Atlas of Abdominal Wall Reconstruction

456 Pages·2016·120.73 MB·English

by  Michael J. Rosen

Atlas of
Abdominal Wall
Reconstruction
Second Edition
Michael J. Rosen, MD, FACS
Professor of Surgery
Lerner College of Medicine;
Director, Cleveland Clinic Comprehensive Hernia Center
Cleveland Clinic Foundation
Cleveland Ohio
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF ABDOMINAL WALL RECONSTRUCTION, SECOND EDITION ISBN: 978-0-323-37459-0
Copyright © 2017 by Elsevier, Inc. All rights reserved.
Jeffrey Janis retains copyright for the original figures in Chapter 11.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Previous edition copyrighted 2011.
International Standard Book Number: 978-0-323-37459-0
Content Strategist: Michael Houston
Content Development Specialist: Ann Ruzycka Anderson
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Ryan Cook
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
I would like to dedicate this atlas to all of my patients.
It is through their surgical treatment that we constantly improve and find the
best surgical approaches for their disorders.
Contributors
Conrad Ballecer, MD, FACS Jorge Daes, MD, FACS
Co-director of the Center for Minimally Invasive and Director
Robotic Surgery Minimally Invasive Surgery
Peoria, Arizona Clinica Bautista
Barranquilla, Atlantico, Columbia
Laurel J. Blair, MD
Minimally Invasive Surgery Fellow George DeNoto III, MD, FACS
Department of Gastrointestinal and Minimally Chief, Division of General Surgery
Invasive Surgery St. Francis Hospital
Carolinas Medical Center Roslyn, New York;
Charlotte, North Carolina Clinical Associate Professor of Surgery
Hofstra Northwell School of Medicine
Alfredo M. Carbonell II, DO Hempstead, New York
Chief, Division of Minimal Access & Bariatric Surgery
Department of Surgery Gregory A. Dumanian, MD
Greenville Health System; Stuteville Professor of Surgery
Associate Professor of Surgery Division of Plastic Surgery
University of South Carolina School of Medicine— Northwestern Feinberg School of Medicine
Greenville Chicago, Illinois
Greenville, South Carolina
Karen Kim Evans, MD
Harvey Chim, MD Associate Professor of Plastic Surgery
Assistant Professor Center for Wound Healing
Surgery/ Plastic Surgery Georgetown University Medical Center
University of Miami Miller School of Medicine Washington, D.C.
Miami, Florida
Brian Gastman, MD
William S. Cobb IV, MD Associate Professor/Staff
Associate Professor of Clinical Surgery, University of Department of Plastic Surgery
South Carolina—Greenville Cleveland Clinic
Vice Chair of Clinical Affairs Cleveland, Ohio
Co-Director, Hernia Center
Department of Surgery A. Daniel Guerron, MD
Greenville Health System General Surgery Resident
Greenville, South Carolina Digestive Disease Institute/General Surgery
Cleveland Clinic
Michelle Coriddi, MD Cleveland, Ohio
Resident
Department of Plastic Surgery Raffi Gurunluoglu, MD, PhD, FACS
Ohio State University Professor of Surgery
Columbus, Ohio Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cory N. Criss, MD Department of Plastic and Reconstructive Surgery
Resident, Department of Surgery Cleveland Clinic
University Hospitals Case Medical Center Cleveland, Ohio
Cleveland, Ohio
v
vi Contributors
William W. Hope, MD Melissa Phillips LaPinska, MD, FACS
Assistant Professor Assistant Professor
Department of Surgery Department of Surgery
New Hanover Regional Medical Center University of Tennessee Health Science Center
University of North Carolina, Chapel Hill Knoxville, Tennessee
Wilmington, North Carolina
Samir Mardini, MD
Ron Israeli, MD, FACS Professor and Program Director
Clinical Assistant Professor of Surgery Division of Plastic Surgery
Division of Plastic Surgery Department of Surgery
Hofstra Northwell School of Medicine Mayo Clinic
Hempstead, New York Rochester, Minnesota
