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A Novel Minimally Invasive Technique for Components Separation

Mirzabeigi, Michael N. M.S.; Valerio, Ian L. M.D.; Sbitany, Hani M.D.; Stofman, Guy M. M.D.

Plastic and Reconstructive Surgery: August 2011 - Volume 128 - Issue 2 - p 99e-101e
doi: 10.1097/PRS.0b013e31821ef274
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Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pa. (Mirzabeigi)

Division of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa. (Valerio)

Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pa. (Sbitany)

Division of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa. (Stofman)

Correspondence to Dr. Mirzabeigi, Division of Plastic Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 10 Penn Tower, Philadelphia, Pa. 19104, michael.mirzabeigi@uphs.upenn.edu

Technique presented at the 26th Annual Meeting of the Northeastern Society of Plastic Surgeons, in Charleston, South Carolina, September 23 through 27, 2009, and the 55th Annual Meeting of the Plastic Surgery Research Council, in San Francisco, California, May 22 through 26, 2010.

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Sir:

Local wound complications have been prevalent with the components separation technique for abdominal wall reconstruction. High rates of wound complications are believed to be a direct consequence of the extensive undermining in the suprafascial plane necessary to access the external oblique along its full vertical extent. Wide undermining of the subcutaneous tissue results in ligation of the perforators coursing upward from the underlying deep epigastric system, and those inferiorly from the circumflex iliac and external pudendal arteries. Theoretically, preservation of these perforators, termed zone I and zone II, would increase blood supply to the tenuous midline portion of the abdominal subcutaneous flaps and reduce local wound breakdown.1–3

Using common operating room materials, we propose a minimally invasive technique that provides excellent perforator preservation: following completion of the laparotomy and hernia reduction, 4- to 5-cm transverse incisions are made just lateral to the linea semilunaris within the waistline bilaterally. Dissection is carried down to the suprafascial level, taking care to preserve the ilioinguinal nerve. A 300-cc balloon dissector (Spacemaker; Covidien, Mansfield, Mass.) is then inserted into the subcutaneous plane and advanced superiorly to the costal margin (Fig. 1). Using a lighted fiberoptic retractor, the external oblique is identified under direct visualization (Fig. 2). An extended tip electrocautery device is then used to incise the external oblique fascia longitudinally (1 to 2 cm lateral to the semilunar line), followed by blunt dissection of the avascular intermuscular plane. Bilateral myofasciocutaneous flaps are then created with minimal subcutaneous undermining while achieving preservation of the more medial cutaneous perforators from the deep epigastric arcade. Adequate release of the flaps is achieved to allow for low-tension approximation of the rectus abdominis edges during closure (Table 1).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Table 1

Table 1

Much like the technique described above, Ko et al. elegantly described a large series of patients undergoing perforator-preserving components separation through 6- to 8-cm subcostal transverse incisions.4 Unique to our approach, the advent of the subcutaneous balloon dissector and fiberoptic retractor both allow for a smaller transverse dissection, greater safety with optimized direct visualization, and a more time-efficient approach.3,5

In summary, we present a novel minimally invasive components separation technique that was designed independently by the senior author (G.M.S.). The widely adaptable nature of our approach allows for more surgeons to offer the innumerable benefits of minimally invasive separation of parts following a short learning curve. Our experience suggests that the improved patient outcomes and the time and resources conserved by minimizing local wound morbidity are well worth the added intraoperative measures to preserve the perforators to the abdominal wall.

Michael N. Mirzabeigi, M.S.

Division of Plastic Surgery

University of Pennsylvania

Philadelphia, Pa.

Ian L. Valerio, M.D.

Division of Plastic Surgery

University of Pittsburgh

Pittsburgh, Pa.

Hani Sbitany, M.D.

Division of Plastic Surgery

University of Pennsylvania

Philadelphia, Pa.

Guy M. Stofman, M.D.

Division of Plastic Surgery

University of Pittsburgh

Pittsburgh, Pa.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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REFERENCES

1. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45:612–617.
2. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg. 2002;109:2275–2280; discussion 2281–2282.
3. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE. Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast Reconstr Surg. 2000;105:720–729.
4. Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction: Lessons learned from 200 “components separation” procedures. Arch Surg. 2009;144:1047–1055.
5. Levin LS, Rehnke R, Eubanks S. Endoscopy of the upper extremity. Hand Clin. 1995;11:59–70.

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