Where is the incision made for a Transverse Abdominis (TA) release?

Incision Location for Transversus Abdominis Release (TAR)

The incision for a Transversus Abdominis Release (TAR) is typically made as a midline laparotomy through the skin, subcutaneous tissue, linea alba, and peritoneum. 1

Anatomical Considerations

The TAR procedure involves several key anatomical planes and structures:

1. Initial Access:

   • The procedure begins with a midline incision that allows access to the retromuscular space
   • This space is then developed laterally to the edge of the rectus sheath 2

2. Key Surgical Steps:

   • The posterior rectus sheath is incised 0.5-1 cm medial to the linea semilunaris
   • This exposes the medial edge of the transversus abdominis muscle
   • The transversus abdominis muscle is then divided, allowing entrance to the space anterior to the transversalis fascia 2

3. Mesh Placement:

   • The posterior rectus fascia is advanced medially
   • Mesh is placed as a sublay (retromuscular position)
   • The linea alba is restored ventral to the mesh 2

Technical Variations

While the standard approach uses a midline incision, there are variations in how the TAR procedure can be performed:

• Open TAR: Traditional approach with midline laparotomy incision
• Laparoscopic TAR: Uses small incisions for trocar placement with transperitoneal approach 3
• Robotic TAR: Similar to laparoscopic but with robotic assistance

Considerations for Complex Cases

In cases of large ventral or incisional hernias where standard TAR may be insufficient:

• The double peritoneal flap-TAR (DPF-TAR) technique may be employed for very large defects
• This modification allows for placement of a retromuscular mesh completely isolated from both the peritoneal cavity and subcutaneous space 4

Outcomes and Complications

When performed correctly, TAR has shown favorable outcomes:

• Studies report recurrence rates as low as 4.7% at 26 months follow-up 2
• Wound complications requiring reoperation occur in approximately 21-24% of cases 5

Important Caveats

• TAR should only be performed by surgeons with expertise in complex abdominal wall reconstruction
• Patient selection and optimization are critical to avoid potentially devastating complications 6
• The procedure requires a thorough understanding of the abdominal wall anatomy, particularly the neurovascular bundles that must be preserved during the release

The midline approach remains the standard for TAR as it provides optimal exposure for the complex dissection required, though minimally invasive approaches are emerging as viable alternatives in selected cases.