Complex Abdominal Wall Reconstruction Following Colorectal Surgery
Clayton C. Petro
Michael J. Rosen
Perioperative Considerations
For the most part, complex abdominal wall reconstruction implies the utilization of a component separation technique, which, in our hands, is typically a transverses abdominis muscle release (TAR).
The technique is relevant as hernia rates follow colorectal surgery can be as high as 18% and often occur in the context of permanent, temporary, or prior ostomy sites.
Although the TAR technique has been described elsewhere in great detail, in this chapter, we focus on subtle caveats to consider following a previous colorectal operation.
Specifically, we focus on the impact of a prior colectomy, proctectomy, and/or ostomy site on the retromuscular dissection as these planes may have been violated during a previous colorectal procedure.
Parastomal repairs will be addressed separately in Chapter 45.
Sterile Instruments
Sterile blue or green surgical towel, moistened
10 Kocher clamps
Bonney or Ferris-Smith forceps
Right-angle clamp
Two large Richardson retractors
Kittner (blunt) dissector on a medium or long Kelley clamp
Two large Crile retractors
Carter-Thomason suture passer
Large malleable
Positioning
Patients are approached in a supine position, and both arms can be left out.
We widely prep and drape the patient in a diamond configuration so that the xyphoid, pubis, and lateral abdominal wall (including both anterior superior iliac spines) are sterile and palpable within the surgical field. This allows for wide placement of transfascial fixation sutures once the retromuscular mesh is in place (Fig. 51-1).
We routinely place a Foley catheter.
 FIGURE 51-1 ▪ Sterile preparatory and draping landmarks. The bold black line indicates the boundaries of draping—xyphoid, pubis, and bilateral anterior superior iliac spines (black star) should be palpable within the sterile field. Red stars indicate the typical placement of transfascial sutures fixating mesh reinforcement. The thin gray line highlights the prior ostomy site in the right lower quadrant. Note the previous right lower quadrant paramedian incision from a remote appendectomy. This patient had laparoscopic ports from a more recent sigmoid colectomy for diverticular disease. An anastomotic leak required a laparotomy and diverting loop ileostomy that has subsequently been reversed. He now has a 12-cm wide midline ventral hernia. |
INTRA-ABDOMINAL ACCESS, ADHESIOLYSIS, AND SETUP
Technique
We begin with a midline laparotomy extending cephalad to the previous incision, when possible, in order to divide a native portion of the linea alba. A complete adhesiolysis is done to free the anterior abdominal wall—see Pearls and Pitfalls.
Laterally, the intra-abdominal adhesiolysis should extend to the white lines of Toldt so as not to dissect the colon away from the lateral abdominal wall and inadvertently enter the retroperitoneum. To address adhesiolysis at a prior colectomy site, see Pearls and Pitfalls.
When possible, all interloop adhesions should be taken down unless the risk of an enterotomy is prohibitory and the patient did not have obstructive symptoms.
The bowel should be examined thoroughly to confirm the absence of any full-thickness enterotomies, and serosal tears should be oversewn.
Once the viscera are freed from the abdominal wall, they are covered with a moistened blue or green surgical towel. This step signifies that the intra-abdominal portion of the procedure is complete—the surgeon should be satisfied with the viscera (ie, anastomoses, serosal injuries, hemostasis).
After placement of the towel, with no tension on the abdominal wall, the dimensions of the defect should be measured from its widest point by the length of the laparotomy incision.
TIPSIf the patient is in a split-leg or lithotomy position for the colorectal portion of the procedure (ie, Hartmann reversal), this should not disrupt the operation if the thighs are placed leveled with the torso. We do place a fresh set of sterile drapes in these concomitant scenarios when the contaminated portion of the procedure is complete.
Avoiding inadvertent enterotomies during multiply reoperative surgery is critical. We advocate for taking down adhesions from the midline first to optimize exposure of the lateral abdominal walls, which are approached separately.
PEARLS AND PITFALLS
When taking down adhesions from the lateral abdominal wall, be cautious not to enter the preperitoneal plane. When possible, place your hand behind—lateral to—the small bowel and omentum being removed from the abdominal wall so that you have a defined lateral endpoint and do not inadvertently dissect into the abdominal wall.
The dictum “better to leave abdominal wall on the bowel than bowel on the abdominal wall” can ultimately leave you with holes in your visceral sac of peritoneum and make the TAR dissection much more difficult. Visceral adhesions should be taken directly off the peritoneum in order to preserve it when possible.
The lateral extent of the adhesiolysis should be the peritoneal reflection over the colon. However, if the patient has had a previous colectomy, this plane was likely entered in the past. Dissect the viscera away from the anterior abdominal wall just enough so that it can be covered with a towel during the TAR dissection. Attempting to dissect the viscera away from the abdominal wall too far lateral at a prior colectomy site will lead to the retroperitoneum and detach the peritoneum from its lateral/retroperitoneal fixation point. Lateral detachment of the peritoneum is an almost unfixable problem for even the most experienced abdominal wall surgeon.
