What are the steps for hernia surgery with component separation?

Steps for Hernia Surgery with Component Separation (TAR)

The transversus abdominis release (TAR) technique is the preferred approach for complex ventral hernia repair, offering wide mesh reinforcement and functional abdominal wall reconstruction with good outcomes. 1

Preoperative Preparation

• Optimize modifiable risk factors:
  • Smoking cessation
  • Diabetes control (HbA1C <7%)
  • Weight management (BMI <40 kg/m²) 2
• Consider preoperative botulinum toxin A injections into lateral abdominal muscles for complex cases to increase abdominal volume and lengthen retracted muscles 3
• For unstable patients or those with severe sepsis/septic shock, open management is recommended 2
• Immediate surgical exploration via laparotomy is necessary when signs of peritonitis, hemodynamic instability, or evidence of bowel ischemia/perforation are present 2

Surgical Approach Selection

• Laparoscopic approach: Preferred for stable patients without signs of strangulation or peritonitis 2
• Open approach: Recommended for patients with hemodynamic instability or when direct visualization of the defect and assessment of potential bowel compromise is needed 2
• Robotic TAR (rTAR) shows lower complication rates (9.3% vs 20.7%), shorter hospital stays, but longer operative times compared to open TAR 4

TAR Surgical Technique Steps

1. Access and Initial Assessment:

   • Create pneumoperitoneum and place trocars
   • Perform adhesiolysis from the anterior abdominal wall 5
   • Assess hernia defect size and contents

2. Posterior Component Separation:

   • Incise the posterior rectus sheath
   • Develop the retrorectus plane 1

3. Transversus Abdominis Release:

   • Release the transversus abdominis muscle medial to the linea semilunaris
   • This creates a broad plane extending from the diaphragm superiorly to the space of Retzius inferiorly, and laterally to the retroperitoneum
   • This technique preserves neurovascular bundles innervating the medial abdominal wall 1

4. Midline Reconstruction:

   • Reconstruct the linea alba to create a functional abdominal wall 1, 5

5. Mesh Placement:

   • Place mesh in a sublay fashion above the posterior layer 1
   • For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential
   • Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates and higher resistance to infections 2
   • Ensure at least 3 cm overlap of the defect 2

6. Closure:

   • Close fascial defects
   • Close skin incisions

Special Considerations

• For laparoscopic TAR, expect longer operating times (median 313 min) but shorter hospital stays (median 4 days) 5
• Patients on antiplatelet therapy: Single aspirin therapy can be safely continued preoperatively for laparoscopic hernia repair without increased bleeding risk 6
• Caution with heparin bridging or direct oral anticoagulant replacement, which are independent risk factors for postoperative bleeding 6
• For pregnant women with hernias: emergency repair if incarcerated/strangulated, elective repair if symptomatic, postpone repair for asymptomatic hernias until after childbirth 2

Postoperative Management

• Implement multimodal analgesic regimen to minimize opioid use:
  • Non-opioid medications as first-line (acetaminophen, NSAIDs)
  • Regional or neuraxial anesthetic techniques 2
• Early mobilization
• Monitor for complications:
  • Hematoma (1.6-1.86%)
  • Seroma (0.4%)
  • Wound infection (0.4-1.6%)
  • Chronic pain 2

TAR has shown promising results with follow-up periods of 2-18 months without recurrence in initial studies 1, making it an excellent technique for complex hernia repairs when performed by experienced surgeons.