hen repairing larger hernias, it can sometimes be difficult to bring the edges of the abdominal wall back together. Muscles can only pull, they do not push. Therefore, when they contract, they need the attachments of other muscles to pull back into normal position again. With the abdominal wall, the normal attachments of the abdominal muscles to each other are important in maintaining the usual shape and size of the muscles. When these muscles are disconnected, such as with a large hernia in the midline, the muscles can become contracted and shortened. This can make it difficult to restore the normal anatomy during hernia repair. In these settings, advanced surgical techniques may be needed to increase the stretch of the abdominal wall to allow normal anatomy to be reconstructed. Broadly speaking, this is abdominal wall reconstruction. Abdominal wall reconstruction typically involves some sort of component separation, which simply means separating some of the components of the abdominal wall to get that increased stretch to bring the tissues back together.
The simplest form of component separation is to separate the fascia off the deep surface of the rectus muscle. Fascia is the tough connective tissue that gives the abdominal wall its strength. Through most of the abdomen, the rectus muscle has a layer of fascia on the superficial and deep surfaces of it. By separating the fascia off of the deep surface, this allows the muscle stretch and reach better to the midline.
Sometimes, additional component separation is needed to get sufficient stretch. This usually involves dividing the attachments of one of the oblique muscles. There are three layers of oblique muscles that wrap around the sides of the abdomen. They extend from the muscles around the spine, the ribs, and the pelvis, and attach to the fascia around the rectus muscles. Practically speaking, it is possible to detach either the outer oblique muscle or the inner oblique muscle. The outermost oblique muscle is called the external oblique muscle and separating this layer is called an external oblique release. The innermost oblique muscle is called the transversus abdominis muscle and separating this layer is called a transversus abdominis release. Each type of release has its advantages and disadvantages.
This decision-making must be individualized to each patient.
It is important to note that performing component separation in abdominal wall reconstruction is a one-shot opportunity. This cannot be repeated in the future. Therefore, preoperative preparation is incredibly important. If you have a large hernia that requires the added morbidity and complexity of abdominal wall reconstruction to repair, it is vitally important that we do everything possible to be sure that we have given you the best chance for success.
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