The placement of a towel protects the underlying viscera from an inadvertent injury during the TAR dissection.
Conversely, if the viscera are left adhered to the retroperitoneum at a prior colectomy site and not covered by the towel, the surgeon must be cautious not to injure the underlying intestine during the TAR dissection.
Regaining proper intraperitoneal exposure after the TAR dissection can be challenging, potentially ruin the dissection by tearing the peritoneum, and should not be relied upon. Do not routinely plan on returning to the peritoneal cavity once the towel is placed over the viscera.
RETRORECTUS DISSECTION
Technique
Place four to five Kocher clamps on the medial aspect of the anterior rectus fascia. Be sure to palpate the tubular rectus muscle so as not to inadvertently clamp the hernia sac (Fig. 51-2).
FIGURE 51-2 ▪ Kocher placement on medial edge of rectus. Bold black line indicates medial edge of rectus.
Identify the defect in the posterior rectus sheath at a prior ostomy site (Fig. 51-3). The lateral dissection will occur superior and inferior to the Kocher clamps, marking the defect in the posterior sheath.
FIGURE 51-3 ▪ Prior ostomy site. Black circle highlights the defect in the posterior rectus sheath indicative of a previous ostomy.
The retromuscular dissection is begun by incising the posterior rectus sheath medially to expose the medial edge of the underlying rectus muscle (Fig. 51-4). Bonnie forceps are helpful for retraction.
FIGURE 51-4 ▪ Initiation of retrorectus dissection. Incision of the posterior rectus sheath (purple arrow) exposes the medial edge of the underlying rectus muscle (black arrow) to confirm entry into the retrorectus space.
Once the rectus muscle is exposed, the entire length of the posterior sheath can be incised following the medial edge of the rectus muscle (Fig. 51-5).
FIGURE 51-5 ▪ Complete division of medial posterior rectus sheath. Black arrows pointed at medial cut edge of the posterior rectus sheath that exposes the entire rectus abdominis.
The remaining five Kocher clamps can then be placed on the exposed edge of the posterior rectus sheath for countertraction while developing the retrorectus plane using a combination of blunt dissection and electrocautery for hemostasis (Fig. 51-6). Take care to preserve laterally perforating neurovascular bundles, and note that the prior ostomy site is avoided at this point.
FIGURE 51-6 ▪ Retrorectus space developed. Green arrows highlight neurovascular bundles demarcating the lateral extent of the retrorectus dissection. The blue arrow points out the subtle loss of the posterior rectus sheath indicative of the arcuate line.
Inferiorly, take care to protect the epigastric vessels as they are not yet enveloped by the rectus muscle below the arcuate line. Dissect them anteriorly with the rectus muscle.
TIPSBegin incising the posterior rectus sheath at a point where the rectus is clearly identified and do not proceed until muscle is visualized. We find the rectus muscle is most consistently found cephalad near the costal margin, though a large epigastric hernia, previous subcostal incision, or diastasis can distort this finding.
If part of the rectus is exposed elsewhere by virtue of you initial laparotomy, use this as a landmark to divide the rest of the posterior sheath, taking care to stay as medial as possible.
PEARLS AND PITFALLS
When developing the retrorectus plane, most lateral perforating neurovascular bundles should be preserved. That said, there are consistently several perforators that will encroach on the medial retrorectus space. Although an attempt should be made to mobilize these laterally if possible, it is not unusual to have to sacrifice some of these in order to completely mature the retrorectus pocket. This should only be done once it is clear that the retrorectus space extends far lateral to these perforators.
Note that the linea semilunaris is immediately lateral to the majority of neurovascular perforators.
Inferiorly, the epigastric vessels need to be identified and should be preserved. There is typically a large medial branch off of the epigastric artery just below the arcuate line that will need to be divided.
Again, the linea semilunaris is often found ˜1 cm lateral to the epigastric vessels. When developing the retrorectus space, be sure to keep the vessels anterior with the rectus muscle.
INFERIOR TAR DISSECTION
Technique
The inferior TAR dissection is begun by incising the posterior lamina of the internal oblique just medial to the perforating neurovascular bundles. This is typically ˜1 cm lateral to the epigastric vessels. The surgeon should attempt to identify the linea semilunaris so as not to dissect too far lateral.
Dividing the posterior lamina of the internal oblique will expose the aponeurotic portion of the transversus abdominis muscle above the arcuate line—this layer must also be divided carefully to preserve the underlying peritoneum (Fig. 51-7). Often, it is difficult and unnecessary to distinguish between these two aponeurotic layers. Rather, the remaining thin/translucent peritoneum is the landmark that indicates the correct depth of dissection.Related posts:
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