|Year : 2020 | Volume
| Issue : 3 | Page : 81-86
Comparison between transversus abdominis release and anterior component separation technique in complex ventral hernia
Md Yusuf Afaque, Amjad Ali Rizvi
Department of Surgery, J N Medical College, AMU, Aligarh, Uttar Pradesh, India
|Date of Submission||23-Dec-2019|
|Date of Decision||18-Feb-2020|
|Date of Acceptance||19-Apr-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Md Yusuf Afaque
Department of Surgery, J N Medical College, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Transversus abdominis release (TAR) is the new revolution in hernia surgery and hernia surgeons are passionately doing it all over the world. With the increase in the popularity of TAR technique, there seems a decrease in anterior component separation technique (ACST) popularity. ACST despite gone modification such as endoscopic and perforator preserving method is seen as an inferior procedure to TAR. Is TAR better than ACST? What are its theoretical limitations? We have done a literature review to compare the postoperative outcomes and technicality of open ACST and open TAR procedure.
METHODS: We performed a search in the database of PubMed, EMBASE, and Cochrane library for articles that have compared ACST with TAR procedure for postoperative outcomes and technical superiority. The search was limited to human studies and in the English language with cadaveric studies included.
RESULTS: We found seven studies that have compared ACST and TAR for various outcomes. They are three systemic reviews with meta-analysis, one multicentric prospective randomized controlled trial, one prospective study, and two cadaveric studies. They have compared the surgical site infection and surgical site occurrence rates, recurrence rate, quality of life (QOL), and extent of mobilization of the rectus muscle. Most of the studies found no significant difference between ACST and TAR; however, the overall quality of the studies may be limited.
CONCLUSION: Open ACST is comparable to open TAR procedure and has equally acceptable outcomes. In ACST, it seems to be essential to preserve the perforator vessels; however, altogether further studies are needed to gain more clarity in the daily decision-making process in the repair of complex ventral hernias.
Keywords: Anterior component separation, complex ventral hernia, component separation technique, posterior component separation, transversus abdominis release
|How to cite this article:|
Afaque MY, Rizvi AA. Comparison between transversus abdominis release and anterior component separation technique in complex ventral hernia. Int J Abdom Wall Hernia Surg 2020;3:81-6
|How to cite this URL:|
Afaque MY, Rizvi AA. Comparison between transversus abdominis release and anterior component separation technique in complex ventral hernia. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2022 Jan 19];3:81-6. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/3/81/292775
| Introduction|| |
uge ventral hernias were unsolved issues a couple of years back and the only option was watchful waiting. These untreated hernias ultimately become more complex with time, with an increase in the suffering of the patients. The reason for not attempting repair in such hernia was fear of raising intra-abdominal pressure enough to alter with the diaphragmatic movement and respiration. Recently, we have understood these hernias better and have developed methods to deal with these. The patients who were earlier told not to get operated are now getting operated at hernia centers. Now, one can analyze these hernias better and can predict difficulty respective from the preoperative stage. There are objective as well as subjective methods to assess them. The objective measure of how much volume of hernia will have difficulty in the closure is described as the loss of domain. If the ratio of hernia sac volume to abdominal cavity volume is more than 0.25 on computed tomography (CT) volumetry, then it is considered a significant loss of domain and these hernia cannot be closed with conventional methods. Another objective measure of complexity of giant incisional hernia is described by Carbonells algorithm. It says that if the width of the hernia defect is equal or larger than the sum of two recti muscle width, then the direct defect closure will not be feasible. During surgery also it can be subjectively assessed whether direct closure of the hernia defect can be done or not. Defect margins are brought in the midline and tension is assessed. If tense closure is expected, then direct closure should not be done.
To deal with such large hernia, additional maneuver to expand the abdomen will be required, and now, it has been done surgically with component separation techniques. Component separation techniques have revolutionized the world of ventral hernia repair. Ramirez et al. in 1990 first described the technique of open anterior component separation in 10 cadavers. They divided longitudinally the external oblique muscle lateral to linea semilunaris and separated this muscle from the internal oblique muscle. It needed dissection in the subcutaneous plane with the division of all perforators and resulted in skin necrosis in 20% of patients. Perforator preservation in component separation was described by Lowe et al. in 2000 in a comparison of open and endoscopic techniques. Open perforator preserving anterior component separation technique (ACST) with undermining of the subcutaneous tissues described by Saulis and Dumanian showed fewer wound complications compared with traditional open techniques (2% vs. 20%, P < 0.05). Initially, ACST was done without mesh and so had high recurrence rates up to 37.7%, but now, mesh is routinely applied.
