COMPONENT SEPARATION

This young man came to us last year. He had an intraabdominal disaster-ruptured appendix with delayed presentation and severe peritonitis. He survived this problem after multiple surgeries with an open abdomen. Finally we closed the wound leaving a large ventral hernia. Today we operated after 6 months recovery. We were able to close the fascia with the technique of component separation.

VENTRAL HERNIA

This lady had a large ventral hernia with a palpable mass about 6 cm in diameter. We performed a ventral hernia repair with mesh and removed the mass. It was an ovarian teratoma-full of hair!

Mesh repair

Dermoid cyst

VICRYL MESH

Sometimes, in the face of an intraabdominal disaster and/or loss of the abdominal wall, a temporary closure of the abdomen is needed. Synthetic absorbable mesh has been used extensively in this situation. Polyglactin (Vicryl) and polyglycolic acid (Dexon) have been in the surgical armamentarium for approximately 25 years. This type of prosthetic mesh implant has been used in the repair of traumatic liver, splenic, and renal injuries and in pelvic floor repair in the setting of abdominal peroneal resection of the rectum. Although early burst strength (at 8 wk) is comparable to that of permanent mesh, as the mesh is absorbed (at 10-12 wk), hernias inevitably develop in most patients.

As described by Bender et al, the mesh is applied loosely over the abdominal contents and then covered with fine mesh gauze packing, maintaining the bowel below the absorbable mesh and within the abdominal contents.^[3] This may decrease bowel wall distention, thinning, and subsequent desiccation, which may decrease the incidence of enterocutaneous fistula.

An example of the use of Vicryl Mesh can be seen at this link.

PLUG AND PATCH

The patient illustrated here came with a recurrent left inguinal hernia. During the previous surgery, the cord was extensively skeletonized. The recurrence came through a defect of the floor and the sac contained momentum. The sac was pushed back into the peritoneum without excision. A plug was then placed in the defect. Following, a piece of mesh was used to patch the floor using a running 0 prolene.

Recurrent defect of the inguinal floor

Mesh plug placed in defect

Mesh patch to inguinal floor

INTRAABDOMINAL DISASTER

Patient six months after her disaster, holding a picture showing
 her emaciated state during the acute process.

This lady came in with an intraabdominal disaster. Perforated typhoid ileitis! We operated multiple times via an open abdomen technique and finally closed the abdomen with skin flaps-leaving a large fascial defect. She had a large iatrogenic hernia. She was emaciated but alive. We saw her back after 6 months and she had put on quite a bit of weight. We repaired her hernia with polypropylene mesh. She had an uneventful recover.

