الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
Complex ventral hernias are challenging surgical conditions. Well known to
be associated with occurrence of serious complications. Since surgery remain the
only modality of treatment, an effective repair with low morbidity and recurrence
rates should be performed.
Several etiologies account for the development of complex ventral hernias.
These include failure of abdominal wound to heal either by acute development
shortly after surgery leading to wound dehiscence and burst abdomen or chronic
development later after surgery leading to incisional hernia. A defect in the linea
alba is an additional cause producing a paraumbilical or epigastric hernia.
Reconstruction of massive abdominal wall defects has long been a difficult
clinical challenge. Since the overall morbidity and recurrence rate following the
initial musclofascial repair of ventral hernia were unacceptably high, the prosthetic
reinforcement of the abdominal wall defects has been widely advocated. Means of
mesh affords a contiguous closure; its static nature can lead to complaints of a stiff
and noncompliant abdominal wall. Although mesh repair had a significant
reduction in recurrence rates compared with suture repairs for ventral hernias, risks
for seroma and surgical site infections increased.
In 1990, Ramirez and colleagues published the components separation
procedure for reconstruction of the anterior abdominal wall. Proposed benefits of
this procedure focus on its use of innervated, vascularized, autologous tissue for
reconstructing anterior abdominal wall defects. Additionally, beyond providing for
a tensionless closure, the use of these innervated, myofascial flaps helps to recreate
the dynamic nature of the native abdominal wall.
Summery
208
Although this method gained a wide spread acceptance it suffered a
relatively high recurrence rate compared to the mesh repair. Moreover, there is the
possibility of a lateral blowout, in which a hernia recurs at the site where the
external oblique muscle is separated from the lateral border of the rectus muscle.
The best method of complex ventral hernia repair has not been developed
yet, as evidenced by multitude of procedures described in various textbooks and
significant failure rates associated with these methods.
In this study we used the combined benefit of the components separation
technique with respect to the tension free closure in large complex ventral defects
in combination with the benefit of the reduced recurrence rate of the mesh repair.
An onlay polypropylene mesh was added as onlay mesh reinforcement to the
underlying components separation release. Compared to other types of meshes,
polypropylene is available and at an affordable price in comparison to the biologic
meshes which are more expensive.
The onlay mesh placed in this manner improves the hernia repair through
three distinct mechanisms. First, the addition of an extra layer of mechanical
support reinforces the midline fascial closure. Second, the reattachment of the
released external oblique muscles repairs the bilateral donor sites and reduces the
risk of lateral bulging at these areas of weakness. Third, and perhaps most
important, we postulate that the prosthetic material used in this method of repair
acts as a “load-sharing” construct, thereby off-loading tension from the underlying
fascial closure. Together, the restoration of functional anatomy and use of a loadsharing
prosthesis may decrease risk for hernia recurrence by reducing undue
tension on the repair.
This study aimed to apply the rationale of combining the components
separation technique with an onlay polypropylene mesh. This combination
significantly reduces hernia recurrence with an accepted complication rate.
Summery
209
The study included thirty patients for whom we analyzed the demographic
and clinical data relevant to age, gender, lifestyle, job, medical condition, body
mass index, etiology of hernia and defect size. Postoperative complications in form
of recurrence, seroma, and hematoma were also followed up and analyzed. The
length of hospital stay, return to normal activity and patient’s satisfaction were also
investigated.
The current study results suggest that combining the components separation
technique with an onlay polypropylene mesh is an alternative, affordable and
effective way in management of complex ventral hernias.