular dissection, an average advancement of 10 cm for the anterior fascia and of 11 cm for the posterior fascia on each side was obtained.[21] This can provide a significant increase of the abdominal cavity inner diameters and subsequently an increase of the whole visceral sac volume. Our data confirmed these increases since there was no statistical difference between preoperative values of the PV and after TAR volumes (PVTAR) (P = 0.076). This mean global increase of the PVTAR compared to PV is strictly dependent on the ACV (r Pearson = 0.93) and less on HSV (r Pearson = 0.654). These results are in line with the negative correlation between PVTAR and PI (r Pearson = −0, 51), which indicates that the higher the index the smaller the volume increased. As can be seen from [Figure 3], the smallest increase of the volumes occurs at a PI of 0.3. When the patients were divided into two groups according to PI, the increase of the volumes after TAR was smaller and inadequate for patients with PI ≥0.3, and the difference was significant (P = 0.002). The necessary volume to reach preoperative PV was larger for patients with PI ≥0.3 [Table 4].
Figure 3: The decrease of the abdominal perfusion pressure (app postop) (a) and of the 24 h postoperative urinary output (urine 124) (b) is strongly correlated with a peritoneal index of 0.34

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Myofascial release of the transversus abdominis muscle can generate elevated IAP immediately following repair, clearly demonstrated by our results. All our patients developed IAH to varying degrees: Grade 1 (12–15 mmHg) – 8 patients, Grade 2 (16–20 mmHg) – 13 patients and Grade 3 (21–25 mmHg) – 2 patients. No values larger than 15 mmHg were recorded in patients with PI smaller than 0.3. These elevated IAP could be considered permissible due to the fact that no organ dysfunction, except for some reversible decrease of the urinary output, were recorded. Probably maintaining of the APP above the critical value of 60 mmHg was an important contributing factor to the positive outcomes of the patients. In these conditions, it can be suggested that IAH or abdominal compartment syndrome (ACS) immediately after an elective abdominal wall reconstruction creates a clinical aspect that must be distinguished from the settings in which they were originally described. The fact that IAH decreased after 24 h postsurgery and the urinary output returned to physiologic values does not guarantee that this is the normal outcome for all the patients. As there are still no preoperative factors to suggest the irreversible evolution towards ACS, we can consider that PI ≥0.33 may be the threshold from which to associate the preoperative augmentation of the abdominal wall with PPP and/or Botulin Toxin B.

The assertion is based on the fact that 15 of the patients with PI over 0.3 developed intrabdominal hypertension of grade 2 and 3 compared with those with PI <0.3 where no such values were recorded (OR 155; 95% CI = 5.61–4275.69; P = 0.0029). More than that, when PI was larger than 0.33, the most decreased urine output and APP were recorded [Figure 3].

Abdominal compliance (Cab) is a measure of the ease of abdominal expansion and it is determined by the elasticity of the abdominal wall and diaphragm.[22] It should be expressed as the change in intraabdominal volume per change in IAP. Cab plays a key role in the understanding of deleterious effects of un-adapted IAV on IAP and end-organ perfusion, although at present, it is one of the most neglected parameters in abdominal wall reconstruction. Correct measurement of Cab together with the identification of patients at risk for poor Cab will help avoiding progression from normal IAP to IAH to ACS and its associated complications [Table 7].
Table 7: Risk factors associated with decreased abdominal compliance (modified after malbrain)

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There are a lot of ways to determine Cab but no one is perfect.[22] In our study, we considered that the membrane of the abdomen responds to the linearity of Young.[22] This means that a variation in the IAV implies a proportional variation in the IAP exerted by the membrane. This can be expressed with the formula ΔP = kΔV where k is a constant of the elastance of the abdomen or the reciprocal of the compliance k = 1/Cab. Replacing k in the formula results that Cab is the ratio between ΔV and ΔP.

Factors determining the reshaping properties of the abdominal wall and diaphragm are not well understood, but the mechanical properties are related to Cab. The stretching capacity is influenced by several factors related to demographics and anthropomorphy, comorbidities, and related to the abdominal wall and diaphragm[22] [Table 7]. In our study demographic factors that influenced Cab were age (decreased in younger patients), sex (decreased in males), and onset (the longer the evolution the lower compliance). The anatomy of the defect also influenced the values of the compliance which was directly related to the width, length, area, ACV, HSV, PI, and preoperative IAP. This seems logical as the long evolution of LIH leads to lateral retraction of the muscles, with increasing of the defect size and increasing of the HSV. Muscular fibrosis due to suboptimal muscle function and chronic contracture induced by chronic low back pain are factors that influence abdominal wall compliance and must be considered for outcome evaluation.