Transversus abdominis release (TAR) is an extension of retrorectus Rives-Stoppa repair, which involves incising the posterior rectus sheath following retrorectus dissection, allowing exposure of the transversus abdominis (TA) muscle and aponeurosis and division along the length of the muscle and development of a sublay space. Its original description was by Novitsky et al.,, and an initial comparative study by them showed that it provides equivalent myofascial advancement and significantly less wound morbidity compared to ACST. They also did a cadaveric study and concluded that TAR provides substantial medial advancement of both anterior and posterior myofascial components. Retromuscular dissection deep to the divided TA muscle appeared to be the key step of the procedure. The TA muscle is the primary stabilizer of the spine, but TAR does not affect core stability in the short term and leads to improved back pain and hernia QOL. TAR achieved good results in various types of complex hernias like recurrent hernias and in patients with an open abdomen. It was also successfully done in hernias after liver transplant and kidney transplant. Innovations in TAR continued with the start of minimally invasive approaches, the laparoscopic TAR, and the robotic TAR popularly called roboTAR.,
TAR is the new revolution in hernia surgery, and hernia surgeons are passionately doing it all over the world. With the increase in the popularity of the TAR technique, there seems a decrease in ACST popularity. ACST despite gone modification such as endoscopic and perforator preserving method is seen as an inferior procedure to TAR. Is TAR better than ACST? What are its theoretical limitations? We have done a literature review to compare the postoperative outcomes (SSI and surgical site occurrence [SSO] rates, recurrence rate, and QOL) and extent of medial translation of abdominal musculature after ACST and TAR procedures.
| Methods|| |
We searched the database of PubMed, EMBASE, and Cochrane library for studies which have compared ACST with TAR for postoperative outcomes and technicality. Search terms used were anterior component separation AND hernia; posterior component separation AND hernia; “components separation AND hernia;” “separation of components AND hernia;” external oblique release AND hernia; transverse abdominis release AND hernia; abdominal myofascial release AND hernia. The search was limited to human studies and in the English language. Studies involving cadavers were included. The references of the eligible studies were also screened. If a study is found included in our selected systemic reviews, then that study was not taken separately. The author screened all databases on four separate occasions with the last search on May 25, 2019.
| Results|| |
Despite these techniques being recent, we found seven articles eligible for our review that has compared ACST and TAR for various outcomes. They are three systemic reviews, one multicentric prospective randomized controlled trial, one prospective study, and two cadaveric studies. They have compared the degree of medial translation of abdominal musculature, SSI and SSO rates, QOL, and recurrence rate. Systemic reviews and meta-analysis have overlap in studies, and it will be there as there is limited published literature on this subject.
The first systemic review by Cornette et al. included 36 observational cohort studies with 2544 patients for data-analysis and divided them into four groups: open anterior approach (OAA), Transversus Abdominis Release (TAR), laparoscopic anterior approach (LAA), and perforator preserving approach (PPA). SSO was found to be 21.4% in the OAA, 23.7% in transversus abdominis release, 20.3% in LAA, and 16.0% in PPA, respectively. Recurrence rate was 11.9% (OAA), 5.25% (TAR), 7.02% (LAA), and 6.47% (PPA). Adding the period of follow-up as relative weight, where longer follow-up is regarded as more important than short follow-up, the calculated incidence rate showed the highest recurrence in the LAA group (7.6%) and the lowest in the PPA group (3.4%). Hence, comparing PPA with TAR, the PPA has lower SSO as well as the yearly incidence of recurrence [Table 1].
The meta-analysis by Hodgkinson et al. identified seven studies describing 281 cases of TAR for midline incisional hernia using a retromuscular mesh placement and six comparable studies describing 285 cases of OAA with retromuscular mesh placement. Studies which described endoscopic anterior component separation and/or non-retromuscular mesh placement (onlay mesh placement) were not included. Pooled analysis showed a hernia recurrence rate of 5.7% (3.0-8.5) for TAR and 9.5% (4.0-14.9) for open anterior component separation and it was not significant (P = 0.23). There was also no significant difference in wound complication rates between TAR and open ACST, “superficial” 10.9 versus 21.6% (P = 0.15); and “deep” 9.5 versus 12.7% (P = 0.53).
A systematic review of five retrospective cohort studies with 646 patients by Wegdam et al. found that the TAR has a wound morbidity rate comparable to the ACSTs (15% vs. 20%) but a much lower recurrence rate (4% vs. 13%). The authors commented that the low recurrence rate in TAR group may be largely because one tertiary expert center accounted for 66% of the 646 patients, the number of studies was threefold lower in this TAR review than in the ACST meta-analysis, and mesh was used in all TAR patients but 61%-73% of ACST patients.
The first prospective multicentric randomized trial has evaluated clinical outcomes in 120 patients comparing both mesh type (biological meshes, human acellular dermal matrix vs. porcine acellular dermal matrix) and also the surgical technique (ACST/overlay vs. TAR/underlay). They found no statistically significant difference in recurrence rates at 1 year between the two techniques (ACST = 9.8%, TAR = 11.9%) and the ACST group has advantages including lower surgical site infection rate (1.6% vs. 11.9% P = 0.03) and improved physical functioning over 1 year. However, ACST group had a higher seroma rate.
