component separation technique Guide

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Bard* * impLant
Technical Aspects of the Component Separation
Technique Utilizing the Bard* * Implant and
Synthetic Mesh to Reconstruct the Abdominal Wall
component separation
technique Guide
Karl A. LeBlanc, MD, MBA, FACS
Director, Minimally Invasive Surgery Institute
and Fellowship Program
Baton Rouge, LA
Clinical Professor, Surgery, Louisiana State University
New Orleans, LA

Technical Aspects of the Component Separation
Technique utilizing the Bard* CollaMend* Implant and
Synthetic Mesh to Reconstruct the Abdominal Wall

Karl A. LeBlanc, MD, MBA, FACS

Director, Minimally Invasive Surgery Institute
and Fellowship Program
Baton Rouge, LA
Clinical Professor, Surgery, Louisiana State University
New Orleans, LA
The technique presented contains the opinions of, and personal
surgical techniques practiced by, this surgeon. The opinions and
technique presented herein are for informational purposes only.
The decision of which techniques to use in a particular surgical
application should be made by the surgeon based on the individual
facts and circumstances of the patient and previous surgical

Surgeons are increasingly faced with multiple
recurrent, massive hernias that involve much of the
anterior abdominal wal . Incarceration and skin necrosis over
the underlying intestine as wel as fistulas or infection are
frequent complications related to these hernias. The repair
of these hernias requires much greater effort than generally
seen with less complex situations. Additional y, this may be
the one best chance to reconstruct the abdominal wall
musculature of these patients to permanently repair the
function and appearance of the abdomen.
The technique described within this guide has developed
over a period of years. It depends heavily on the newer
technologies available to surgeons, specifically biologic
biomaterials, to afford the greatest opportunity to secure
an effective treatment of these complex defects.

patient selection
patient preparation and positioning
Generally, such patients that present with these
Colonic cleansing is recommended if there is colon
conditions have multiple co-morbidities. These include,
within the hernia. Preoperative antibiotics, appropriate to
but are not limited to, advanced age, diabetes mellitus,
the condition of the patient, are given prophylactically.
hypertension, chronic obstructive pulmonary disease
General endotracheal anesthesia is administered. Urinary
and/or cardiovascular abnormalities. Nearly all of them
drainage catheters are used routinely. Central venous
will have had multiple prior intra-abdominal operations
access and nasogastric suction tubes are used selectively.
and hernia repairs, frequently with mesh.
All patients are placed in a prone position with the
All should have preoperative CT scans to assess the
arms out to the side of them. Wide skin preparation
extent of defect(s) and intestinal involvement. Medical
and draping are required due to the extensive exposure
clearance is considered ideal to assure that they are in
of the abdominal wall tissues that is required. Antibiotic
their best steady state. Patients with significant loss of
impregnated plastic drapes are not used because of the
domain should be carefully evaluated from a pulmonary
need to clearly evaluate the integrity and vascularity of
standpoint and warned that the use of mechanical
the abdominal skin.
ventilation postoperatively may be required. Any
nutritional issues should be addressed and smoking
should stop.
Most individuals will be candidates for this procedure
if all of the above are performed. The inability to tolerate
general anesthesia will contraindicate this procedure for
these patients. Age, in and of itself, is not a contraindication.

technical steps of the procedure
This skin is then incised. The hernia sac should
be entered as soon as technically possible to provide
adequate visualization of the intestine. Al adhesions
should be lysed past the lateral border of the rectus
muscle or to the anterior axil ary line. This is necessary
to allow placement of the intraperitoneal mesh.
Any intestinal injury should be repaired in the usual
manner and should not deter the surgeon from
completion of the intended operation unless there
is gross fecal contamination.
The skin and subcutaneous tissue are then dissected
laterally using electrocautery or ultrasonic dissection.
An attempt should be made to lessen the amount
of subcutaneous fat that remains on the fascia to
al ow for rapid mesh incorporation. This dissection
continues to approximately 5-6cm above the xyphoid
tissue dissection
in the cephalad direction. The lateral dissection
should extend to at least the anterior axil ary line or
The skin that is to be excised is marked with a skin
the anterior iliac spine. To do this dissection properly,
marker. One should initially leave a bit of excess skin
it will require the division of perforating vessels that
to assure adequate closure of the operative field at
supply to overlying skin. This is unavoidable and does
the conclusion of the operation. Transverse incisions
predispose these areas to the risk of interruption of
are preferred, when feasible, but this is frequently
an adequate blood supply. It is necessary, however,
not possible due to the need to excise the thin skin
to continue this despite this risk to permit the large
that exists from the xyphoid to the pubis.
overlap of the prosthetic biomaterial that will occur
at the end of the reconstruction. The caudal dissection
extends onto the pubic area and just above the
inguinal ligament bilaterally.

