Rives-Stoppa Retromuscular Repair for Incisional Hernia

There is no consensus on the optimal method of ventral hernia repair, and the choice of techniques is typically dictated by a combination of patient factors and surgeon expertise. Component separation techniques allow medial advancement of the rectus abdominis muscle to create a midline tension-free fascial closure. In this case, we describe a posterior component separation with retrorectus mesh placement, also known as a Rives-Stoppa retromuscular repair. With low morbidity and mortality, this technique provides a durable repair with low rates of recurrence and surgical site infection while providing dynamic muscle support and physiologic tension, preventing eventration, and allowing incorporation of mesh into the existing abdominal wall. 

Abdominal wall hernias affect an estimated five million Americans a year. Hernias form as a result of a loss of structural integrity of the abdominal wall. The best available estimates suggest that about one-third of all hernia repairs in the United States are for ventral hernias, and of all the ventral hernias repaired, two-thirds are primary ventral hernias and one-third are incisional hernias.¹ Connective tissue disorders, obesity, smoking, steroid use, diabetes, and other factors may predispose patients to primary hernia formation, while incisional hernias result, by definition, from breakdown of the fascial closure. Risk factors for incisional hernia formation include patient factors, as above, as well as technical factors at the time of the index operation, such as wound infection, the technique of fascial closure, type of surgery, and choice of the incision. Once a hernia has formed, its natural history is progressive enlargement due to an increase in wall tension at the location of the hernia. Hernia repair should be strongly considered for symptomatic hernias and is a necessity for incarcerated hernias resulting in a bowel obstruction or strangulated hernias. An estimated three billion dollars are spent on abdominal wall hernia-related health care expenditure each year.^2, 3 In this case, we perform a Rives-Stoppa retromuscular repair for a symptomatic incisional hernia. 

This is a 76-year-old female with a history of an abdominal aortic aneurysm status post endovascular repair, chronic obstructive pulmonary disease, as well as a right colectomy for colon cancer resulting in incisional hernia who presented for an elective hernia repair. The patient was in her usual state of health until May of 2017 when a screening colonoscopy identified a right colon cancer. She went on to have a laparoscopic-assisted right colectomy in June 2017, followed by chemotherapy and radiation for the treatment of a T4N2 colonic adenocarcinoma. Her colectomy was complicated by a large incisional hernia, and her chemotherapy treatment was complicated by anorexia and significant weight loss. During surveillance, she was noted to have developed a 5.2-cm infrarenal abdominal aortic aneurysm for which she underwent endovascular repair in September 2018. Her hernia progressively enlarged over time and was increasingly symptomatic, interfering with her activities of daily living. Repair with retrorectus mesh placement was planned electively. Her preoperative body mass index (BMI) was 20.2, serum albumin was 4.0 g/dl, and her American Society of Anesthesiologists (ASA) status was 3. Given a stool-filled and distended colon on preoperative axial imaging, a preoperative bowel prep was given to decompress the colon. Cefazolin and enoxaparin were administered preoperatively. 

On exam, she was noted to have a soft abdomen with a large ventral hernia that was reducible and non-tender with no overlying skin changes. 

Abdominal computed tomography (CT) revealed progressive enlargement of a midline, central abdominal ventral hernia containing small and large bowel without evidence of bowel compromise or upstream bowel dilation. It also demonstrated her prior right colectomy and endovascular repair of her infrarenal abdominal aortic aneurysm (Figure 1).

Figure 1: Preoperative abdominal CT scan of the patient. The axial plane (left) and sagittal plane (right) of the CT scan show prior right colectomy and previous endovascular repair of the patient's infrarenal abdominal aneurysm. 

