Novitsky 2012 - Am J Surg - TAR Release

Summary

This paper describes a novel surgical technique called transversus abdominis muscle release (TAR) for abdominal wall reconstruction in complex ventral hernia repair. The technique was developed by Dr. Yuri Novitsky and colleagues at the University of Connecticut Health Center and University Hospitals Case Medical Center.

The introduction highlights that ventral hernias after abdominal surgery remain a significant challenge, with high failure rates up to 54% for primary suture repair and 32% for open mesh repair. The Rives-Stoppa retromuscular hernia repair technique places mesh in the space between the posterior rectus fascia and rectus muscle, but is limited to about 6-8cm on either side of the midline. Several modifications have aimed to extend the dissection beyond the lateral border of the rectus sheath for larger hernias.

TAR is an innovative approach for posterior component separation during major abdominal wall reconstructions. It allows for wide lateral dissection while preserving neurovascular bundles. The key steps are:

1. Develop retromuscular space laterally to the edge of the rectus sheath.

2. Incise 0.5-1cm of posterior rectus sheath underlying the linea semilunaris to expose the medial edge of the transversus abdominis muscle.

3. Divide the transversus abdominis muscle along its medial edge, entering the space between transversalis fascia and muscle.

4. Advance the posterior rectus fascia medially.

5. Place mesh as a sublay in the dissected retromuscular space.

6. Close the linea alba to restore anterior rectus sheath over the mesh.

The authors performed a retrospective review of 42 consecutive patients (76% women, mean age 52 years) undergoing TAR between 2006-2009. 76% were recurrent hernias and 71% had incarcerated hernias. Mean OR time was 235 minutes, blood loss 310mL. Mean mesh size was 1201 cm2.

There were no intraoperative complications. Postoperatively, 10 patients had wound complications including 3 major infections requiring debridement. At median 26 months follow up, there were only 2 (4.7%) recurrences.

Advantages of TAR highlighted:

• Significant medial advancement of posterior rectus fascia

• Extensive lateral dissection in the retromuscular space

• Avoids disruption to rectus neurovascular supply

• No skin flaps needed

• Allows large sublay mesh placement

• Restores native abdominal wall anatomy with medialisation of rectus muscles

In conclusion, TAR is a useful addition to the repertoire of plastic surgeons performing complex abdominal wall reconstruction. It allows wide retromuscular dissection for sublay mesh placement while preserving neurovascular bundles and avoiding skin flaps. Early results demonstrate low morbidity and recurrence. Further study will better delineate outcomes and best application of this novel approach.