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Yuri W. Novitsky - One of the best experts on this subject based on the ideXlab platform.
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Evaluation of anterior versus posterior component separation for hernia repair in a cadaveric model
Surgical Endoscopy, 2019Co-Authors: Arnab Majumder, Luis A. Martin-del-campo, Heidi J. Miller, Dina Podolsky, Hooman Soltanian, Yuri W. NovitskyAbstract:Background Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via Transversus Abdominis Muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model. Methods Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), Transversus Abdominis Muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann–Whitney U test. Values are represented as average myofascial medialization in centimeters. Results Following MLL an average of 5.0 ± 0.9 cm (range 3.4–6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3–10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6–12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535. Conclusions Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. Graphic Abstract
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The Transversus Abdominis Muscle Release (TAR) Procedure
The Art of Hernia Surgery, 2018Co-Authors: Luis A. Martin-del-campo, Yuri W. NovitskyAbstract:The retromuscular repair described by Rives and Stoppa can frequently meet the goals of a hernia repair. Nevertheless, retrorectus-only repair offers restricted myofascial medial advancement and a limited area for mesh placement, which are critical in complex ventral hernias. During recent years, Transversus Abdominis Muscle release (TAR) has gained popularity because it facilitates medial myofascial advancement without creation of large skin flaps or damage to the neurovascular supply of the rectus Abdominis Muscle and retromuscular reinforcement of the visceral sac.
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Abdominal Closure after TRAM Flap Breast Reconstruction with Transversus Abdominis Muscle Release and Mesh.
Plastic and reconstructive surgery. Global open, 2016Co-Authors: Antonio Espinosa-de-los-monteros, Héctor Avendaño-peza, Yuri W. NovitskyAbstract:In the setting of breast reconstruction, pedicled transverse rectus Abdominis Muscle (TRAM) flap is known to be associated with abdominal bulging and ventral hernias in up to 63% and 18% of patients, respectively.1 To overcome this high donor-area morbidity, one option is to perform deep inferior epigastric perforator flaps, for which reported rates of abdominal bulging and ventral hernias are 7% to 9%.1 Another option involves the addition of mesh during abdominal wall closure, for which rates of abdominal bulging and ventral hernias are 2% to 6% and 1% to 2%, respectively.2–4 Cost utility of mesh reinforcement has been well established.5 Traditionally, meshes are placed as a subcutaneous onlay or as an inlay.1 However, both techniques have limitations and are associated with frequent wound morbidity.6–9 Alternatively, in the setting of abdominal wall reconstruction for ventral hernias, retromuscular sublay repairs are shown to have superior morbidity profiles and lower hernia recurrence rates.6,7,10–13 A recently described posterior components separation (PCS) with Transversus Abdominis Muscle release (TAR) has been gaining popularity among the surgical community worldwide for the treatment of complex ventral hernias.14–18 Advantages of this method include the creation of a well-vascularized retromuscular plane for sublay mesh placement and significant myofascial medialization.14
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Posterior Component Separation Via Transversus Abdominis Muscle Release: The TAR Procedure
Hernia Surgery, 2016Co-Authors: Yuri W. NovitskyAbstract:Evolution of hernia surgery has led to popularization of a variety of reconstructive techniques. The traditional approach described by Ramirez involves creation of large skin flaps and associated significant wound morbidity. Minimally invasive modifications are known to reduce skin flaps and wound complications, but limit mesh placement to intraperitoneal underlay in the vast majority of cases. Classic Rives-Stoppa retrorectus repairs provide durable outcomes with low morbidity, but provide for limited medial myofascial advancement and insufficient sublay space for sufficient overlap of the visceral sac in many hernias. To address the shortfalls of the traditional retromuscular repairs, I have recently developed another novel technique of posterior component separation using Transversus Abdominis Muscle release (TAR). This modification allows for significant myofascial cutaneous advancement, wide lateral dissection, preservation of the neurovascular supply of the rectus Abdominis Muscle, and provides a large space for mesh sublay. Most importantly, TAR allows for medialization of the abdominal wall components without raising lipocutaneous flaps. This chapter will describe the history of TAR, its anatomic and physiologic basis, indications/limitations, detailed technical considerations as well as a variety of clinical outcomes.
