Minimally Invasive Component Separation Reduces Wound-Healing Complications from Abdominal Surgery
By Sarah Bronson
|In minimally invasive component separation with inlay bioprosthetic mesh, subcutaneous tunnels allow access to the external oblique aponeurosis. Used with permission from Atlas of Abdominal Wall Reconstruction, Michael J. Rosen (ed.), Page 175, Copyright Elsevier Inc. 2012.
Component separation, a major advance in abdominal wall reconstruction, can prevent hernia recurrence in many patients.
Recently, a surgeon at The University of Texas MD Anderson Cancer
Center developed a minimally invasive approach to component separation
that reduces complications and potentially improves functional
Component separation was introduced in 1990 for abdominal wall
reconstructions in ventral hernia repair or other surgeries requiring
resection along the midline of the rectus abdominis complex.
Traditional, open component separation enables the surgeon to close
musculofascial defects without excessive tension and without a distant
transposition flap. However, the amount of dead space created and the
need to transect the blood vessels that supply the overlying fat and
skin during the open procedure can lead to seromas, infections, and
In response to these complications, Charles E. Butler, M.D., a
professor in the Department of Plastic Surgery, developed minimally
invasive component separation with inlay bioprosthetic mesh (MICSIB), a
new technique that preserves the rectus abdominis perforator vessels
and maintains the connection between the subcutaneous fat and the
anterior rectus sheath.
“The minimally invasive operation was de signed to be more predictable
and more reliable and to achieve better outcomes with lower
complication rates than open component separation. This may help cancer
patients to be able to start postoperative chemotherapy or radiation
therapy sooner,” Dr. Butler said.
Abdominal wall defects in cancer patients
Concurrent cancer and abdominal wall defects such as hernias can be
difficult to manage because treatments for one condition can exacerbate
the other. For example, complications such as an unhealed wound that
persists or an infection that develops after hernia repair can delay
chemotherapy or radiation therapy. Conversely, surgeons are less likely
to immediately repair a hernia if treatments like chemotherapy and
radiation therapy, which deplete the body’s ability to withstand and
recover from hernia repair surgery, need to be given first.
|In many patients undergoing minimally invasive component separation with inlay bioprosthetic mesh, complete primary fascial closure is possible with bioprosthetic mesh used as an underlay reinforcement. Used with permission from Atlas of Abdominal Wall Reconstruction, Michael J. Rosen (ed.), Page 181, Copyright Elsevier Inc. 2012.
Chemotherapy, radiation therapy, and cancer itself are risk factors for
hernias, and cancer treatments increase the risk of wound-healing
complications and hernia occurrence after abdominal surgery. By
decreasing wound-healing complications, MICSIB can reduce the
interference of one intervention with another.
Cancer patients have both a high rate of ventral hernias and an
increased risk of hernia recurrence and wound complications after
repair. Many of Dr. Butler’s patients have ventral hernias that other
surgeons did not consider for elective repair because of the hernias’
severity, the high risk of complications associated with repairing the
hernias, the patients’ comorbidities, or the need for extremely complex
reconstructions, which sometimes require the use of a tissue flap to
close the wound. MICSIB can improve these patients’ outcomes, enabling
optimal cancer care. MICSIB is also used for immediate reconstruction
of the abdominal wall following tumor resection.
Open component separation
Component separation reduces the muscular tension that can accompany
the closure of the rectus abdominis muscle by separating the rectus
abdominis muscle from the topmost of the three layers of oblique
muscles to the left and right of the rectus abdominis.
The surgeon creates skin flaps on each side of the semilunar line,
which is just lateral to the rectus abdominis muscle. The external
oblique aponeurosis is then released from the costal margin to near the
pubis. This release and subsequent separation of the internal and
external oblique muscles enables the surgeon to advance the rectus
complex toward the midline, thus reducing the size of the defect. If
the defect is narrow enough, the surgeon can perform a primary
musculofascial closure reinforced with an inlay of synthetic or
bioprosthetic mesh; in large defects mesh is used as a bridge between
the musculofascial edges.
