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Endoscopic Components Separation and Seroma Management. Gina L. Adrales MD, MPH, FACS Associate Professor Dartmouth Medical School Dartmouth-Hitchcock Medical Center. Endoscopic Components Separation Technique (CST).
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Endoscopic Components Separation andSeroma Management Gina L. Adrales MD, MPH, FACS Associate Professor Dartmouth Medical School Dartmouth-Hitchcock Medical Center
Endoscopic Components Separation Technique (CST) • Combines technology and technique learned from minimal access surgery with open (or increasingly laparoscopic) complex hernia repair • Aimed to reduce the morbidity associated with the large skin flaps of the open approach to Components Separation
Endoscopic CST • Lowe described an endoscopically assisted CST for abdominal wall closure in 2000 • Rosen et al 2007 • Porcine model endoscopic CST-achieved 86% advancement of open approach with reduction of wound complications to 14% Lowe JB et al. Plast Reconstr Surg 2000;105:720-30 Rosen MJ et al. Am J surg 2007;194:385-9
Endoscopic CST • University of KY group presented retrospective series of open CST to endoscopic CST • Lower wound complications in endo group (9 v 57%) • Very short follow up of mean 4 months (1-12 m), no recurrences
Endoscopic CST:Applicability • Same indications as open CST • Do not use when plan to excise scar widely/laterally
Endoscopic CST:Technique • Arms tucked • Subcostal cutdown small transverse incision in the far lateral abdomen to ensure away from semilunar line • Exposure of the external oblique aponeurosis
Endoscopic CSTTechnique • Grasp external oblique fascia and elevate and incise • Develop bluntly the space between the external and internal • Place balloon dissector and inflate with camera visualization
Endoscopic CSTTechnique • Additional one to two 5mm ports lateral to linea semilunaris • Exposure of the external oblique aponeurosis lateral and parallel to the linea semilunaris • Vertical incision of external oblique aponeurosis to inguinal ligament and superiorly to costal margin
Endoscopic CSTTechnique • For full release • Divide muscular portion above costal margin • Release Scarpa’s fascia • Careful hemostasis is needed due to limited exposure • Must stay well lateral to semilunar line to avoid disruption of the internal oblique aponeurosis and lateral herniation
Seroma prevention and management • Careful tissue handling • Avoidance of wide thermal injury • Preservation of perforating vessels • Prevention techniques • Excision of hernia sac, cautery of sac • Closure of dead space • Talc instillation’ • External pressure
Seroma prevention and management • Open repair • Suprafascial drain placement, continued until low output • Laparoscopic repair • Various techniques have been tried as previously outlined with sac excision, cautery of sac • Inevitable seroma formation and expected to be temporary so patient education is key • Abdominal binder
Seroma prevention and management • Longstanding seroma • Image-guided drainage • May require laparoscopic drainage and resection of pseudocapsule