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Outcomes of Posterior Component Separation with Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement
Annals of surgery, 2016Co-Authors: Yuri W. Novitsky, Mojtaba Fayezizadeh, Arnab Majumder, Ruel Neupane, Heidi L. Elliott, Sean B. OrensteinAbstract:Objective:To evaluate the safety and efficacy of Transversus Abdominis Muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients.Background:Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popula
Michael J. Rosen - One of the best experts on this subject based on the ideXlab platform.
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Transversus Abdominis Muscle release for repair of complex incisional hernias in kidney transplant recipients
American journal of surgery, 2015Co-Authors: Clayton C. Petro, Sean B. Orenstein, Michael J. Rosen, Cory N. Criss, Edmund Q. Sanchez, Kenneth J. Woodside, Yuri W. NovitskyAbstract:Abstract Background Incisional hernias in kidney transplant recipients (KTRs) can be complex because of adjacent bony structures, proximity of the allograft/transplant ureter, and context of immunosuppression. We hypothesized that our novel posterior component separation with Transversus Abdominis Muscle release (TAR) and retromuscular mesh reinforcement offers a safe and durable repair. Methods KTRs with incisional hernias repaired using the aforementioned technique were identified within our prospective database (2007 to 2013) and analyzed. Results Eleven patients were identified (median age 49 years, body mass index 32). The median hernia size was 30 cm 2 (range 88 to 1,040 cm 2 ) and 8 of the 11 patients were recurrent. Intraoperative morbidity consisted of one transplant ureter injury repaired primarily over a stent. Postoperative morbidity consisted of 2 superficial surgical site infections that resolved and 1 readmission for a blood transfusion. There were no instances of mesh infection, explantation, graft loss, or graft dysfunction. With a median follow-up of 12 months (range 3 to 69), 1 (9%) lateral recurrence has been documented. Conclusions For complex incisional hernias in KTRs, TAR is associated with low perioperative morbidity and durable repair.
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Posterior component separation and Transversus Abdominis Muscle release for complex incisional hernia repair in patients with a history of an open abdomen.
The journal of trauma and acute care surgery, 2015Co-Authors: Clayton C. Petro, Yuri W. Novitsky, John J. Como, Sydney Yee, Ajita S. Prabhu, Michael J. RosenAbstract:BACKGROUNDThe best reconstructive approach for large fascial defects precipitated from a previous open abdomen has not been elucidated to date. We use a posterior component separation with Transversus Abdominis Muscle release (TAR) in this scenario.METHODSPatients with a history of an open abdomen w
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Posterior component separation with Transversus Abdominis release successfully addresses recurrent ventral hernias following anterior component separation.
Hernia : the journal of hernias and abdominal wall surgery, 2014Co-Authors: Eric M. Pauli, Yuri W. Novitsky, Clayton C. Petro, J. Wang, Ryan M. Juza, Michael J. RosenAbstract:Purpose Anterior component separation (ACS) with external oblique release for ventral hernia repair has a recurrence rate up to 32 %. Hernia recurrence after prior ACS represents a complex surgical challenge. In this context, we report our experience utilizing posterior component separation with Transversus Abdominis Muscle release (PCS/TAR) and retromuscular mesh reinforcement.
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Transversus Abdominis Muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction.
American journal of surgery, 2012Co-Authors: Yuri W. Novitsky, Heidi L. Elliott, Sean B. Orenstein, Michael J. RosenAbstract:Abstract Background Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of Transversus Abdominis Muscle release (TAR) for posterior component separation during major abdominal wall reconstructions. Methods Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5–1 cm underlying medial to the linea semilunaris to expose the medial edge of the Transversus Abdominis Muscle. The Muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh. Results Between December 2006 and December 2009, we have used this technique successfully in 42 patients with massive ventral defects. Thirty-two (76.2%) patients had recurrent hernias. The average mesh size used was 1,201 ± 820 cm2 (range, 600–2,700). Ten (23.8%) patients developed various wound complications requiring reoperation/debridement in 3 patients. At a median follow-up period of 26.1 months, there have been 2 (4.7%) recurrences. Conclusions Our novel technique for posterior component separation was associated with a low perioperative morbidity and a low recurrence rate. Overall, Transversus Abdominis Muscle release may be an important addition to the armamentarium of surgeons undertaking major abdominal wall reconstructions.
