Journal of Pediatric Surgery (2013) 48, 2525–2529
www.elsevier.com/locate/jpedsurg
Component separation for complex congenital abdominal wall defects: not just for adults anymore Shauna Levy, KuoJen Tsao ⁎, Charles S. Cox Jr., Uma R. Phatak, Kevin P. Lally, Richard J. Andrassy Department of Pediatric Surgery and Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston and The Children's Memorial Hermann Hospital, Houston TX Received 15 March 2013; revised 13 May 2013; accepted 14 May 2013
Key words: Abdominal wall defect; Component separation; Gastroschisis; Omphalocele; Ventral hernia
Abstract Purpose: Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. Methods: After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. Results: Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days–10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3–34 months). Conclusion: CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain. © 2013 Elsevier Inc. All rights reserved.
1. Background Large abdominal wall defects in pediatric patients are a surgical challenge, and they can lead to significant morbidity [1]. There is neither evidence nor consensus indicating which ⁎ Corresponding author. Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, 6431 Fannin St, Suite 5.254, Houston, Texas 77030. Tel.: + 1 713 500 7305; fax: + 1 713 500 7296. E-mail address: [email protected] (K. Tsao). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.05.067
repair technique is superior for repair. Ramirez et al introduced the component separation technique (CST) in 1990 as a ventral hernia repair technique that did not require mesh [2]. CST as it was originally described involves incising the external oblique aponeurosis and releasing the external oblique from the internal oblique. This release leads to improved tissue mobility and decreased tension, making fascial approximation possible after the tissue release [3]. CST is now increasingly used in adults with and without a supportive mesh layer to repair giant ventral hernias with loss of abdominal domain [4]. Despite the increasing utilization
2526
S. Levy et al.
of CST in adults, the use of CST in the pediatric population has only been described by one center [5]. The use of CST has not been described in neonates or in children with abdominal wall defects owing to a cause other than omphalocele. Additionally, CST with mesh has not been described in children. The purpose of this report is to describe our experience with CST including its application as primary treatment for abdominal wall defects in the newborns.
2. Methods 2.1. Study design After IRB approval, we performed a retrospective review of all children who underwent abdominal wall defect repair with CST since we began performing this technique in June 2010. Demographic data, cause of the abdominal wall defect, prior surgery, and comorbidities were reviewed. Operative details including specifics of the CST, use of mesh, and placement of drains were reviewed. The details of the postoperative course were also reviewed post-operative day (POD) of extubation, length of hospital stay (LOS), time to full activity, and complications. Patient outcomes were tracked until most recent clinic appointment or phone call. Prior to abdominal wall defect repair, these patients were evaluated for any comorbidities that could preclude the operation, and the patients were all considered medically stable prior to operative repair.
2.2. Component separation technique The operation begins by excising the hernia sac or any midline scars to enter the abdomen. Entry of the abdomen is followed by a lysis of adhesion to ensure that the abdominal wall is free. Bilateral tissue flaps including skin and subcutaneous tissue are made to expose the external oblique fascia. Tension is created by grasping the fascia with a clamp while counter-tension is created by retraction of the tissue flap as it is dissected off the external oblique. The dissection continues until the external oblique aponeurosis is exposed 1–2 centimeters lateral to the rectus sheath (Fig. 1). Next, the external oblique fascia is incised approximately one centimeter lateral to the rectus muscle, and the external oblique muscle is separated from the internal oblique muscle. The amount of tissue release is increased by extending the incision in the external oblique fascia either superiorly or inferiorly. Thus, the release of the external oblique is carried out to allow the approximation of the midline with minimal to no tension. The same technique is repeated on the contralateral side. After the tissue release, the rectus sheath is approximated and is followed by skin closure. Either onlay or underlay biologic mesh is used to support the midline closure in most of our
Fig. 1 Bilateral tissue flaps (A) are created to expose the external oblique fascia (B) 1–2 centimeters lateral to the rectus sheath. The external oblique fascia is incised (C) approximately one centimeter lateral to the rectus muscle (D) exposing the internal oblique (E).
