1 Clinical Anatomy ▴ An umbilical hernia ( Fig. 20.1 ) occurs when contents of the abdomen pass through a defect in the abdominal wall at or near the umbilicus. When umbilical hernias occur in infants, surgical repair is generally necessary only if the hernia persists beyond age 2. ▴ Paraumbilical hernias occur in adults at locations superior or inferior to the umbilicus. They are considered…
1 Clinical Anatomy ▴ The abdominal wall is composed of four paired muscle groups: rectus abdominus, external oblique, internal oblique, and transversalis ( Fig. 19.1 ). The rectus muscles are separated by the linea alba, which is a fascia extending from the xyphoid process to the pubic symphysis. It is formed by aponeuroses of the transverse abdominal, external oblique, and internal oblique muscles. It functions to…
1 Preoperative Considerations ▴ Management of the open abdomen begins with the decision to open the abdomen. Practice patterns have evolved from an era where management of an open abdomen was extremely rare to a culture of damage control surgery with a very low threshold to leave the abdomen open. In those scenarios, patients were returned to the operating room for re-exploration and possible closure after…
1 Preoperative Considerations 1 Risk Stratification ▴ Smoking, uncontrolled diabetes, chronic obstructive pulmonary disease, morbid obesity, immunosuppression, long-term use of steroids, advanced age, and malnutrition (serum albumin <2.0 g/dL) increase the risk for surgical site infections and can compromise abdominal wall reconstruction. ▴ Congenital or acquired disorders leading to a hypercoagulable state can put any pedicled or free flap reconstruction at risk and need to be…
1 Clinical Anatomy 1 Features and Characteristics of Defect ▴ Definition of loss of abdominal domain: There is no consensus in the literature on the definition of loss of abdominal domain. Determination of this condition is subjective and typically refers to massive hernias with a significant amount of intestinal contents that have herniated through the abdominal wall into a hernia sac that forms a secondary abdominal…
1 Surgical Anatomy ▴ The robotic platform enables exploitation of the individual layers of the abdominal wall. Although it is possible to do this with conventional laparoscopic instrumentation, working high on the anterior abdominal wall remains technically challenging. ▴ It is critical to have a thorough understanding of the layers of the abdominal wall ( Fig. 15.1 ) to execute this technique properly. ▴ The robotic…
1 Clinical Anatomy ▴ Perineal hernias are caused by a defect in the pelvic floor and can be classified based on location and cause ( Fig. 14.1 ). ▴ A perineal hernia defect is classified as either anterior or posterior in relationship to a line drawn between the ischial tuberosities of the hip bones ( Fig. 14.2 ). ▴ An anterior perineal hernia is found in…
1 Clinical Anatomy of the Anterior Abdominal Wall 1 Relevant General Anatomy ▴ When considering panniculectomy in the setting of abdominal hernia repair, important anatomic considerations include the underlying musculature, aponeurotic layers, and adipocutaneous structures. These components are interrelated and should be addressed systematically to optimize outcomes after panniculectomy. 2 Relevant Muscular Anatomy ▴ The support and contour of the anterior abdominal wall are derived from…
1 Clinical Anatomy ▴ Comprehensive knowledge of the lateral abdominal wall muscles is required to understand the function of these muscles and to ensure adequate coverage with botulinum toxin (BTX). ▴ External oblique fibers run inferomedially to provide lateral flexion and rotation. ▴ Internal oblique fibers run superomedially, directly perpendicular to the external oblique fibers, to provide abduction and rotation. ▴ Transversus abdominis fibers run medially…
1 Clinical Anatomy ▴ Tissue expansion is a valuable tool that can be used to help reconstruct soft tissue defects of the abdominal wall. These defects can be classified as congenital or acquired; the former result from issues such as gastroschisis or omphalocele, and the latter result from issues such as trauma, infection, tumor resection, or previous surgery. Tissue expansion provides autogenous, neurotized, well-vascularized tissue for…