Ventral hernias do not need to be repaired unless symptomatic given that bowel obstruction and strangulation are rare. Even in symptomatic patients, all hernias need not be repaired as non-operative management is a safe alternative. The complexity of the repair, patient comorbidities, and severity of symptoms contribute to the risk-benefit profile for any given patient. An international consortium of hernia specialists identified smoking status, obesity (BMI greater than 35), ASA status 3 or above, previous surgical site infection, superficial skin changes, and enterocutaneous fistula formation as the most relevant risk factors that affect operative outcome after ventral hernia repair.⁴ Hernia experts agree that elective ventral hernia repair is not recommended for patients with a BMI of 50 or greater without a weight loss intervention, for active smokers, or for those with glycosylated hemoglobin (HbA1c) >8%.^4–6 

In the setting of acute incarceration or strangulation, urgent surgical repair is the treatment of choice and may be the only option, even in high-risk patients who might not be offered elective repair. The objective of urgent repair is to relieve acute pain and bowel obstruction, when present, and to prevent or treat bowel infarction. The optimal technique for repair varies depending on the exact situation including nutritional status, acute physiology, and the presence of contamination, amongst other factors. In general, the greater the degree of patient comorbidity, the simpler the repair should be under urgent circumstances. Occasionally a well-nourished patient without severe physiologic derangement or any contamination may present acutely and still be a candidate for a complex, definitive repair.

There are numerous techniques for the repair of midline ventral or incisional hernias. Hernia repairs can be performed with or without mesh, and in an open, laparoscopic, or robotic fashion. Mesh can be placed as an underlay (below the peritoneum), sublay (between the rectus muscles and posterior rectus sheath), onlay (above the fascia), or inlay (between fascial edges).

According to guidelines, mesh repair should be considered for defects >1 cm and is recommended for defects >2 cm.⁵ Mesh repair offloads tension from the abdominal wall. Several randomized trials demonstrate lower rates of recurrence with mesh.^7–9 Mesh is, however, associated with a higher rate of complications, including infections, erosions, and fistula than repairs without mesh.^7, 10, 11 A registry-based cohort study in Denmark demonstrated that mesh repair was associated with fewer reoperations for recurrences (open mesh 12.3%, laparoscopic mesh 10.6%, non-mesh 17.1%).¹² At a five-year follow-up, the cumulative incidence of mesh-related complications was 5.6% for patients who underwent open mesh repair.¹² 

Hernia mesh can be generally categorized into two broad classes: synthetic and biologic. Tissue ingrowth and adherence of synthetic mesh are appealing; however, it has the disadvantage of causing adhesions to serosal surfaces. Some synthetic mesh products incorporate anti-adhesives to the side of the mesh in contact with the viscera to allow intraperitoneal placement with less concern for tissue erosion. Biologic mesh offers an alternative for use in a contaminated field and may reduce the severity of wound infections and the need for mesh explantation when infection occurs compared with synthetic mesh. Despite these theoretical advantages, the dogma that biologic is preferable to synthetic mesh in an infected field has been increasingly scrutinized due in part to high costs as well as high rates of recurrence and complications associated with biologic mesh. Recent studies offer increasing support for the suitability of synthetic or biosynthetic mesh in contaminated settings while challenging the purported advantages of biologic mesh.^13–15

Head to head comparisons of open and laparoscopic techniques for hernia repair have been the subject of many randomized trials. A 2014 systematic review demonstrated lower rates of wound infection and drainage but higher rates of bowel injury for laparoscopic compared with open repair.¹⁶ A Cochrane review and subsequent meta-analysis reached the same conclusions.^17, 18 Circumstances in which laparoscopic repair may be advantageous may include large hernia defect, suspicion of multiple defects, and obesity. With the proliferation of robotic surgical platforms, robot-assisted hernia repairs have become more common. While they have a similar set of indications as laparoscopic repair, robot-assisted hernia repair does not improve outcomes but does prolong operative time and increase the cost.^19, 20

Large or complex abdominal wall defects present a particularly challenging surgical problem. The European Hernia Society classified hernias with a defect of  >10 cm as large.²¹ The choice of technique to address large or complex hernia defects is often dictated by surgeon expertise and patient circumstance. Posterior component separation with retrorectus mesh placement offers the advantages of low recurrence rates, low rates of wound complications such as seroma or infection, and excellent incorporation of inexpensive, uncoated mesh into the abdominal wall.

