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Anterior Components Separation (ACS) by Endoscopic Pathway: Alternative Pathway to Approach the Abdominal Wall
Author(s) -
Barros Mirna Duarte,
Roll Sergio,
Nishio Ricardo Tadashi,
Silva Rodrigo Altenfelder,
Ayres Neto Daniel P.,
Mendes Carlos José Lazzarini
Publication year - 2017
Publication title -
the faseb journal
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.709
H-Index - 277
eISSN - 1530-6860
pISSN - 0892-6638
DOI - 10.1096/fasebj.31.1_supplement.735.1
Subject(s) - aponeurosis , abdominal wall , medicine , anatomy , rectus abdominis muscle , fascia , abdomen , umbilicus (mollusc) , cadaver , iliac fossa , surgery
The abdominal wall hernias constitute a great challenge to the surgeon. The Giant, classified with a hernia orifice greater than or equal to 10cm, and the Complex, associated with diseases, infection, digestive or urinary ostomies present complications in the reconstruction of the abdominal wall. Primary closings with sutures, relaxing incisions in aponeuroses, positioning of supraponeurotic, bridge, subaponeurotic and intraperitoneal prosthetics, in addition to the shifting of the wall muscles, by open surgery or laporoscopy (robotic or not), are part of the alternatives for restitutio ad integrum of the wall. Knowledge of the stratigraphy of the wall allowed for the sectioning of muscles and aponeuroses, now called components. The Anterior Components Separation (ACS), described in 1990, is the sectioning of the aponeurosis of the external oblique muscle, parallel to the lateral border of the rectus abdominis muscle, in the craniocaudal direction, which is detached from the internal oblique muscle. For adequate execution of this technique, the lateral detachment of the skin and subcutaneous tissue is extensive, to the point of damaging the perforating vessels and paraumbilical branches of the lower epigastric artery, with ischemia and necrosis of the scar and umbilical region. The advent of video‐assisted procedures promoted access to these anatomical repairs. The objective of this study was to verify the viability of using a cadaver fixed in modified Larsen solution to perform ACS for teaching and training. Method The sectioning of the aponeurosis of the external oblique muscle was performed by means of a transverse incision of 12mm in the left iliac fossa, followed by divulsion by digitoclasy of the space between the internal oblique muscle and aponeurosis of the external, positioning the metal dilator, 10mm in diameter, in this space, promoting blunt dissection in the caudocranial direction to the left costal margin. Next came the insertion of 10‐mm optics at a 30‐degree angle, so as to visualize the aponeurosis and section it with Metzembaum scissors. To verify the efficacy of the procedure, two transversal flaps 25mm in depth were confectioned in order to demonstrate if the aponeurosis had been adequately sectioned or not ( Figure 1). Results The external oblique muscle aponeurosis was adequately sectioned. Discussion and conclusion The ACS, perfectly performed by the video‐assisted method, diminished the quantity of detached and dissected tissue. We believe the procedure to be anatomically safe and that it effectively attends to the sectioning and shifting of the denominated components. The use of a cadaver fixed in modified Larsen solution presents a safe and reliable alternative for the teaching of video‐assisted anatomy and for the training of the resident surgeon.