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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 63-66

Comparing outcomes of the endoscopic and open external oblique myofascial release

Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina, USA

Date of Submission16-Apr-2020
Date of Decision18-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. William W Hope
Department of Surgery, New Hanover Regional Medical Center, 2131 South 17th Street, PO Box 9025, Wilmington, North Carolina 28401
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_13_20

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AIMS: The external oblique release (EOR) is a well-described technique for myofascial advancement during hernia repair. One of the reported drawbacks of an open approach is the high wound morbidity associated with this procedure. One proposed technique to reduce wound morbidity is the endoscopic EOR. The purpose of this study was to compare the outcomes of the open and endoscopic EOR.
METHODS: Data from the Americas Hernia Society Quality Collaborative were queried on May 10, 2017. All patients undergoing open or endoscopic incisional hernia repair with an EOR were evaluated with comparative outcomes including hernia recurrence, quality of life, and 30-day wound complications.
RESULTS: Four hundred and eighty-five patients met inclusion criteria of undergoing open or endoscopic EOR. Surgical site infections (SSIs) occurred in 6% of the patients undergoing open EOR and 14% undergoing endoscopic EOR. There were no differences in outcomes comparing open and endoscopic EOR for hernia recurrence, quality of life, or 30-day SSI rate (P > 0.05). Laparoscopic EOR had a significantly higher rate of surgical site occurrences (SSOs) compared with open EOR (P < 0.05); however, this did not result in an increase in procedure intervention for the SSOs (P > 0.05).
CONCLUSIONS: Equivalent outcomes were achieved using the open or endoscopic EOR technique in open repair of incisional hernia. Both techniques offer good outcomes and are important adjuncts in the repair of complex incisional hernias.

Keywords: Component, hernia, myofascial, release, separation

How to cite this article:
Appleby PW, Bilezikian JA, Faulkner JD, Fox SS, Hope WW. Comparing outcomes of the endoscopic and open external oblique myofascial release. Int J Abdom Wall Hernia Surg 2020;3:63-6

How to cite this URL:
Appleby PW, Bilezikian JA, Faulkner JD, Fox SS, Hope WW. Comparing outcomes of the endoscopic and open external oblique myofascial release. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2022 Oct 2];3:63-6. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/2/63/284090

  Introduction Top

A major advancement in hernia surgery is the ability to perform a myofascial release to allow for closure of the fascial defect and re-approximation of the linea alba. Since the first report documenting a method for myofascial release and amount of fascial advancement achieved,[1] multiple techniques have been described that allow fascial advancement by releasing different layers of the abdominal wall.

A common technique for myofascial release, originally described by Ramirez et al.,[1] is the anterior component separation. This technique involves raising skin flaps to expose and consequently incise the external oblique fascia. This external oblique release (EOR) technique has been well documented with good results; however, there is a concern for potential wound complications.[2] This has been theorized to be related to an interruption of the blood supply to overlying skin flaps by disrupting small perforators.[3] To reduce the infection rate associated with the external oblique myofascial release, Rosen et al. popularized a minimally invasive method that uses a laparoscopic dissecting balloon to access the plane between the external and internal oblique musculature to allow the release of the external oblique with minimal subcutaneous dissection.[4] Using this endoscopic or laparoscopic component separation technique aims to reduce wound complications by avoiding a large soft-tissue dissection.

While good outcomes have been reported using both myofascial release techniques,[5],[6],[7],[8],[9],[10] there remains concern of infection using the open external oblique technique, and to date, there are very little data comparing the two methods. The purpose of this study was to compare outcomes, especially wound complications, of the open and endoscopic EOR techniques using a large hernia database, the Americas Hernia Society Quality Collaborative (AHSQC).

  Methods Top

Data from the AHSQC were queried on May 10, 2017, for all ventral hernia repairs. Inclusion criteria were patients undergoing repair of a ventral incisional hernia using open or endoscopic EOR. The AHSQC was developed in 2013 by hernia surgeons in the United States as a continuous, patient-centered database to aid in quality improvement, performance feedback, and collaborative learning to improve the value of hernia care.