1 Introduction ▴ Anterior endoscopic component separation (ECS) creates a compound flap from the rectus abdominis, internal oblique, and transversus abdominis muscles that can be advanced across the abdominal wall to close defects with minimal tension. ECS contributes to the structural, functional, and cosmetic reconstruction of the abdominal wall while greatly diminishing the morbidity associated with classic anterior open component separation. ▴ Two different anterior ECS…
1 Introduction ▴ Surgical site occurrences and surgical site infections (SSIs) are serious complications of ventral hernia repair. Both surgical site occurrences and SSIs are related to technical factors directly under the surgeon’s control. ▴ Component release hernia repair need not be associated with high rates of surgical site occurrences and SSIs, provided that the surgeon can maintain skin vascularity with perforator preservation and adequately distribute…
1 Clinical Anatomy ▴ Thorough knowledge of the abdominal wall anatomy is needed when performing a ventral hernia repair. ▴ The rectus abdominis consists of a pair of vertically oriented muscles that span the length of the abdominal wall and are separated by the linea alba. The rectus muscles arise from the symphysis pubis and insert onto the fifth, sixth, and seventh costal cartilages and xiphoid…
1 Introduction ▴ Many open and laparoscopic techniques for parastomal herniorrhaphy have been described, and each technique has its own strengths and weaknesses. In this chapter, we describe our preferred method for open parastomal herniorrhaphy: posterior component separation (PCS) with transversus abdominis release (TAR) with or without stoma relocation. We prefer this method because of its ability to address large parastomal hernias and concurrent ventral hernias.…
1 Clinical Anatomy ▴ Flank hernias can be divided broadly by etiology into hernias that are congenital in nature and hernias that are acquired, often after previous surgery or trauma. Congenital flank hernias, also known as lumbar hernias, are less common than the acquired type and can be subclassified into superior triangle (Grynfeltt) or inferior triangle (Petit) defects. Acquired flank hernias can develop after previous operations,…
1 Clinical Anatomy ▴ Retrorectus repair requires a thorough knowledge of the relative anatomy of the myofascial components of the abdominal wall. ▴ The rectus abdominis, a long, broad, straplike muscle, is the principal vertical muscle of the anterior abdominal wall. Its origin is at the pubic symphysis and pubic crest. The muscle is inserted into the cartilages of the fifth, sixth, and seventh ribs. The…
1 Clinical Anatomy 1 Types of Parastomal Hernias ▴ Parastomal hernia has been anatomically classified into four subtypes ( Fig. 4.1 ). ▴ Subcutaneous: The hernia sac goes alongside the stoma into the subcutaneous tissue. This is the most common type of paracolostomy hernia. ▴ Interstitial: The hernia sac is within the layers of the abdominal wall. This hernia is at a high risk for strangulation.…
1 Introduction ▴ Suprapubic, subxiphoid, and lumbar/flank hernias, often referred to as atypical hernias, occur close to bony structures or off midline, making them challenging to repair. Their location can limit the surgeon’s ability to provide wide mesh overlap and adequate fixation. The laparoscopic approach is a viable option for repairing these hernias for surgeons with a thorough knowledge of abdominal wall and intra-abdominal anatomy of…
1 Introduction and Clinical Anatomy ▴ Compared with traditional open ventral hernia repair, minimally invasive approaches offer several advantages, including reduced wound and mesh infections, quicker return of bowel function, and reduced length of hospitalization as well as improved cosmesis. However, not everyone is a candidate for laparoscopic repair. Size and complexity of defects, history of infection, prior hernia repairs or abdominal surgeries, body habitus, and…
1 Clinical Anatomy 1 Overview ▴ The anterior abdominal wall ( Figs. 1.1–1.3 ) is a hexagonal area defined superiorly by the costal margin and xiphoid process; laterally by the midaxillary line; and inferiorly by the symphysis pubis, pubic tubercle, inguinal ligament, anterior superior iliac spine (ASIS), and iliac crest. ▴ Layers of the anterior abdominal wall include skin, subcutaneous tissue, superficial fascia, deep fascia, muscle,…