What is the recommended approach for Posterior Component Separation (PTEP) repair of central hernias?

Posterior Component Separation (PTEP) for Central Hernias

For central hernia repair, posterior component separation with transversus abdominis muscle release (TAR) is the recommended approach, allowing placement of a large mesh in the retromuscular space with wide overlap of the defect.

Surgical Technique for PTEP/TAR

Approach Selection

• Laparoscopic approach is preferred for stable patients without signs of strangulation or peritonitis 1
• Open approach is recommended for unstable patients or those with suspected bowel compromise 2

Key Steps in the TAR Procedure

1. Posterior rectus sheath incision to access the retrorectus plane
2. Release of transversus abdominis muscle medial to the linea semilunaris
3. Development of broad plane that extends:
   • Superiorly to the central tendon of the diaphragm
   • Inferiorly to the space of Retzius
   • Laterally to the retroperitoneum
4. Mesh placement in sublay fashion above the posterior layer
5. Reconstruction of linea alba when possible to create a functional abdominal wall 3

Mesh Selection and Placement

• For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential 1
• Biosynthetic, biologic, or composite meshes are preferred due to:
  • Lower recurrence rates
  • Higher resistance to infections
  • Lower risk of displacement 1
• Mesh should have at least 3 cm overlap of the defect on all sides 2

Advantages of PTEP/TAR

• Preserves neurovascular bundles innervating the medial abdominal wall
• Creates a wide plane for mesh placement
• Allows for functional reconstruction of the abdominal wall
• Achieves low recurrence rates (reported as <10% in complex cases) 4
• Provides durable repair for large incisional hernias 3

Learning Curve Considerations

• TAR has a learning curve that requires proper training
• Surgeons should understand the detailed anatomy of the extraperitoneal space
• Consider performing open preperitoneal procedures first to master the anatomy before attempting laparoscopic approaches 5, 6

Special Considerations

• For contaminated fields, biological mesh may be considered, though recent evidence challenges the notion that synthetic mesh cannot be used in these settings 4
• In unstable patients or those with severe sepsis, open management may be necessary 1
• For patients with oral intake difficulties post-repair, consider gastrostomy or jejunostomy 1

Potential Complications

• Wound complications (reported in approximately 21% of cases) 3
• Seroma formation
• Hematoma
• Infection
• Recurrence

The TAR technique represents an evolution in the management of complex ventral hernias, providing a comprehensive solution that addresses both the functional and anatomical aspects of hernia repair while minimizing recurrence rates.