patients. While both synthetic and biologic mesh are used in adults, only naturally degraded materials such as biologic mesh as well as absorbable suture were utilized in our patient group. Polydioxanone suture (PDS) is used for the fascial closure, and either PDS or vicryl is used to suture the mesh in place. The knots for mesh underlay are placed superficial to the rectus muscle; thus in patients with a thin abdominal wall, these knots can be seen or felt through the skin. Parents and patients are warned about this possibility and the temporary nature of this situation. Subcutaneous drains are placed at the surgeons' discretion to manage seroma formation.
3. Results Between June 2010 and January 2012, nine children with abdominal wall defects that were too large for primary fascial closure underwent repair with CST. This group included two patients with gastroschisis and seven with omphalocele. CST was utilized to primarily repair the original abdominal wall defect in five patients, including three newborns, as well as repair recurrent hernia defects in four patients (Table 1). The median (range) age of the patients was 13 months (5 days–10
CST for complex congenital abdominal wall defects Table 1
2527
Baseline characteristics of CST patients.
Patient #
Gender
Age
Weight (kg)
Original defect
Other congenital anomalies
Prior abdominal surgeries
1 2 3 4 5 6 7 8 9
Male Male Male Female Male Female Female Male Male
7 days 5 days 6 days 13 months 10 months 9 years 7 years 3 years 10 years
3.8 2.1 1.6 9 7.6 22.7 19 12.7 42.7
Omphalocele Gastroschisis Gastroschisis Omphalocele Omphalocele Omphalocele Omphalocele Omphalocele Omphalocele
None Patent foramen ovale/patent ductus arteriosus None Patent ductus arteriosus None None Ventricular septal defect, pulmonary hypertension Patent foramen ovale, pulmonary hypertension Ventricular septal defect, diaphragm eventration, pulmonary insufficiency, pulmonary hypertension
0 0 0 0 0 5 5 2 3
years), and the median (range) patient weight was 9 kg (1.6– 42.7 kg). Mesh was utilized in eight of the patients. The median (range) operative time was 119 minutes (57–192 minutes) (Table 2). The median follow up was 16 months (3–34 months) without any evidence of recurrence (Table 3).
4. Discussion The management of large gastroschisis defects and omphaloceles greater than 5 cm with liver out can be challenging. The optimal timing and method of repair are still unknown for these large abdominal wall defects; thus, many different treatment strategies are utilized [6]. Typically, these patients undergo a staged repair of their abdominal wall defect, which begins with epithelialization for omphalocele patients and reduction of herniated contents with skin closure for gastroschisis patients. These closure options then lead to at least one, if not multiple reoperations to address the fascial defect [7,8]. Most repair techniques for large abdominal wall defects do not allow the approximation of the rectus sheath because of existing visceroabdominal
disproportion and lateral retraction of the rectus muscle, and mesh is frequently used to bridge the fascial defect. Although long term data are sparse, hernia recurrence has been reported in a median 50% (range 0–100%) of children with abdominal wall defects who underwent primary closure with mesh and a median 18% (0–75%) of those who underwent a staged repair [6]. Van Eijck et al presented an alternative technique of utilizing CST as part of a delayed repair for giant omphalocele, and there was no evidence of recurrence in their original series [5]. Additionally, a subset of their patients were reevaluated after a median of 4.5 years and demonstrated similar muscle size and functionality to age matched controls without clinical evidence of recurrence [9]. Our series further supports the use of CST in children, but also demonstrates that this technique is possible for closure of primary defects in newborns and recurrent hernias. Additionally, no evidence of recurrence was seen during our follow up period. Although the original CST was designed to allow fascial closure without utilizing mesh, in the adult literature mesh is commonly used to reinforce the fascial closure with CST. Mesh can alleviate some of the tension that exists with the
Table 2
Operative details of CST patients.