Exclusion criteria were patients undergoing off midline hernia repair, parastomal hernia repair, minimally invasive (laparoscopic or robotic) intraperitoneal repair, or minimally invasive converted to open repairs. Outcome measures were 30-day surgical site infection (SSI) rate, 30-day surgical site occurrence (SSO) rate, 30-day SSO rate requiring procedural intervention, quality of life (Hernia-Related Quality of Life Survey [HerQLes]), and 1-year recurrence rate. The HerQLes was designed and validated for use in postoperative hernia patients.[11] The questions are targeted to the patient's functional status and take into account the patient's pain at the surgical site and the surgery's impact on physical restriction and cosmetic discomfort.[11]

  Results Top

There were 18,237 patients initially queried; 485 patients met inclusion criteria. Open EOR was performed in 427 patients and 58 underwent endoscopic EOR [Table 1]. There was no difference in type of hernias or number of recurrent hernias repaired between the two groups (P > 0.05) [Table 2]. Fifty sites contributed data for open EOR, and 6 sites contributed data for laparoscopic EOR with no difference in the type of practice (academic, private, or academic affiliated) among the sites (P > 0.05) [Table 3]. SSIs occurred in 6% of the patients undergoing open EOR and 14% undergoing endoscopic EOR [Table 4]. SSOs occurred in 18% of the patients undergoing open EOR and 33% of the patients undergoing endoscopic EOR [Table 4]. There was no difference in outcomes comparing open and endoscopic EOR for hernia recurrence, quality of life, or 30-day SSI rate [Table 4]. The endoscopic EOR had a significantly higher rate of SSOs compared with open (33% vs. 18%, P < 0.05); however, this did not result in an increase in procedure intervention for the SSO (P > 0.05) [Table 4].
Table 1: Flow diagram displaying patients meeting inclusion criteria

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Table 2: Hernia characteristics for patients undergoing open and endoscopic release

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Table 3: Surgeon characteristics in the Americas Hernia Society Quality Collaborative that contributed data to the study

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Table 4: Outcome measures comparing endoscopic and open external oblique release

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  Discussion Top

A major principle of incisional hernia repair is the tension-free re-approximation of the midline fascia. The addition of mesh to midline fascial closure has shown to significantly reduce recurrence rates compared with primary fascial closure alone.[12],[13] A major advancement in hernia surgery has been the introduction and proliferation of myofascial release techniques that allow surgeons to close large hernia defects. These techniques involve incising a layer of the abdominal wall to allow for a tension-free approximation of the linea alba.

One of the most commonly performed and well-studied techniques is the EOR. As originally described,[1] this technique involves three key steps which include incising the posterior rectus sheath, creating subcutaneous flaps to expose the external oblique, and incision of the external oblique fascia. A reported disadvantage to this technique has been the associated wound complications related to the subcutaneous dissection that is required to reach and incise the external oblique.[2] This subcutaneous dissection creates a large tissue defect and has been theorized to disrupt the perforating vessels that supply the overlying skin flap leading to potential ischemia and a higher rate of wound complications. Secondary to this concern, there have been many attempts to modify the EOR technique including minimally invasive options[4] and open methods that minimize the amount of soft-tissue dissection.[3]

While there have been no randomized trials comparing the endoscopic and open EOR, there have been several animal studies, single-institutional reports, comparative studies, and meta-analyses. One initial study evaluated whether the endoscopic technique achieved release similar to the open approach. Rosen et al. reported that the endoscopic method achieved 86% of the myofascial advancements in a porcine model compared with the open approach.[14] Clinical comparative studies followed and report mixed results. Many studies including some meta-analyses have reported decreased SSIs with endoscopic release compared with open;[2],[15],[16],[17],[18],[19] however, this has been disputed in other studies/meta-analysis,[5],[7],[9],[10] and to date, there is no definitive conclusion of one technique being superior to another. This is likely due to the small number of patients included in these studies/trials.

Our findings are contrary to some of the previous studies and the commonly held belief that the minimally invasive approach to EOR decreases wound complications compared with the traditional open technique. Our results show a statistically significant increase in SSOs using the minimally invasive technique compared with open. It is unclear why the minimally invasive technique had higher rates of SSOs; however, this may be related to technical factors or related to the surgical experience and learning curve of the surgeons. However, the clinical implications of the increase in SSOs are limited since there was no difference in procedural intervention on these patients. It is also unclear why the SSI rates showed no difference between the minimally invasive and open techniques since most of the literatures in hernia repair generally favor a minimally invasive approach when compared with open.[2],[15],[16],[17],[18],[19] It is likely that the surgeons performing the open EOR are well skilled in this procedure, have appropriate patient selection, and perform technically sound operations.