Annelies Poolgoudzwaard - One of the best experts on this subject based on the ideXlab platform.
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the influence of simulated Transversus Abdominis Muscle force on sacroiliac joint flexibility during asymmetric moment application to the pelvis
Clinical Biomechanics, 2015Co-Authors: Rafael Gnat, Kees Spoor, Annelies PoolgoudzwaardAbstract:AbstractBACKGROUND:The role of so-called local Muscle system in motor control of the lower back and pelvis is a subject of ongoing debate. Prevailing beliefs in stabilizing function of this system were recently challenged. This study investigated the impact of in vitro simulated force of transversely oriented fibres of the Transversus Abdominis Muscle (a part of the local system) on flexibility of the sacroiliac joint during asymmetric moment application to the pelvis.METHODS:In 8 embalmed specimens an incremental moment was applied in the sagittal plane to one innominate with respect to the fixed contralateral innominate. Ranges of motion of the sacroiliac joint were recorded using the Vicon Motion Capture System. Load-deformation curves were plotted and flexibility of the sacroiliac joint was calculated separately for anterior and posterior rotations of the innominate, with and without simulated Muscle force.FINDINGS:Flexibility of the sacroiliac joint was significantly bigger during anterior rotation of the innominate, as compared to posterior rotation (Anova P<0.05). After application of simulated force of Transversus Abdominis, flexibility of the joint did not change both during anterior and posterior rotations of the innominate.INTERPRETATION:A lack of a stiffening effect of simulated Transversus Abdominis force on the sacroiliac joint was demonstrated. Earlier hypotheses suggesting a stiffening influence of this Muscle on the pelvis cannot be confirmed. Consistent with previous findings smaller flexibility of the joint recorded during posterior rotation of the innominate may be of clinical importance for physio- and manual therapists. However, major limitations of the study should be acknowledged: in vitro conditions and simulation of only solitary Muscle force.
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simulated Transversus Abdominis Muscle force does not increase stiffness of the pubic symphysis and innominate bone an in vitro study
Clinical Biomechanics, 2013Co-Authors: Rafael Gnat, Kees Spoor, Annelies PoolgoudzwaardAbstract:Abstract Background The Transversus Abdominis Muscle is thought to exert a stiffening effect on the sacroiliac joints. However, it is unknown whether this Muscle is capable of increasing pubic symphysis and innominate bone stiffness during load exerted on the pelvis. The objective of this study is to investigate whether in vitro simulated force of transversely oriented fibres of the Transversus Abdominis increases stiffness of the pubic symphysis and innominate bone. Methods In 15 embalmed specimens an incremental moment was applied in the sagittal plane to one innominate with respect to the fixated contralateral innominate. For pubic symphysis motion and innominate bone deformation load–deformation curves were plotted and slopes of adjusted linear regression lines were calculated. The slopes are considered to be a measure of pubic symphysis and innominate bone stiffness. Slopes were tested for significant differences before and after simulation of the Transversus Abdominis force. Findings Stiffness of pubic symphysis and innominate bone does not change under influence of simulated force of the Transversus Abdominis. For pubic symphysis, the slope of the regression line hardly changes, from 0.0341 mm/Nm (SD 0.0277) before Transversus Abdominis force simulation to 0.0342 mm/Nm (SD 0.0273) during simulation. For innominate bone, the mean slope increases minimally, from 0.0368 mm/Nm (SD 0.0369) to 0.0413 mm/Nm (SD 0.0395), respectively. Interpretation Simulation of the force of a single Muscle – Transversus Abdominis – does not increase stiffness of the pubic symphysis and innominate bone. The hypothesized stiffening influence of the Transversus Abdominis on the pelvic ring was not confirmed in vitro.
Conor P. Delaney - One of the best experts on this subject based on the ideXlab platform.
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Laparoscopic-guided Transversus Abdominis plane block for colorectal surgery.