Patient #
Operation performed
Mesh location
Mesh type
Operative time (min)
Drains
1 2 3 4 5
CST with mesh CST with mesh CST CST with mesh CST with mesh, bilateral inguinal hernia repair, circumcision CST with mesh CST with mesh Takedown of previous mesh, CST with mesh CST with mesh
Onlay Onlay None Onlay Underlay
Human acellular dermis Porcine acellular dermis None Porcine acellular dermis Porcine acellular dermis
96 70 57 73 136
0 0 0 2 3
Underlay Onlay Underlay
Porcine acellular dermis Porcine acellular dermis Porcine acellular dermis
192 157 119
Underlay
Porcine acellular dermis
127
6 7 8 9
Drain location
Last drain removal (POD)
Above fascia Above and below fascia
2 7
3 2 1
Above fascia Above fascia Above fascia
25 4 5
2
Above fascia
6
2528 Table 3
S. Levy et al. Post-Operative details of CST patients.
Patient #
Extubation (POD)
Discharge (POD)
Post-operative complications and management
Time to full activity (months)
Follow up duration (months)
1 2 3 4 5
1 3 0 0 4
10 46 35 3 11
Indeterminate Indeterminate Indeterminate 0.5 1
14 27 7 16 15
6
1
7
7
34
7 8 9
0 0 0
4 6 7
None Cellulitis—intravenous antibiotics Stitch abscess—debrided in clinic Seroma—drained in clinic Persistent insufficiency—4 days of post-operative mechanical ventilation and 6 weeks of home oxygen via nasal cannula Infected seroma—long term intravenous antibiotics, multiple irrigations via drains and placement of new drains None None 1. Respiratory distress—short term noninvasive respiratory support and diuresis 2. Skin necrosis—local wound care
3 0.5 2
28 22 3
hernia repair and provide a scaffold for cellular growth [10]. There are no studies that evaluate CST with and without mesh in children; additionally, high quality evaluations of the same topic in adults are also absent. A 2011 Cochrane review showed that in adult patients with large ventral hernia defects that can be closed primarily, the risk of recurrence was decreased when the closure was supported by either mesh onlay or sublay [11]. The benefit of CST is that the release of muscle layers allows an expansion of abdominal wall and closure of the midline fascia. It offers the potential for definitive repair as a newborn as well as avoidance of the morbidity associated with recurrent hernias and multiple operations. CST is also an option for recurrent hernias. However, the mobilization of the skin and subcutaneous tissues that is necessary to perform CST predisposes patients to several complications including surgical site infection, hematoma, and seroma [1,4,12]. De Vries et al showed in a randomized trial of adult patients that despite the complications that can occur with CST, the complications were more extensive after bridged repair of their abdominal wall defect and frequently led to removal of mesh [1]. Although mesh was placed in a majority of the patients in our series, they all received biologic mesh which does not need to be removed in a contaminated field [10]. Another complication that can occur after CST is skin necrosis, which can happen secondary to the extensive dissection which frequently involves the ligation of perforating epigastric vessels [1,5,12]. The risk of skin necrosis is further increased in patients with prior abdominal surgeries, especially those with subcostal incisions because of the pre-existing damage to the abdominal wall vasculature including epigastric vessels. Endoscopic CST is a method described in adult literature to minimize damage to epigastric vessels [13], but this technique has not been described in a pediatric population.
5. Limitations There are several limitations to this study. First, the abdominal wall defect size was not recorded in the medical record; thus, these defects can only be described as large and unable to be closed primarily. Second, the number of patients eligible for CST is small, which limits the study design as well as sample size. Third, the patients selected for this operation were all medically stable, and the results of this study might not be generalizable to a population more severely affected by comorbidities. Fourth, although these patients were followed for a median of 16 months, longer follow up periods will better inform our understanding of long term outcomes and recurrence rates.