technical steps of the procedure
instead, this initial incision is usually over the rectus
muscle. This incision is carried from the inguinal area
to the ribs. This fascia thins out over the ribs so that
one should use the electrocautery to incise this layer
as it continues over the muscles that overly the ribs
for a distance approximately 3-5cm. One should also
be careful not to damage the cord structures in the groin.
These maneuvers are not sufficient to al ow for
adequate medial movement of the rectus muscles.
One must grasp the edge of the newly divided
external oblique fascia with Kocher clamps and
manual y dissect lateral y to separate the external
oblique muscle from the internal oblique muscle.
Of course, this is done bilateral y. Once these
components are separated the surgeon can then
pul the medial border of the rectus muscles together
in the midline. Typically, one will realize an 8-10cm
separation of the components
shift from either side of the rectus muscles, al owing
coverage of approximately 20cm in the midportion of
This is a critical step in this operation and requires
the abdominal wal . If these maneuvers stil do not
the dissection that was done prior to this step. The
al ow for complete re-approximation of the rectus
surgeon identifies the lateral of the rectus sheath,
sheath, one may incise the posterior rectus sheath
first on one side and then later on the other. This is
on either side to gain an additional 2-3cm from each
done both by palpation and by visual inspection. A
side of fascia that could be then closed. If that might
hemostat is inserted approximately one centimeter
prove to stil be insufficient, one could, instead,
lateral to that sheath to penetrate into the external
incise the anterior rectus sheath lateral y on either
oblique fascia. This is then incised with either the
side and rotate each of them to cover the midline,
scalpel or the electrocautery. Once this is started,
the so-cal ed “open book” repair. In either case, the
a layer of fat will be seen. If muscle tissue is seen
following mesh repairs are still required.

intraperitoneal placement
An overlap of at least 5cm on either side of the
of the Bard* collamend* implant
closed rectus sheath is a minimum standard for this
repair. Consequently, a piece of the Bard* CollaMend*
The best results of an incisional hernia repair are
Implant is cut to a 10cm width. A typical choice of this
to place the prosthetic in the intraperitoneal or
material would be a 20x25cm piece from which 5cm
retrorectus position. The intraperitoneal placement of
would be cut from either side of the 20cm width. If
the long lasting biological material such as the Bard*
the rectus fascia is quite weak, one may choose to
Col aMend* Implant serves to provide a scaffold for
only remove 3 or 4cm from either side.
the patient’s own tissues to repair a portion of this
abdominal wal . The longevity of this biomaterial is
The Bard* CollaMend* Implant is then marked every
provided by the crosslinkage of its col agen when it
2 or 3cm along the entire border of the product with
is processed. This is felt to be a significant benefit
a skin marking pencil. At each of these markings a
and because of this fact it is a critical factor in the
monofilament nonabsorbable suture is placed and
success of this operation.
will be used to fixate the prosthesis to the anterior
wall. An ePTFE suture is usually utilized because it

intraperitoneal placement continued...
is soft and pliable and will not “stick” to the patients’
exact to assure that the distance of transfascial placement
subcutaneous tissues and/or skin. Because of the
mimics the distance of the suture placement on the
strength of the Bard* CollaMend* Implant, these sutures
Bard* CollaMend* Implant.
do not need to be tied. They will be held in place nicely
throughout the implantation. It is important to leave these
If this is done in a non-exact manner, gaps will be
sutures at lengths of at least 15-20cm long to facilitate
created between the sutures predisposing to the slippage
transfascial placement.
of intestine at these sites. This would then create a
potential risk of re-herniation or bowel obstruction in the
The two sutures in the midportion of the long axis of the
future. Only one side of the prosthesis is fixed initially.
prosthetic are placed transfacially first. This will allow the
These sutures are tied once all of them have been
surgeon to assess the tautness of the product before
placed. Typically, the location of these will be lateral to
the sutures are tied. These are placed with a Reverdin
the final position of the lateral edge of the rectus sheath.
needle, although one of the laparoscopic suture-passing
devices could also be used (albeit not as easily). If the
Now the surgeon must locate the site of the placement
hernia defect extends to the xyphoid or to the pubis,
of the sutures on the opposite side of the Bard*
these sutures cannot be placed in that manner. In these
CollaMend* Implant. This is done by again grasping the
situations, one must secure the Bard* CollaMend*
medial rectus sheath from each side and drawing them
Implant to the diaphragm or Cooper’s ligament with the
together as they will be when the midline is closed later.
same nonabsorbable suture to ensure adequate overlap
They are released and suture placement commences on
of the defect and fixation of the product.
the side of the remaining untied sutures. Once they are
al placed, these are tied. It is helpful to have the assistant
Once the cephalad and caudal portions of the prosthetic
surgeon approximate the midline during this time to take
are taut, these initial two sutures are tied. Then, each of
the tension of the sutures as they are tied down. Visual
the lateral pre-placed sutures are pushed transfascially
inspection of the entire anterior surface should confirm
with the Reverdin needle. One must be careful and
that there are no gaps or intestine between any of these
transfascial sutures.