The steps of a posterior component separation with mesh placement are as follows: 

1) Incision and access to the abdominal cavity.

2) Hernia sac dissection and excision.

3) Posterior rectus sheath dissection and closure.

4) Mesh placement.

5) Drain placement.

6) Anterior rectus sheath closure.

7) Skin closure.

Once access to the abdominal cavity is obtained, adhesiolysis may be required depending on the degree of adhesions. Once the viscera are free from the abdominal wall, the hernia sac must be dissected off the abdominal wall and fascia. If you think you might need the hernia sac to assist with closure, do not excise all of it yet. We use blunt dissection to peel off the hernia sac, facilitating rapid dissection in the correct plane and thus preserving the maximum thickness of the overlying skin and subcutaneous fat. The hernia sac is typically excised along the fascial edge, though can be preserved in planned retrorectus repairs to be used as additional tissue for posterior sheath closure. The posterior rectus sheaths are then incised, and the posterior fascia is separated from the rectus abdominis. This creates the space into which the retrorectus mesh is placed. This dissection is carried laterally to the linea semilunaris, the lateral border of the rectus abdominis muscle. It is important to visualize the linea semilunaris, as recognition of this structure and the lateral perforating neurovascular bundles is key to avoiding some of the most potentially devastating complications in abdominal wall reconstruction. Getting out to just medial to the linea semilunaris is important, getting down to Cooper's in the space of Retzius is important, and getting up under the xiphoid superiorly constitutes adequate dissection. As this dissection occurs, perforating vessels are encountered. Medially, these must be sacrificed to develop this space, but lateral perforators should be preserved. The inferior dissection below the arcuate line enters the space of Retzius and can extend all the way to Cooper’s ligaments. The superior dissection in the subxiphoid space can be challenging, as the posterior sheath needs to be detached from the posterior aspect of the linea alba without entering the anterior fascia. Once both sides are connected at the superior and inferior portions of the dissection, the posterior rectus sheath is closed. The sheath is closed in a running fashion with small bites placed close together to spread out tension. This layer of the closure is not for strength but functions to provide a layer of protection between the mesh and intra-abdominal viscera. The posterior sheath may be weak and thin due to multiple sites of hernia, prior repairs, and ostomies, amongst other reasons. In this case, we use successive bisection with an interrupted figure-of-eight sutures to approximate the thin posterior sheath. The posterior sheath closure should be tension free. If the posterior sheath is not able to be closed in the midline, or there is too much tension, a transversus abdominis release (TAR) can be performed, the gap can be bridged with the hernia sac (which needs to be preserved at the start of the case if this is possible), or alternatively a coated mesh could be used. In this case, the decision to not perform a TAR might be controversial, but we did not feel there was tension to warrant this. Once the posterior fascia is closed, attention is turned to mesh placement. In this case, we used a 30x30-cm polypropylene mesh that was cut to size, filling the retrorectus space from semilunar line to semilunar line, and from costal margin to pubis. Non-barrier coated mesh has the advantage of allowing rapid incorporation on both sides of the mesh. The mesh is secured in place with transfascial sutures through the anterior fascia. Care should be taken to place the transfascial sutures in such a way that they evenly distribute the tension across the mesh and incision. The mesh is secured at the superior and inferior aspects and then successively on both sides, alternating sides to ensure even tension. Variation in this technique is common—some surgeons tack the mesh to the anterior or posterior fascia without placing transfascial sutures, and some use no sutures at all relying on the friction of the mesh to keep it in place. Drains, in this case two 19-round Blake drains, are then placed into the rectrorectus space above the level of the mesh. The anterior fascia is then closed in a running fashion over the top of the mesh and drains. This is a strength layer, and the fascia should come together without excessive tension. Redundant skin is then excised, the subcutaneous space is drained if necessary, and the skin is closed.