6. Conclusion In our patient series, CST was utilized to repair complex abdominal wall defects in children of varying ages including the first description of use in newborns. Functional abdominal wall reconstruction in children is challenging, but our series suggests that CST is a safe and viable option. This technique was utilized in children with and without prior abdominal wall reconstruction attempts. We have not identified any evidence of early recurrence, but further follow up is needed to evaluate for long term durability.
References [1] de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair of giant midline abdominal wall hernias: “Components separation technique” versus prosthetic repair: Interim analysis of a randomized controlled trial. World J Surg 2007;31:756-63.
CST for complex congenital abdominal wall defects [2] Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26. [3] Mazzocchi M, Dessy LA, Ranno R, et al. “Component separation” technique and panniculectomy for repair of incisional hernia. Am J Surg 2011;201:776-83. [4] Tong WM, Hope W, Overby DW, et al. Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation. Ann Plast Surg 2011;66:551-6. [5] van Eijck FC, de Blaauw I, Bleichrodt RP, et al. Closure of giant omphaloceles by the abdominal wall component separation technique in infants. J Pediatr Surg 2008;43:246-50. [6] van Eijck FC, Aronson DA, Hoogeveen YL, et al. Past and current surgical treatment of giant omphalocele: Outcome of a questionnaire sent to authors. J Pediatr Surg 2011;46:482-8. [7] Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal Neonatal Med 2011;16:164-72. [8] Minkes RK. Abdominal Wall Defects. In: Oldham KT, Colombani PM, Foglia RP, et al, editors. Principles and Practice of Pediatric
2529
[9]
[10]
[11]
[12]
[13]
Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 1103-19. van Eijck FC, van Vlimmeren LA, Wijnen RM, et al. Functional, motor developmental, and long-term outcome after the component separation technique in children with giant omphalocele: A case control study. J Pediatr Surg 2013;48:525-32. Shankaran V, Weber DJ, Reed 2nd RL, et al. A review of available prosthetics for ventral hernia repair. Ann Surg 2011;253: 16-26. den Hartog D, Dur AH, Tuinebreijer WE, et al. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008: CD006438. de Vries Reilingh TS, van Goor H, Rosman C, et al. “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg 2003;196:32-7. Giurgius M, Bendure L, Davenport DL, et al. The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 2012;16:47-51.
www.elsevier.com/locate/jpedsurg
Component separation for complex congenital abdominal wall defects: not just for adults anymore Shauna Levy, KuoJen Tsao ⁎, Charles S. Cox Jr., Uma R. Phatak, Kevin P. Lally, Richard J. Andrassy Department of Pediatric Surgery and Center for Surgical Trials and Evidence-based Practice, University of Texas Medical School at Houston and The Children's Memorial Hermann Hospital, Houston TX Received 15 March 2013; revised 13 May 2013; accepted 14 May 2013
Key words: Abdominal wall defect; Component separation; Gastroschisis; Omphalocele; Ventral hernia
Abstract Purpose: Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. Methods: After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. Results: Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days–10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3–34 months). Conclusion: CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain. © 2013 Elsevier Inc. All rights reserved.
1. Background Large abdominal wall defects in pediatric patients are a surgical challenge, and they can lead to significant morbidity [1]. There is neither evidence nor consensus indicating which ⁎ Corresponding author. Department of Pediatric Surgery, The University of Texas School of Medicine at Houston, 6431 Fannin St, Suite 5.254, Houston, Texas 77030. Tel.: + 1 713 500 7305; fax: + 1 713 500 7296. E-mail address: [email protected] (K. Tsao). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.05.067
repair technique is superior for repair. Ramirez et al introduced the component separation technique (CST) in 1990 as a ventral hernia repair technique that did not require mesh [2]. CST as it was originally described involves incising the external oblique aponeurosis and releasing the external oblique from the internal oblique. This release leads to improved tissue mobility and decreased tension, making fascial approximation possible after the tissue release [3]. CST is now increasingly used in adults with and without a supportive mesh layer to repair giant ventral hernias with loss of abdominal domain [4]. Despite the increasing utilization
2526
S. Levy et al.
of CST in adults, the use of CST in the pediatric population has only been described by one center [5]. The use of CST has not been described in neonates or in children with abdominal wall defects owing to a cause other than omphalocele. Additionally, CST with mesh has not been described in children. The purpose of this report is to describe our experience with CST including its application as primary treatment for abdominal wall defects in the newborns.