Iatrogenic hernia

Mesh repair

Iatrogenic hernia

MOSQUITO NET MESH

The following is an excerpt from an article by Udwadia TE. The Inguinal hernia repair: The total picture. J Min Access Surg 2006;2:144-6. One of the key points is that mesh is, unfortunately, not available to most of the world. Papers on hernia repair at conferences and publication on hernia repair in journals are made by herniologists who work in ideal conditions in developed countries and urban centres in the developing world. Cocooned in their sophistication they kneel at the alter of what they believe is "evidence based medicine". Sadly, most do not know (and some do not care) about the problems of hernia repair in 70% of the world population, where for example, in East Africa patients with strangulated hernia get no treatment.[7] In 1998, I was interested and excited to learn that surgeons in rural areas of India were doing tension-free repairs using indigenous mesh which was autoclavable (the only mean of sterilization to them) and had similar weave, tensile strength, chemical composition and biological response as commercially available mesh.[8] God in his wisdom made mosquitoes endemic in the developing world, necessitating the manufacturing of cheap mosquito-net for mass use. As the editor of Indian Journal of Surgery I accepted for publication the article on "Preliminary multicentric trial of cheap indigenous mosquito net cloth for tension free hernia repair". By doing so I invited the wrath of Heads of Department in prestigious Indian teaching hospitals who questioned my Editorial propriety in accepting an article with no animal toxicology study, no controlled trial and questionable follow up. I gently explained my acceptance of the article by reminding them that the first clinical mesh study was done without experimental work in 1958, that the Heads of Department were in a stronger position to do such a study than the rural surgeon, that research not applicable to the needs of a developing country was unethical[9] and that follow-up in a village or small town was far more reliable than urban cities because small town surgeon knew each one of his patient for years and by name. I am aware that like those Heads of Department, all herniologists who talk and write on hernia will find the use of this simple cheap mesh (cost ratio 1:2000) surgical blasphemy. History of hernia repair teaches us that Bassini, Shouldice, Lichtenstein much after they advocated their procedure were held in ridicule. In 1972, the role of laparoscopy in surgery was blasphemy and both Semm who performed the first laparoscopic appendicectomy and Muhe who performed the first laparoscopic cholecystectomy were ostracized for years for their blasphemy. Appropriately George Bernard Shaw wrote "Most truths start off as blasphemy". Time will tell if this ingenious work of rural Indian surgeons is a truth. If it is, it will be a true landmark in the history of hernia repair, for it will provide all the benefits of the Lichtenstein procedure, at virtually no cost for the mesh, underscoring the true role of surgery - good surgical care too all people, in all places. Another related article Surgeons use mosquito nets for cheap hernia operations Jan Piotrowski 26 December 2011 | EN | FR The cost of life-changing hernia operations could be cut by using mosquito net mesh instead of expensive medical products, a study has found. Hernias occur when an organ, usually the intestine, breaks free from the cavity which contains it. The condition affects one in every 1,000 people worldwide and not only causes extreme discomfort but, in many cases, restricts movement and prevents the sufferer from working. Surgeons from Operation Hernia — an organisation that provides low-cost surgery in developing countries — found that one mosquito net, bought for around US$15, could be cut into enough meshes for 3,000 operations. This is around three times cheaper than conventional treatment, making it ideal for low income countries in the developing world. "To provide an operation that can be truly life-changing is great — but at this price it is fantastic," said Andrew Kingsnorth, a surgeon at the Plymouth Hospital, United Kingdom, head of Operation Hernia and an author of the study, published in the British Medical Journal (15 December). Although mosquito net mesh has been used for several years in hernia operations, surgeons still had legitimate safety concerns over their cleanliness which needed to be answered if their use was to become more widespread, he told SciDev.Net. "It is very important that we produce data that proves that [the technique] is safe. Combined with past studies, [the new study] does just that." His team found that simple steam or chemical sterilization - possible in all but the most basic rural clinics produced mosquito net mesh that was as safe to use as expensive medical-grade products. Of the 2,000 people treated with mosquito mesh by Kingsnorth and his team, only two have suffered complications caused by the material. But only particular nets, imported from India and untreated with insecticides, have been proven to work safely and effectively. The potential impact of the technique in the developing world could be huge, argued Kingsnorth. He estimated that the incidence of hernias in Africa could be ten times higher than in developed nations, because they are left untreated. Providing cheap hernia procedures could drastically improve life for the patients — many of whom are unable to work. Oluyombo Awojobi, a rural surgeon in Nigeria, told SciDev.Net that the latest study is further proof that using mosquito net mesh to mend hernias is "far superior" to conventional medical supplies. He hopes that the new research would encourage more surgeons to start using the cheap mesh. But he added: "The biggest problem standing in the way in rural regions is training. We need more people who are capable of doing the procedure". Operation Hernia is aiming to plug this gap. Kingsnorth has helped train surgeons to use the technique in the 18 developing country locations that the organisation regularly visits.

NO MESH FOR YOU!

I often use mesh to repair large incisional hernias. But, not every patient with a large incisional hernia needs mesh. A young patient, for example, may be better served with hernia repair without mesh, especially if you think you may have to enter the abdomen again. 

The young girl pictured here presented with intraabdominal sepsis following an abortion. She was extremely ill. We explored her and found a perforated uterus and generalized peritonitis. We packed the abdomen and stabilized the patient then returned after 36 hours. The abdomen was still grossly contaminated so we repeated the process. On the third laparotomy, the abdomen looked improved but the bowel was quite swollen and closure was impossible. We raised skin flaps and closed the skin leaving a large fascial defect. The patient improved but deteriorated after about 1 week. I suspected a subphrenic abscess since she had hiccups. We reexplored her and that is what we found. The abscess was drained and the abdomen closed and she recovered!

Component Separation-note release of external oblique muscle

After 3 months, she returned wanting her hernia repaired. She looked good and had gained weight but I wanted her to recover further.  I told her to go home and eat 6 eggs per day and I would reevaluate her in 3 months. After 6 months we  repaired her large defect using the Component Separation Technique. She had an uneventful recovery with a strong abdominal wall.

Component Separation-the external oblique muscle is separated from
the internal oblique. This allows the rectus muscle to be advanced.