There are several limitations of this study. First, there is a small sample size of the endoscopic EOR. Patient data came from only select centers, which may limit the generalizability of these data. Second, we do not have a clear description of each open EOR performed and whether principles to decrease wound complications, such as perforator-sparing techniques, were used.

  Conclusions Top

We found no difference in recurrence rate, quality of life, or 30-day SSIs when comparing patients undergoing endoscopic versus open EOR. While we found a higher rate of 30-day SSOs in the endoscopic EOR group compared with the open EOR group, there was no increase in interventions related to these SSOs. The open and endoscopic EOR are both excellent techniques to perform myofascial releases that result in equivalent outcomes and are valuable strategies for surgeons performing complex hernia repairs.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ramirez OM, Ruas E, Dellon AL. Components separation method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26.  Back to cited text no. 1
Scheuerlein H, Thiessen A, Schug-Pass C, Köckerling F. What do we know about component separation techniques for abdominal wall hernia repair? Front Surg 2018;5:24.  Back to cited text no. 2
Butler CE, Campbell KT. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 2011;128:698-709.  Back to cited text no. 3
Rosen MJ, Jin J, McGee MF, Williams C, Marks J, Ponsky JL. Laparoscopic component separation in the single-stage treatment of infected abdominal wall prosthetic removal. Hernia 2007;11:435-40.  Back to cited text no. 4
Tong WM, Hope W, Overby DW, Hultman CS. Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation. Ann Plast Surg 2011;66:551-6.  Back to cited text no. 5
Thomsen CØ, Brøndum TL, Jørgensen LN. Quality of life after ventral hernia repair with endoscopic component separation technique. Scand J Surg 2016;105:11-6.  Back to cited text no. 6
Muse TO, Zwischenberger BA, Miller MT, Borman DA, Davenport DL, Roth JS. Outcomes after ventral hernia repair using the rives-stoppa, endoscopic, and open component separation techniques. Am Surg 2018;84:433-7.  Back to cited text no. 7
Daes J, Dennis RJ. Endoscopic subcutaneous component separation as an adjunct to abdominal wall reconstruction. Surg Endosc 2017;31:872-6.  Back to cited text no. 8
Azoury SC, Dhanasopon AP, Hui X, De La Cruz C, Tuffaha SH, Sacks JM, et al. A single institutional comparison of endoscopic and open abdominal component separation. Surg Endosc 2014;28:3349-58.  Back to cited text no. 9
Feretis M, Orchard P. Minimally invasive component separation techniques in complex ventral abdominal hernia repair: A systematic review of the literature. Surg Laparosc Endosc Percutan Tech 2015;25:100-5.  Back to cited text no. 10
Krpata DM, Schmotzer BJ, Flocke S, Jin J, Blatnik JA, Ermlich B, et al. Design and initial implementation of HerQLes: A hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 2012;215:635-42.  Back to cited text no. 11
Giordano S, Garvey PB, Baumann DP, Liu J, Butler CE. Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: A propensity score analysis. Surgery 2017;161:499-508.  Back to cited text no. 12
Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, et al. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 2013;217:999-1009.  Back to cited text no. 13
Rosen MJ, Williams C, Jin J, McGee MF, Schomisch S, Marks J, et al. Laparoscopic versus open-component separation: A comparative analysis in a porcine model. Am J Surg 2007;194:385-9.  Back to cited text no. 14
Jensen KK, Henriksen NA, Jorgensen LN. Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: A systematic review and meta-analysis. Surg Endosc 2014;28:3046-52.  Back to cited text no. 15
Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 2010;199:342-6.  Back to cited text no. 16
Switzer NJ, Dykstra MA, Gill RS, Lim S, Lester E, de Gara C, et al. Endoscopic versus open component separation: Systematic review and meta-analysis. Surg Endosc 2015;29:787-95.  Back to cited text no. 17
Palmer DS, McDaniel CC, Samra NS, Griffen FD. Comparing surgical site infection for open and endoscopic component separation. Am Surg 2019;85:350-2.  Back to cited text no. 18
Giurgius M, Bendure L, Davenport DL, Roth JS. The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 2012;16:47-51.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3], [Table 4]


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