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Biomechanical Considerations in Abdominal Wall Reconstruction using the Extended Component Separation Technique
Henrik O. Berdel, MD1, Mirza Mujadzic, Medical Student2, Nina Yoo, Medical Student2, Jack C. Yu, MD, DMD, ME Ed., FACS2, Mirsad Mujadzic, MD2, Edmond Ritter, MD2
1University of South Carolina, Columbia, SC, 2Medical College of Georgia, Augusta, GA
Large midline abdominal wall hernias are challenging surgical problems with no optimal solution to date. The Component Separation Technique (CS), initially described by Ramirez in 1990, provides an effective alternative to mesh reconstruction. Although Ramirez reported a 0% recurrence rate in a series of 11 patients, other authors observed higher recurrence rates, as well as complications including wound infection, skin necrosis, dehiscence, and abdominal compartment syndrome. In order to increase efficacy and safety by further reducing tension, the Extended Component Separation (ECS) was introduced. To our knowledge the load-displacement characteristics of the human abdominal fascia in either technique, though critically important, have not been determined. The aim of this study is to measure such tensile behaviors, as well as to establish possible differences in load-displacement characteristics between CS and ECS in a human cadaver model.
10 fresh human cadavers were dissected first with conventional CS, followed by ECS. Advancement toward the midline was measured in millimeters at preset tensions of 0, 22, 44, and 65 Newtons (N) using a tension gauge applied to the middle abdominal fascial edge with Kocher clamps. The advancements were recorded in millimeters, and statistical analysis was performed using a 2-tailed student’s t-test to compare the load-displacement data of CS and ECS. A P-value of less than 0.05 was considered as statistically significant.
With ECS, a statistically significant increase in advancement could be achieved in comparison to CS at all preset tensions. In the conventional CS the advancement of the mid-abdomen was 37.10 +/- 8.08 mm (Mean +/- SD) at 0N, 49.90 +/-10.61 mm at 22N, 59.30 +/- 11.06 mm at 44N, and 67.67 mm at 65N. The advancement in the mid abdomen with ECS resulted in 58.70 +/-9.20 mm at 0N, 74.40 +/-10.62 mm at 22N, 82.40 +/- 11.32 mm at 44N, and 89.67 mm at 65N. P-values comparing these means were 0.00006 at 0N, 0.00012 at 22N, 0.00046 at 44N, and 0.04 at 65N. The average net gain at a tension of 0N was 46mm in the middle abdomen.
Autologous reconstruction of large abdominal wall defects necessitates tissue re-deployment under force. However, the quantitative measure of this force, though obviously important, has not been reported. We describe a method of such quantitative measurement, and show that, in a cadaver model, ECS indeed increased mobilization of fascial edges without increasing tension. The key observations from this study are: 1. The theoretical maximum defect that can be closed without a mesh is 18 cm in the mid abdomen. 2. After ECS, the human abdominal wall fascia advances 1-3 mm/N.
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