midline closure
After the Bard* Col aMend* Implant has been
Fol owing this, the rectus sheath should have been
secured, the midline is closed. General y, a
re-approximated. In many cases, however, there can
long-lasting absorbable suture wil be used, such
be laxity of the fascia in some areas or there is a
as #2 PDS* suture. The first closure entails the
significant prominence of the midline closure that
placement of multiple “figure-8” sutures. These
might become a cosmetic issue. For these reasons,
are tied as this is done.
a second suture is used in a running fashion to
plicate the initial sutures to close the midline. This
will result in a taut abdominal wall.

large to cover approximately 5cm lateral to these sites
is used. This frequently requires a second piece of a
prosthetic to accomplish this because it must extend at
least 5cm above the xyphoid and 3-5cm below the pubis
to insure adequate protection.
Usual y a light-weight polypropylene mesh is placed to
cover these areas. Occasional y, if the lateral areas seem
especially weak, a heavy-weight mesh is used instead.
The lighter weight is preferred general y because there
may be a more “normal” compliance of the abdominal
wal . Additional y, there is an impression by some that
there may be either more resistance to infection and/or an
easier ability to treat an infection that involves a light versus
a heavy-weight polypropylene mesh should this occur.
placement of synthetic mesh
In either event, this prosthetic covers the entire anterior
abdominal wall. It is fixed with skin staples. It is important
There is a potential risk of the development of lateral
not to place them over bony structures because there
hernias at the site of the incision into the external
seems to be an increase in the incidence in postoperative
oblique fascia to separate the components. Despite
pain if that is done. Sutures are not required but could be
the fact that the transversalis fascia is still intact, there
used if desired by the surgeon. General y, only one staple
can be a relative protrusion of the weakened abdominal
gun is required.
wall at the site where the rectus sheath had been
prior to the separation. To mitigate against this
unwanted result, a synthetic mesh that is sufficiently

drainage and Final closure
postoperative care
It is important to provide significant drainage because
These patients usually remain hospitalized for about
of the large amount of serosanguinous fluid that will
3-4 days. Pain tolerance is the usual determinant of
accumulate due to the large dissection. To accomplish
discharge. However, the patient cannot be discharged
this it is necessary to utilize four rather than two
until the sump drains are removed. During this time,
drains. Two sump drains are placed on one side
all must be observed carefully for any change in
of the abdomen and two closed suction drains are
their respiratory status, because the replacement
placed on the other side of the abdomen. These are
of the intestinal contents into the closed space
exited in the most dependent portion of the dissected
of the abdominal cavity may result in respiratory
areas taking care not to put these in the folds of
compromise. This is infrequent but needs immediate
skin when the patient would bend at the waist as
attention if it occurs.
this would cause significant discomfort and increase
the risk of infection. The sump drains are removed
During the hospital stay, the skin edges must be
when they are draining less than 100-150 cc per day
inspected frequently. An assessment of any skin
(typically 2-3 days). The closed suction drains remain
necrosis must be made. If this occurs, there usually
for approximately two, but no longer than three,
is deeper subcutaneous necrosis. If not dealt with
weeks (when draining 25-50 cc per day).
in a timely manner, the entire wound will separate,
requiring extensive debridement. If areas of necrosis
Any remaining excess skin is excised once the drains
are apparent, the patient should be returned to the
have been placed. The subcutaneous layer is closed
operating room to have a secondary excision and
with a few interrupted absorbable sutures to lessen
primary closure once the lines of demarcation
the tension on the closure. This is followed by a
are assured.
running absorbable suture along the entire incision.
The skin is initially closed with interrupted vertical
mattress nylon sutures approximately 3-5cm apart.
The method presented herein is not new. It is an adaptation
In between these, skin staples complete the closure.
of the current technologies that are available to repair these
The incision and drain sites are dressed. An abdominal
very difficult situations. Long term results are pending, but
at this time recurrences are rare. The strategic placement of

binder is used to assist in pain relief and possibly
a biologic mesh, the primary closure of the midline with the
reduction in seroma formation.
component technique, and the onlay of a permanent prosthesis
affords the patient a reconstruction of the abdominal wall that
has not been approached so aggressively in the past.