Component separation was first described in 1990.²² Used for moderate- or large-size hernias, this term encompasses a variety of techniques involving musculofascial advancement flaps to allow medial advancement of the rectus abdominis muscle to create a midline tension-free fascial closure. Component separation can be performed with or without mesh; however, the recurrence rate remains higher with suture repair alone. Component separation techniques can be used with hernia defects as large as 20 cm and sometimes even larger if a secondary release or supplemental mesh is used to bridge the residual defect. 

The anatomic and functional elements of a component separation technique include (1) translation of the muscular layer of the abdominal wall to enlarge tissue surface area; (2) separation of muscle layers to allow maximal expansion of each individual muscle unit; (3) disconnection of the muscle unit from its fascial sheath to facilitate expansion; (4) use of abdominal wall musculature to cover intra-abdominal contents; and (5) use of bilateral mobilization to equilibrate forces of the abdominal wall and centralize the midline.^22, 23 Component separation can be performed using an anterior or posterior approach with or without a secondary release to provide additional advancement. The choice of technique is usually dependent on the experience and expertise of the surgeon as both are successful in facilitating the medial advancement of the rectus for the closure of large and complex ventral hernias. An anterior component separation involves division of the external oblique aponeurosis to allow the advancement of the musculofascial flap to the midline.²⁴ The anterior technique is, however, usually performed with the creation of large subcutaneous flaps and thus has more frequent wound complications, though perforator preserving and endoscopic techniques may mitigate some of these problems.²⁵ External oblique release also results in disruption of one layer of the abdominal wall laterally and mandates an intraperitoneal underlay or onlay mesh, if the mesh is to be used.²⁴ This is in contrast to the posterior component separation technique used in this case, in which all layers of the abdominal wall are maintained and there are no large subcutaneous flaps. For larger hernias, the technique used in this case can be expanded by the use of a TAR, which provides more extensive mobilization of the lateral abdominal wall to the midline and allows for placement of larger mesh prosthetics at the cost of lateral disruption of one layer of the abdominal wall (in this case the transversus abdominis).^24-27 

Many advocate the use of mesh reinforcement during a component separation, based largely on extrapolation of the aforementioned benefits of mesh for reducing hernia recurrence rates in ventral hernias. A variety of synthetic and biologic mesh products have been used. There is no large randomized control trial comparing component separation with and without mesh repair. A posterior component separation facilitates the placement of mesh in an extraperitoneal sublay position if the mesh is to be used. Theoretically, this allows the incorporation of vascularized tissue into both sides and may result in lower recurrence rates. As alluded to above, this position in combination with the avoidance of large subcutaneous flaps may reduce wound complications compared with anterior component separation, though direct comparative data is scant.²⁸

Patients with an uncomplicated course are usually hospitalized between three and five days for pain control and diet advancement. Drains are removed based on their location, duration of time in place, and output per day. Physical activity is often restricted in the short term, though this has not been rigorously studied. Morbidity and mortality associated with posterior component separation are rare. For large or complex ventral hernia, a study using component separation to repair a ventral hernia in morbidly obese patients reported that major perioperative morbidity was 8% and perioperative mortality was 1%.²⁵ Morbidity is largely attributable to surgical site infection, seroma/hematoma, and skin flap necrosis, which occur at variable rates. There are limited studies with long-term follow-up after component separation, but the recurrence rates for component separation with mesh appear to be less than 10%. 

The case detailed above was completed in just under two and a half hours with an estimated blood loss of 75 ml. She had an uncomplicated postoperative course and was discharged home on postoperative day (POD) 4. She has been seen in follow-up and has recovered without difficulty. Her drains were removed on POD 13 and POD 17. She has had interval axial imaging for abdominal aortic aneurysm surveillance that demonstrated the integrity of the repair (Figure 2). 

Figure 2: Postoperative abdominal CT scan of the patient. The axial plane (left) and sagittal plane (right) of the CT scan show the integrity of the repair of the ventral hernia.

Laparoscopic suture passer or Reverdin needle.

30x30-cm polypropylene mesh. 

Nothing to disclose. 

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online. There is no identifying information included in either the video or the text article.