الفهرس 
): Anterior Abdominal Wall AnatomyOnly 14 pages are availabe for public view
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Abstract
Abdominal wall hernias complicate between 5% and 11% of abdominal surgery procedures. The repair of these massive ventral hernias remains a challenging problem for surgeons. Many surgeons discourage abdominal wall reconstruction because of the technical difficulties, the high morbidity, and the relatively high recurrence rate associated with this procedure. Primary repair is rarely successful, with recurrence rates ranging from 18% to 62% depending on the defect size. If synthetic mesh is added, recurrence rates DROP significantly to between 2% and 32%.However, many patients with large hernias have invalidating symptoms, such as bulging of the abdominal wall, chronic wounds, immobility, and back pain, which require surgical treatment.
The options the surgeon has are open primary repair, open repair with mesh, laparoscopic repair, or autologous tissue transfer or mobilization. The use of autologous tissue to repair abdominal wall hernias has been described. The tensor fascia lata, Sartorius and rectus femoris can be used as either free flaps or pedicled flaps to close large defects. However, the lack of sufficient tissue may require the insertion of prosthetic material or transposition of autologous material to bridge the fascial gap. Reconstruc-tion using preperitoneally placed prosthetic material is still the most frequently used reconstruction method. The increased risk of infection in case of wound complications is a relative contraindication against the use of prosthetic materials.
However, the use of large sheets of synthetic material for hernia repair often results in a rigid, noncompliant, adynamic abdominal wall and is contraindicated in case of contamination.
In 1990, Ramirez et al introduced the “components separation technique” to bridge the fascial gap without the use of prosthetic material. The technique is based on the enlargement of the abdominal wall surface by separation and advancement of the muscular layers thus permitting a tension-free abdominal closure with medialization of the rectus abdominus muscle in large ventral hernias.
Two other techniques have been studied. The first one is the undermining of the anterior rectus sheath that showed tension reduction comparable to the one obtained when the posterior rectus sheath was undermined.
The other technique is the undermining of the anterior rectus sheath in continuity with the external oblique aponeurosis to decrease tension and, at the same time, to reinforce the area of the semilunaris line. Although very effective in tension reduction on the aponeurotic edges, as demonstrated by these studies, it is possible to combine this technique with the use of mesh.
When mesh is necessary, it is placed over the musculoaponeurotic layer inmost times, as the ‘‘components separation’’technique allows the surgeon to create a layer of musculoaponeurotic tissue between the intra-abdominal organs and the mesh.
The CST is a safe and effective technique, which can be used to treat complex abdominal hernias/defects. It requires close cooperation of multiple surgical specialities and, in defects where primary closure is unsuitable, liaison with the plastic surgical team should be considered at an early stage. The technique is associated with a low rate of hernia recurrence and an acceptable cosmetic outcome.
Combining PAN with VHR allows single-stage reconstruction of the abdominal wall providing excellent surgical access to the abdominal wall and hernia, off loads the weight of a large pannus from the repair, often resects thin skin or a broad or poorly vascularized scar, with good functional and improved cosmetic outcomes and a high degree of patient satisfaction with great safety.