2. Methods 2.1. Study design After IRB approval, we performed a retrospective review of all children who underwent abdominal wall defect repair with CST since we began performing this technique in June 2010. Demographic data, cause of the abdominal wall defect, prior surgery, and comorbidities were reviewed. Operative details including specifics of the CST, use of mesh, and placement of drains were reviewed. The details of the postoperative course were also reviewed post-operative day (POD) of extubation, length of hospital stay (LOS), time to full activity, and complications. Patient outcomes were tracked until most recent clinic appointment or phone call. Prior to abdominal wall defect repair, these patients were evaluated for any comorbidities that could preclude the operation, and the patients were all considered medically stable prior to operative repair.
2.2. Component separation technique The operation begins by excising the hernia sac or any midline scars to enter the abdomen. Entry of the abdomen is followed by a lysis of adhesion to ensure that the abdominal wall is free. Bilateral tissue flaps including skin and subcutaneous tissue are made to expose the external oblique fascia. Tension is created by grasping the fascia with a clamp while counter-tension is created by retraction of the tissue flap as it is dissected off the external oblique. The dissection continues until the external oblique aponeurosis is exposed 1–2 centimeters lateral to the rectus sheath (Fig. 1). Next, the external oblique fascia is incised approximately one centimeter lateral to the rectus muscle, and the external oblique muscle is separated from the internal oblique muscle. The amount of tissue release is increased by extending the incision in the external oblique fascia either superiorly or inferiorly. Thus, the release of the external oblique is carried out to allow the approximation of the midline with minimal to no tension. The same technique is repeated on the contralateral side. After the tissue release, the rectus sheath is approximated and is followed by skin closure. Either onlay or underlay biologic mesh is used to support the midline closure in most of our
Fig. 1 Bilateral tissue flaps (A) are created to expose the external oblique fascia (B) 1–2 centimeters lateral to the rectus sheath. The external oblique fascia is incised (C) approximately one centimeter lateral to the rectus muscle (D) exposing the internal oblique (E).
patients. While both synthetic and biologic mesh are used in adults, only naturally degraded materials such as biologic mesh as well as absorbable suture were utilized in our patient group. Polydioxanone suture (PDS) is used for the fascial closure, and either PDS or vicryl is used to suture the mesh in place. The knots for mesh underlay are placed superficial to the rectus muscle; thus in patients with a thin abdominal wall, these knots can be seen or felt through the skin. Parents and patients are warned about this possibility and the temporary nature of this situation. Subcutaneous drains are placed at the surgeons' discretion to manage seroma formation.
3. Results Between June 2010 and January 2012, nine children with abdominal wall defects that were too large for primary fascial closure underwent repair with CST. This group included two patients with gastroschisis and seven with omphalocele. CST was utilized to primarily repair the original abdominal wall defect in five patients, including three newborns, as well as repair recurrent hernia defects in four patients (Table 1). The median (range) age of the patients was 13 months (5 days–10
CST for complex congenital abdominal wall defects Table 1
2527
Baseline characteristics of CST patients.