All these data suggest that TAR is capable to recreate PV without or with minimal disturbances only in patients with PI ≤0.33. We can consider that when PI is >0.33, a local augmentation of the abdominal wall needs to be evaluated. This is also the conclusion of Sabbagh et al. who demonstrated that a PI <0.2 was predictive for tension-free fascia closure; values >0.2 need optimization with PPP.[23] In Sabbagh's study, no patient was operated by TAR approach. La Meir et al. suggest that a high IHV/PV ratio is an indication for PPP, but they did not quantify the parameter.[24] Tanaka et al. reported for the first time the use of PVs to determine the extent of PPP and arbitrary applied a threshold of 0.25, but no patient was operated by TAR.[12]

Our data suggest that a PI ranging from 0.3 to 0.35 could be a reasonable threshold for PPP in association with TAR for LIH. Values >0.35 can be optimized by Botulin Toxin B in association with PPP. The PPP has many favorable effects in preventing severe complications after abdominal wall reconstruction. By gradual increase of the IAP, it also increases the tolerance to IHV return during surgery.[25] Abdominal muscles are gradually expended and have a contribution to the global increase of the visceral sac volume.[26] Elevation of the diaphragm (even with 10 cm) increases the ACV and contributes in improving the pre and postoperatively respiratory function.[27] Some studies report a reduction in the postoperative surgical site infections due to a massive input of peritoneal neutrophils, and a reduction of the postoperative hospitalization.[28] Pneumatic dissection of visceral bands and adhesions, which facilitates the reinsertion of intestinal loops into the abdominal cavity is another benefit of the PPP.[27]

Regarding the Botulin toxin, this is a patent neuromodulator agent produced by Clostridium botulinum which specifically binds the receptors of the neuromuscular plate and inhibits the release of acetylcholine. The result is a flaccid paralysis of the muscle being it smooth or striate.[29] The toxin requires 24–72 h to take effect, and the maximum paralysis is achieved usually after 4–6 weeks postinjection. The flaccid paralysis is reversible after 4–6 months. All the benefits of Botulin toxin were described in several studies and are listed in [Table 8].[29],[30],[31],[32]
Table 8: The documented advantages of the Botulin toxin in augmentation of the abdominal wall

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The association between PPP and Botulin B toxin is a complementary tool of the surgical procedure and facilitates the integral management of the patients with loss of abdominal domain. Buenno-Lledό et al. are the first who reported a large series of LIH and LOD preoperatively prepared with the combination of PPP and Botulinum A toxin after a protocol in which a PI >0.2 (20%) was used in patients enrolled for such optimization.[32] The reconstruction technique involved an anterior component separation with an on-lay mesh with complete fascial closure in all patients. Some other studies report similar results but further research is still necessary in order to identify the threshold for this indication.[29],[30],[31],[32],[33]

Our study has several limitations. First, it was performed in a single institution and the applicability of these results should be validated. Second, the number of enrolled patients was limited and a high number of exclusion criteria could be a source of bias, but nonparametric analysis shows a modal distribution for almost all variables except for pain. Further multi-centric studies are necessary. Third, a bias can result from the method of calculation, but because it was done in the same conditions and by the same person, this can be excluded. Measuring the volumes with a software could offer more precise data. Another bias can result from the IAP evaluation. The indirect measurement is being not the most precise method of detection. This can be eliminated because the determination has been done by the same investigator and in the same conditions.

  Conclusions Top

To our knowledge, this is the first report examining the efficacy of TAR in recreating the normal PVs. The procedure is strongly effective when the PI (IHV over PV) is <0.3. In these circumstances, the repair increases PV without any disturbances. When the PI is >0.33, the increased IAP resulted from the repair, even it was transient and resilient, can discuss the augmentation of the abdominal wall as an option. Further studies are needed to establish a threshold for PPP and the combination between PPP and Botulinum toxin as a sure indication for abdominal wall augmentation in order to prevent severe outcomes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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Hernia. 2021;
[Pubmed] | [DOI]


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