Jeffrey E. Janis, MD, FACS Jay Mittal, MD
Professor of Plastic Surgery Chief Resident
Neurosurgery, Neurology, and Surgery; Department of Surgery
Executive Vice Chairman Cleveland Clinic Foundation
Department of Plastic Surgery; Cleveland, Ohio
Chief of Plastic Surgery
University Hospitals Matthew L. Moorman, MD, FACS
Ohio State University Director, Division of Acute Care Surgery
Wexner Medical Center General Surgery
Columbus, Ohio Cleveland Clinic;
Assistant Professor of Surgery
Donald H. Jenkins, MD Case Western Reserve University, Cleveland Clinic
Consultant; Lerner College of Medicine
Associate Professor of Surgery; Cleveland, Ohio
College of Medicine Medical Director
Division of Trauma, Critical Care and General Surgery Maurice Y. Nahabedian, MD, FACS
Trauma Center Mayo Clinic Professor
Rochester, Minnesota Department of Plastic Surgery
Georgetown University
Kent W. Kercher, MD, FACS Washington, D.C.;
Professor Associate Professor
Division of Gastrointestinal and Minimally Invasive Department of Plastic Surgery
Surgery Johns Hopkins University
Department of Surgery Baltimore, Maryland
Carolinas Medical Center
Charlotte, North Carolina Sean B. Orenstein, MD
Assistant Professor
David M. Krpata, MD Department of Surgery
Fellow Oregon Health & Science University
General Surgery Portland, Oregon
Cleveland Clinic
Cleveland, Ohio Cemile Nurdan Ozturk, MD
Assistant Professor
Gregory A. Lamaris, MD, PhD Department of Head, Neck and Plastic Surgery
Plastic Surgery Fellow Roswell Park Cancer Institute
Department of Plastic and Reconstructive Surgery Buffalo, New York
The Cleveland Clinic Foundation
Cleveland, Ohio
Contributors vii
Eduardo Parra-Davila, MD, FACS, FASCRS Carley E. Schroering
Director of Minimally Invasive and Colorectal Surgery Medical Student
Director of Hernia and Abdominal Wall University of Kentucky
Reconstruction Lexington, Kentucky
Celebration Health Florida Hospital
Celebration, Florida Nathaniel F. Stoikes, MD, FACS
Assistant Professor of Surgery
Eric M. Pauli, MD University of Tennessee Health Science Center
Assistant Professor of Surgery Memphis, Tennessee
Director of Endoscopic Surgery
Department of General Surgery Jeffrey Ustin, MD, MS, FACS
Penn State Milton S. Hershey Medical Center Acute Care Surgeon
Hershey, Pennsylvania General Surgery
Cleveland Clinic
Clayton C. Petro, MD Cleveland, Ohio
General Surgery Resident
University Hospitals Case Medical Center Guy R. Voeller, MD, FACS
Cleveland, Ohio Professor of Surgery
University of Tennessee Health Science Center
Ajita S. Prabhu, MD Memphis, Tennessee
Assistant Professor
Department of Surgery David L. Webb, MD, FACS
University Hospitals Case Medical Center Assistant Professor
Cleveland, Ohio Department of Surgery
University of Tennessee Health Science Center
Michael J. Rosen, MD, FACS Memphis, Tennessee
Professor of Surgery
Lerner College of Medicine; Joshua S. Winder, MD
Director, Cleveland Clinic Comprehensive Hernia Research Fellow
Center Department of General Surgery
Cleveland Clinic Foundation Penn State Milton S. Hershey Medical Center
Cleveland Ohio Hershey, Pennsylvania
Steven Rosenblatt, MD, FACS Benjamin Zendejas-Mummert, MD
Staff Surgeon Resident in Surgery
General Surgery Mayo Clinic
Cleveland Clinic Rochester, Minnesota
Cleveland, Ohio
Martin D. Zielinski, MD, FACS
J. Scott Roth, MD, FACS Associate Professor
Professor of Surgery and Chief, Gastrointestinal Department of Surgery
Surgery Mayo Clinic
Department of Surgery Rochester, Minnesota
University of Kentucky
Lexington, Kentucky
Christopher J. Salgado, MD
Professor
Division of Plastic Surgery
Department of Surgery
University of Miami
Miami, Florida
Preface
The field of abdominal wall reconstruction and hernia repair has seen an explosion of innova-
tive approaches, reconstructive options, and multi-disciplinary collaboration in the past decade.