Patient #
Gender
Age
Weight (kg)
Original defect
Other congenital anomalies
Prior abdominal surgeries
1 2 3 4 5 6 7 8 9
Male Male Male Female Male Female Female Male Male
7 days 5 days 6 days 13 months 10 months 9 years 7 years 3 years 10 years
3.8 2.1 1.6 9 7.6 22.7 19 12.7 42.7
Omphalocele Gastroschisis Gastroschisis Omphalocele Omphalocele Omphalocele Omphalocele Omphalocele Omphalocele
None Patent foramen ovale/patent ductus arteriosus None Patent ductus arteriosus None None Ventricular septal defect, pulmonary hypertension Patent foramen ovale, pulmonary hypertension Ventricular septal defect, diaphragm eventration, pulmonary insufficiency, pulmonary hypertension
0 0 0 0 0 5 5 2 3
years), and the median (range) patient weight was 9 kg (1.6– 42.7 kg). Mesh was utilized in eight of the patients. The median (range) operative time was 119 minutes (57–192 minutes) (Table 2). The median follow up was 16 months (3–34 months) without any evidence of recurrence (Table 3).
4. Discussion The management of large gastroschisis defects and omphaloceles greater than 5 cm with liver out can be challenging. The optimal timing and method of repair are still unknown for these large abdominal wall defects; thus, many different treatment strategies are utilized [6]. Typically, these patients undergo a staged repair of their abdominal wall defect, which begins with epithelialization for omphalocele patients and reduction of herniated contents with skin closure for gastroschisis patients. These closure options then lead to at least one, if not multiple reoperations to address the fascial defect [7,8]. Most repair techniques for large abdominal wall defects do not allow the approximation of the rectus sheath because of existing visceroabdominal
disproportion and lateral retraction of the rectus muscle, and mesh is frequently used to bridge the fascial defect. Although long term data are sparse, hernia recurrence has been reported in a median 50% (range 0–100%) of children with abdominal wall defects who underwent primary closure with mesh and a median 18% (0–75%) of those who underwent a staged repair [6]. Van Eijck et al presented an alternative technique of utilizing CST as part of a delayed repair for giant omphalocele, and there was no evidence of recurrence in their original series [5]. Additionally, a subset of their patients were reevaluated after a median of 4.5 years and demonstrated similar muscle size and functionality to age matched controls without clinical evidence of recurrence [9]. Our series further supports the use of CST in children, but also demonstrates that this technique is possible for closure of primary defects in newborns and recurrent hernias. Additionally, no evidence of recurrence was seen during our follow up period. Although the original CST was designed to allow fascial closure without utilizing mesh, in the adult literature mesh is commonly used to reinforce the fascial closure with CST. Mesh can alleviate some of the tension that exists with the
Table 2
Operative details of CST patients.
Patient #
Operation performed
Mesh location
Mesh type
Operative time (min)
Drains
1 2 3 4 5
CST with mesh CST with mesh CST CST with mesh CST with mesh, bilateral inguinal hernia repair, circumcision CST with mesh CST with mesh Takedown of previous mesh, CST with mesh CST with mesh
Onlay Onlay None Onlay Underlay
Human acellular dermis Porcine acellular dermis None Porcine acellular dermis Porcine acellular dermis
96 70 57 73 136
0 0 0 2 3
Underlay Onlay Underlay
Porcine acellular dermis Porcine acellular dermis Porcine acellular dermis
192 157 119
Underlay
Porcine acellular dermis
127
6 7 8 9
Drain location
Last drain removal (POD)
