As the prevalence of ventral hernias increases, so too does the complexity of their repair, particularly in the 20%–54% that recur. In developed countries, ventral hernia repair costs are estimated to exceed 3 billion annually 1. Abdominal wall reconstruction has evolved into a distinct subspecialty, with modern techniques relying on a clear understanding of anatomical abdominal wall planes 2. The two Frenchman, Jean Rives and Rene Stoppa, are credited for independently describing retromuscular and preperitoneal mesh repair of ventral hernias respectively in the 1960's 3. These principles were further advanced by the description of posterior component separation with transversus abdominis muscle release (TAR), which was described by Novitsky et al. 4 in 2012. Most modern hernia specialists confidently rely on a combination or modification of these three techniques, whether open or minimally invasive, for abdominal wall reconstruction. For large, complex, or recurrent ventral hernias in the presence of mesh, or those with significant loss of domain, we employ a novel transversalis fascial repair. This technique involves precise dissection of the posterior rectus sheath into its constituent lamellae near the midline, allowing mesh placement posterior to the posterior lamella of the internal oblique muscle but anterior to the transversalis fascia, rather than immediately preperitoneal (Figure 1). While this shares anatomical continuity with the plane developed following TAR, it avoids division of the transversus abdominis muscle. By enabling extensive cranio-caudal and lateral mesh coverage, this approach aims to combine the durability of established sublay repairs with preservation of posterior abdominal wall musculature. All patients receive 300 units of botulinum toxin A injection into the lateral abdominal wall musculature 4 weeks prior to surgical repair. Under general anaesthetic in the supine position, a midline incision is performed and dissection deepened to avoid breach in the hernia sac while defining the neck. Midline incision through the anterior sheath is performed below the arcuate line to enter the preperitoneal/retropubic space, avoiding entry into the peritoneal cavity. A combination of blunt and sharp dissection is used to develop this space bilaterally to ensure the rectus muscle and inferior epigastric vessels remain anterior. This is the same plane used for Rives-Stoppa repairs. The posterior rectus sheath is identified above the arcuate line and incised 0. 5 cm from the midline to develop the retrorectus plane superiorly along the entire length of the abdominal wall. Close to the midline edge of the posterior rectus sheath, a No. 10 scalpel blade on a Barron handle is used to sharply incise the sheath to split the posterior lamella of the internal oblique from the transversalis fascia. This is a technically demanding step as incisions that are too deep, or reliance on diathermy, will pierce the entire posterior sheath and/or peritoneum. With further sharp dissection using Snowden-Pencer Metzenbaum serrated scissors, this transversalis fascial plane is developed laterally along the entire length of the posterior sheath. At the superior end of the posterior sheath, transversalis muscle fibres are well defined and should be bluntly dissected anteriorly along the dissection plane. At the midline and lower aspects of the wound, the transversalis muscle fibres are less prominent and more aponeurotic than muscle. Below the arcuate line, dissection in this plane opens into the retropubic space; laterally, Gerota's fascia will be encountered which allows for wide coverage. The hernia sac is next reduced, and any inadvertent peritoneal breaches should be suture repaired with absorbable suture to protect bowel. Surgeon preference guides mesh selection; we opt for a lightweight polypropylene. Wide coverage of the entire abdominal wall is possible from xiphisternum to pubic symphysis and laterally to the flanks. Tacking with 2–0 nonabsorbable sutures to the pubic tubercle and xiphisternum is advised. Retromuscular suction drains are placed on either side. The anterior sheath is next closed with 1 polydioxanone using the Smead-Jones technique, and skin closure with monocryl. In our unit's experience of over 50 cases, the combination of botulinum toxin with wide mesh coverage offers robust long-term repair in these complex patients. Limitations of this repair include the technical difficulty as it requires precise identification of fascial planes. In the unlikely event that the correct transversalis fascial plane cannot be safely developed, a retrorectus repair with formal TAR or an intraperitoneal repair may be considered. Andrew Gilmore: supervision. Ernest Cheng: project administration, writing – review and editing. Mina Sarofim: conceptualization, visualization, writing – review and editing. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australasian University Librarians The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Sarofim et al. (Mon,) studied this question.