Since our first edition of this atlas, the reconstructive surgeon can now push the boundaries of
hernia surgery utilizing the robot, laparoscope, or open techniques that are all designed to mini-
mize wound and mesh complications and maximize patient outcomes. With growing interest in
the complexities of many of the patients that present with hernias, a renewed interest in preop-
erative optimization has emerged. In this atlas, we have summarized some of the key steps that
every reconstructive surgeon can adhere to in order to adequately prepare a patient to undergo
complex abdominal wall reconstruction and expect the best possible results. This edition will
also highlight some of the rare types of hernias that can challenge even the most experienced
reconstructive surgeon including perineal defects, major soft tissue loss, loss of domain, and
hernias after TRAM procedures. Significant effort has been made to help the reader understand
the intricate anatomy of the abdominal wall in order to make each of these advanced recon-
structive procedures reproducible in their own hands. I am also excited to provide the reader
with a detailed description of approaches and the rationale for each technique for some of the
more routine types of hernia procedures including inguinal hernias, umbilical hernias, and
repair of rectus diastasis. Our field is seeing a rapid growth of robotic ventral hernia repairs as
well. This atlas will provide the surgeon with a detailed description of how to introduce the
robotic platform into their practice and perform minimally invasive complex abdominal wall
reconstructions.
Today it is clear that the reconstructive surgeon must individualize their approach to abdomi-
nal wall reconstruction, and likely no single technique or prosthetic will accomplish the goals for
all repairs. As this field has continued to expand, it now represents a collaborative effort amongst
general surgeons, plastic surgeons, trauma surgeons, and herniologists. This atlas represents the
compilation of these efforts and like reconstructive surgery would not be possible without each of
their respective contributions. Each of these procedures has been described in detail with particu-
lar attention to avoiding common surgical pitfalls and strategies to deal with technical challenges
once they are encountered. In addition, each chapter is accompanied by a representative video of
the reconstructive approach to guide the surgeon in the technical nuances of the procedure. In this
textbook, the robotic, laparoscopic, open, and hybrid approaches are described. While there are
often many ways to repair an abdominal wall defect, this atlas describes a multitude of safe and
effective strategies to deal with these challenging problems across the entire spectrum of ventral
hernia repair as described by experts in the field. I believe that the second edition of this atlas will
provide the practicing surgeon with a useful guide to optimize outcomes for their patients.
ix
1
CHAPTER
Abdominal Wall Anatomy
and Vascular Supply
Harvey Chim, MD, Karen Kim Evans, MD, Christopher J. Salgado, MD, and
Samir Mardini, MD
1. Clinical Anatomy
1. Overview
s T he 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.
s L ayers of the anterior abdominal wall include skin, subcutaneous tissue, superficial fascia,
deep fascia, muscle, extraperitoneal fascia, and peritoneum. 
2. Superficial Fascial Layers (see Figs. 1.1 and 1.2)
s T he superficial fascia of the abdominal wall consists of a single layer above the umbilicus,
comprising the fused Camper and Scarpa fasciae.
s B elow the umbilicus, the superficial fascia consists of a fatty outer layer (Camper fascia)
and a membranous inner layer (Scarpa fascia).
s C amper fascia is continuous inferiorly with the superficial thigh fascia and extends inferi-
orly to the scrotum in males and labia majora in females.
s S carpa fascia fuses inferiorly with the fascia lata of the thigh and continues posteriorly to
the perineum, where it is called Colles fascia.
2
Chapter 1 • Abdominal Wall Anatomy and Vascular Supply 3
Xiphoid process Pectoralis major
muscle
Serratus anterior
muscles
5
Costal margin
6 Rectus
Parietal abdominis
peritoneum 7 muscles
Extraperitoneal
(subserosa) fascia 8 Linea alba
9
Transversalis fascia Linea semilunaris
Transversus 10
abdominis muscle Tendinous inscriptions
Posterior rectus sheath Midaxillary line
(above arcuate line)
External oblique
(cid:127) Transversalis fascia
(cid:127) Internal oblique fascia muscle and
aponeurosis
Internal oblique muscle
Iliac crest
External oblique muscle
Anterior superior iliac
Anterior rectus sheath
spine (ASIS)
(above arcuate line)
(cid:127) Internal oblique fascia
(cid:127) External oblique fascia Umbilicus
Superficial fascia Arcuate line
(cid:127) Camper fascia
(cid:127) Scarpa fascia Inguinal ligament
Fascia lata Pyramidalis muscle
Superficial epigastric and Pubic tubercle
circumflex iliac arteries
Intercrural fibers Symphysis pubis
Femoral vessels
Fig. 1.1
Pectoralis major
muscle
External oblique
muscle
Serratus anterior
muscles
5
Xiphoid process
Midaxillary line 6
7 Costal margin
8
Linea alba
9 Rectus abdominis
Latissimus dorsi muscle muscles
10
11 Umbilicus
12
Tendinous inscriptions
Iliac crest
Linea semilunaris
Arcuate line
Pubic tubercle
Anterior superior iliac
spine (ASIS)
Inguinal ligament
External oblique aponeurosis
Fig. 1.2