Above fascia Above and below fascia
2 7
3 2 1
Above fascia Above fascia Above fascia
25 4 5
2
Above fascia
6
2528 Table 3
S. Levy et al. Post-Operative details of CST patients.
Patient #
Extubation (POD)
Discharge (POD)
Post-operative complications and management
Time to full activity (months)
Follow up duration (months)
1 2 3 4 5
1 3 0 0 4
10 46 35 3 11
Indeterminate Indeterminate Indeterminate 0.5 1
14 27 7 16 15
6
1
7
7
34
7 8 9
0 0 0
4 6 7
None Cellulitis—intravenous antibiotics Stitch abscess—debrided in clinic Seroma—drained in clinic Persistent insufficiency—4 days of post-operative mechanical ventilation and 6 weeks of home oxygen via nasal cannula Infected seroma—long term intravenous antibiotics, multiple irrigations via drains and placement of new drains None None 1. Respiratory distress—short term noninvasive respiratory support and diuresis 2. Skin necrosis—local wound care
3 0.5 2
28 22 3
hernia repair and provide a scaffold for cellular growth [10]. There are no studies that evaluate CST with and without mesh in children; additionally, high quality evaluations of the same topic in adults are also absent. A 2011 Cochrane review showed that in adult patients with large ventral hernia defects that can be closed primarily, the risk of recurrence was decreased when the closure was supported by either mesh onlay or sublay [11]. The benefit of CST is that the release of muscle layers allows an expansion of abdominal wall and closure of the midline fascia. It offers the potential for definitive repair as a newborn as well as avoidance of the morbidity associated with recurrent hernias and multiple operations. CST is also an option for recurrent hernias. However, the mobilization of the skin and subcutaneous tissues that is necessary to perform CST predisposes patients to several complications including surgical site infection, hematoma, and seroma [1,4,12]. De Vries et al showed in a randomized trial of adult patients that despite the complications that can occur with CST, the complications were more extensive after bridged repair of their abdominal wall defect and frequently led to removal of mesh [1]. Although mesh was placed in a majority of the patients in our series, they all received biologic mesh which does not need to be removed in a contaminated field [10]. Another complication that can occur after CST is skin necrosis, which can happen secondary to the extensive dissection which frequently involves the ligation of perforating epigastric vessels [1,5,12]. The risk of skin necrosis is further increased in patients with prior abdominal surgeries, especially those with subcostal incisions because of the pre-existing damage to the abdominal wall vasculature including epigastric vessels. Endoscopic CST is a method described in adult literature to minimize damage to epigastric vessels [13], but this technique has not been described in a pediatric population.
5. Limitations There are several limitations to this study. First, the abdominal wall defect size was not recorded in the medical record; thus, these defects can only be described as large and unable to be closed primarily. Second, the number of patients eligible for CST is small, which limits the study design as well as sample size. Third, the patients selected for this operation were all medically stable, and the results of this study might not be generalizable to a population more severely affected by comorbidities. Fourth, although these patients were followed for a median of 16 months, longer follow up periods will better inform our understanding of long term outcomes and recurrence rates.
6. Conclusion In our patient series, CST was utilized to repair complex abdominal wall defects in children of varying ages including the first description of use in newborns. Functional abdominal wall reconstruction in children is challenging, but our series suggests that CST is a safe and viable option. This technique was utilized in children with and without prior abdominal wall reconstruction attempts. We have not identified any evidence of early recurrence, but further follow up is needed to evaluate for long term durability.
References [1] de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair of giant midline abdominal wall hernias: “Components separation technique” versus prosthetic repair: Interim analysis of a randomized controlled trial. World J Surg 2007;31:756-63.
CST for complex congenital abdominal wall defects [2] Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26. [3] Mazzocchi M, Dessy LA, Ranno R, et al. “Component separation” technique and panniculectomy for repair of incisional hernia. Am J Surg 2011;201:776-83. [4] Tong WM, Hope W, Overby DW, et al. Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation. Ann Plast Surg 2011;66:551-6. [5] van Eijck FC, de Blaauw I, Bleichrodt RP, et al. Closure of giant omphaloceles by the abdominal wall component separation technique in infants. J Pediatr Surg 2008;43:246-50. [6] van Eijck FC, Aronson DA, Hoogeveen YL, et al. Past and current surgical treatment of giant omphalocele: Outcome of a questionnaire sent to authors. J Pediatr Surg 2011;46:482-8. [7] Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal Neonatal Med 2011;16:164-72. [8] Minkes RK. Abdominal Wall Defects. In: Oldham KT, Colombani PM, Foglia RP, et al, editors. Principles and Practice of Pediatric
2529
[9]
[10]
[11]
[12]
[13]
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