Comparative study between ACST and TAR on ten cadavers was done, and the tension and advancement of each technique using a tensiometer were measured. The extent of advancement of the anterior rectus sheath was measured for both the techniques. It was found that ACST gives a greater degree of abdominal wall advancement compared to the TAR technique. An average advancement percentage of the total width for TAR versus ACST was 3.1% versus 4.1% in the epigastric, 8.4% versus 12% in the umbilical and 6.0% versus 9.6% in the suprapubic regions. This was the first study to quantify the degree of abdominal wall advancement in both ACST and TAR techniques. Moores et al. cadaveric study on five cadavers compared the effect of ACST on the anterior layer with TAR on the posterior layer. They found a statistically significant difference in average fascial translation in the favor of TAR in the mid-abdomen (3.62 cm ACS vs. 4.94 cm TAR, P = 0.008) and in the lower abdomen (3.50 cm ACS vs. 4.38 cm TAR, P = 0.026). However, in the upper abdomen, there was no statistically significant difference (3.02 cm ACS vs. 3.62 cm TAR P = 0.209). These cadaveric studies did not compare translation in the anterior layer and the posterior layer separately.
The QOL before and after the various types of open CST was studied prospectively by Blair et al. using the Carolinas Comfort Scale (CCS) in 292 patients. They performed TAR or only posterior rectus sheath release in relatively smaller hernias and ACST along with posterior rectus sheath release in larger hernias. At the end of 1, 6, and 12 months, there was no difference in CCS pain scores, movement limitation, or mesh sensation among the groups (P < 0.05). It was found that QOL was not impacted by the type of component separation on short- or long-term follow-up. The overall QOL improved significantly after repair when compared to preoperative QOL for all three component separation techniques studied.
| Discussion|| |
There has been remarkable progress in understanding the complex ventral hernia and their management. Even anatomy of abdominal musculature has been studied in a different perspective by hernia surgeons, and now, we understand them better. The classical anatomy texts describe the TA muscle to end medially at linea semilunaris, and after that, it continues as aponeurosis up to the midline. The abdominal CT of 100 healthy young individuals was analyzed by Punekar et al. to find the presence of TA muscle below the posterior rectus sheath in different parts of the abdomen. They found the presence of TA muscle within the rectus sheath at the costal margin plane in 100% of cases. However, it was present in 36% at the umbilicus and in only 2% slightly above the posterior superior iliac spine. In TAR we start the division of TA muscle in the upper abdomen where this muscle is present in all the individuals medial to linea semilunaris. Actually what we divide in the lower abdomen is TA aponeurosis and not the muscle. The credits go to hernia surgeons for finding and dividing TA muscle below the posterior rectus sheath where it was not supposed to be there and innovating a novel technique.
In our review, five of the studies have shown that ACST has outcomes comparable or better than TAR. Two studies showed a more favorable outcome with TAR. The systemic review by Wegdam et al. suggested that the TAR has a wound morbidity rate comparable to the ACSTs but a much lower recurrence rate. However, they also suggested that the low recurrence rate with TAR is mainly due to one tertiary expert center that accounts for 66% of the 646 patients, much less patients enrolled in TAR group, and mesh was not used in all ACST patients. The cadaveric study by Moores et al. found a statistically significant difference in average fascial mobilization in the mid-abdomen and the lower abdomen with TAR giving more mobility. In the upper abdomen, there was no difference. They compared the effect of ACST on the anterior layer with TAR on the posterior layer and not their effect on the same layer.
Summary of studies comparing ACST and TAR is shown in [Table 2].
Sometimes in giant hernia, even TAR ends up in bridging repair. In bridging repair, all the abdominal muscles are unable to approximate in the midline. Although it achieves some form of abdominal closure, the advantage of approximated muscles will be missing. It is similar to IPOM patients, in whom the defect is not closed by suturing and the mesh is below the skin and sac. Although IPOM has not been found inferior to IPOM plus (defect closure) for small incisional hernias,, it is not reasonable to accept bridging repair in component separation technique. In our opinion, most of the patients taken for IPOM have a small hernia located within a largely normal abdomen wall presenting with well-approximated muscles. In contrast, complex hernias, in which a component separation technique is indicated, are characterized by large defects and reduced muscle structure of the ventral abdominal wall. Therefore, in these patients, a re-approximation of the muscles seems to be essential.
TAR is a very useful repair technique for complex ventral hernia with the advantage of a huge space for mesh placement, neurovascular bundle preservation, and the possibility that lateral hernias can be dealt with simultaneously. Overall, ACST is comparable to TAR. ACST with preservation of the perforating vessels has a low recurrence, SSI, and skin necrosis rates. It also achieves a good amount of anterior abdominal wall medialisation.
The limitations of our study are that the selected studies have compared different outcomes. Four studies have compared postoperative events, two studies postprocedure abdominal musculature translation, and one study QOL. The selected studies are nonrandomized except one, and the selected systemic reviews with meta-analysis are also of nonrandomized studies. Both the cadaveric studies have low sample size, and the findings on the cadaveric tissues also vary from the living tissues.
| Conclusion|| |
Open ACST is comparable to open TAR procedure and has equally acceptable outcomes. In ACST, it seems to be essential to preserve the perforator vessels; however, altogether further studies are needed to gain more clarity in the daily decision-making process in the repair of complex ventral hernias.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]