In traditional, open component separation, the surgeon accesses the
oblique muscles and external oblique aponeurosis by elevating the skin
flaps over the entire rectus abdominis muscle, thus separating the
subcutaneous fat from the anterior rectus sheath and dissecting the
rectus abdominis myocutaneous perforator vessels that are the main
blood supply to the skin and subcutaneous fat. However, elevating the
skin flaps results in subcutaneous dead space, which can lead to
seromas and infections, and the reduced blood flow caused by cutting
the perforator vessels inhibits wound healing. Thus, open component
separation carries a risk of postoperative complications that can
prolong recovery time and interfere with the management of other conditions.
The minimally invasive procedure
Whereas open component separation fully separates the rectus abdominis
muscle from the overlying skin, MICSIB uses narrow tunnels to access
the external oblique aponeurosis and thus damages few, if any, rectus
abdominis perforator vessels. With more vessels preserved, wounds can
heal faster and more completely. The use of tunnels also limits the
undermining of skin flaps that occurs with the separation of the
anterior rectus sheath and the subcutaneous fat, which would otherwise
devascularize the overlying skin fat and result in dead space.
To access the sites where the aponeurosis will be incised, the surgeon
creates a tunnel 3–4 cm wide between the subcutis and the anterior
rectus fascial sheath to connect the midline and semilunar line. By
retracting the skin around this small tunnel, the surgeon can access
and visualize a large area without the use of a laparoscope. The
surgeon then makes a 1.5-cm incision in the external oblique
aponeurosis just lateral to the semilunar line, inserts a suction
handle (without suction) through the incision and into the avascular
plane between the internal and external oblique aponeuroses (lateral to
the rectus complex), and sweeps the handle inferiorly and superiorly to
bluntly separate those aponeuroses and muscles. Then, the surgeon uses
electrocautery and blunt dissection to create narrow vertical
subcutaneous tunnels over the anticipated line along which the external
oblique aponeurosis will be released.
ABOVE During traditional, open component separation, the rectus abdominis perforating vessels are transected, and a large subcutaneous dead space is created by elevating skin flaps from the anterior rectus sheath.
BELOW During minimally invasive component separation with inlay bioprosthetic mesh, the myocutaneous perforator vessels are preserved.
At this point, the external oblique aponeurosis is not connected to
either the inferior oblique aponeurosis or the subcutis and can be cut
without injuring the overlying or underlying tissues. Scissors are used
to incise the external oblique aponeurosis inferiorly toward the pubis,
and scissors and electrocautery are used to incise the aponeurosis
superiorly over the costal margin, where the amount of interdigitation
between the aponeurosis and underlying muscle is greatest. As the
surgeon incises the external oblique aponeurosis along the semilunar
line, the suction handle is placed against the rectus complex between
the internal and external oblique aponeuroses to guide dissection and
prevent inadvertent incision of the rectus complex. The procedure is
then repeated on the other side of the midline. All of this work is
performed through the lateral access tunnels with use of a headlight
and good retraction. No additional incisions are required, and no
endoscopic equipment is involved, which makes MICSIB an efficient,
fast, safe, and cost-effective procedure.
Outcomes of open component separation and MICSIB
Preserving vascularity and reducing dead space have been shown to
improve wound healing. In a recent retrospective study, Dr. Butler and
his colleagues compared the outcomes of complex ventral hernia repairs
with open component separation in 50 patients and MICSIB in 57
patients. Significantly more patients who had undergone open component
separation had wound-healing complications and skin dehiscences
compared with those who had undergone MICSIB. Dr. Butler noted that,
compared with the group of patients who had undergone open component
separation, the group of patients who had undergone MICSIB had
significantly larger defects and required significantly larger amounts
of mesh for repair, indicating a possible selection bias toward
patients with more severe hernias. Nevertheless, in the outcomes
measured, the group that had undergone MICSIB had similar or better
results compared with the group that had undergone open component
“Seeing cancer patients whose sickness was made more complex by hernias
stimulated me to develop a technology to address the complicated and
severe cases that we see here at MD Anderson,” Dr. Butler said. “This
technique is now used for challenging ventral hernia repairs regardless
of whether patients have cancer.”
contact Dr. Charles E. Butler at 713-794-1247.
Butler CE, Campbell K. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 2011;128: 698-709.
Ghali S, Turza KC, Baumann DP, Butler CE. Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg 2012 Apr 20. [Epub ahead of print] PMID: 22521439.
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