Diseases of the colon and rectum, 2013Co-Authors: Joanne Favuzza, Conor P. DelaneyAbstract:The Transversus Abdominis plane block has been used as a component of postoperative analgesia after hysterectomy and open abdominal surgery. This block involves the injection of anesthetic between the internal oblique and Transversus Abdominis Muscles. We demonstrate an improved method by the use of laparoscopic guidance for Transversus Abdominis plane blocks.Transversus Abdominis plane blocks are performed at the conclusion of an elective laparoscopic procedure by an experienced colorectal surgeon. With the use of direct visualization with a laparoscope, a Braun Stimuplex A insulated needle is passed through the skin at the level of the midaxillary line, midway between the iliac crest and the costal margin. The needle is inserted further until 2 distinct "pops" are felt, indicating the correct needle position between the internal oblique and Transversus Abdominis Muscle. The laparoscope confirms a bulge, which signifies the injectate covered by the Transversus Abdominis Muscle. The procedure is performed at a second injection site on the same side and bilaterally.The Transversus Abdominis plane block is useful as an adjunct to reduce postoperative analgesia in patients undergoing laparoscopic colorectal surgery. Our method for Transversus Abdominis plane blocks with the use of laparoscopy is easily performed at the conclusion of any laparoscopic procedure. Prospective randomized trials are necessary to assess the significance of these blocks in postoperative pain control, length of stay, and cost benefit.
Moritz A. Konerding - One of the best experts on this subject based on the ideXlab platform.
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The anatomic basis of the Transversus and rectus Abdominis musculoperitoneal (TRAMP) composite flap
Hernia, 1999Co-Authors: Andreas Gaumann, M. Hoeckel, Moritz A. KonerdingAbstract:The aim of this study was to provide an anatomic basis for the Transversus and rectus Abdominis musculoperitoneal (TRAMP) flap, recently successfully introduced for vulvovaginal reconstruction. In 25 cadavers the width and length of the portions of rectus and Transversus Abdominis Muscles suitable for the TRAMP flap as well as the length and diameter of the inferior epigastric artery were assessed. The mean length of the rectus Abdominis Muscle was 32.42±0.48 cm and its width 6.15±0.12 cm. The suitable part of the Transversus Abdominis Muscle measured 19.08±0.3 cm mean length with a mean width of 18.62±0.19 cm. No significant left-right differences were observed. The resulting area of the rectus Abdominis Muscle was 197.78±5.09 cm2 and that of the Transversus Abdominis Muscle 356.20±7.87 cm2. The mean extramuscular course of the deep inferior epigastric artery (DIEA) was 4.97±0.09 cm with a mean diameter of 0.29±0.01 cm. This offers numerous possibilities for an anastomosis of the DIEA when the TRAMP flap is desired as a free flap. Because of its dimensions and flexibility the TRAMP offers several possibilities in reconstructive surgery.
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The vascular anatomy of the inner anterior abdominal wall with special reference to the Transversus and rectus Abdominis musculoperitoneal (TRAMP) composite flap for vaginal reconstruction.
Plastic and reconstructive surgery, 1997Co-Authors: Moritz A. Konerding, Andreas Gaumann, Anne Shumsky, Karlheinz Schlenger, Michael HöckelAbstract:This study was designed to clarify the vascularization of the inner anterior abdominal wall with respect to the novel Transversus and rectus Abdominis musculoperitoneal (TRAMP) flap, which was introduced recently for vaginal reconstruction. A series of human cadavers was injected with a lead oxide-gelatine mixture by means of the deep inferior epigastric artery and subsequently dissected and examined by radiography. In all cases we found that the blood supply of the entire rectus Abdominis Muscle from the symphysis to the costal arch and that of the medial 10 to 15 cm of the Transversus Abdominis Muscle, as well as the underlying peritoneum, was provided by several branches of the deep inferior epigastric artery. "Choke" arteries to the superior epigastric artery and also to the intercostal arteries (X, XI, and XII) have been shown to be common features. From the anatomic point of view, these observations offer the possibility of mobilizing large parts of the Transversus Abdominis Muscle together with the rectus Abdominis Muscle for reconstructive surgery.
