Die Komponentenseparation zum Verschluss komplexer Bauchwandhernien: Entwicklung einer Technik von 1990 bis heute

Zusammenfassung

Hintergrund: Die Separation von autologen, funktionell aktiven Komponenten der lateralen Bauchwand zum Verschluss großer Mittelliniendefekte wurde 1990 vorgestellt. Die Originaltechnik der Komponentenseparation (CS) hat seither zahlreiche Veränderungen erfahren. Ziel dieser Arbeit ist es, die wesentlichen Schritte der Weiterentwicklungen zusammenfassend darzustellen. Methode: Gestützt auf eine Literaturanalyse werden die Originaltechnik und ihre Modifikationen hinsichtlich Indikationen, Techniken und Ergebnissen dargestellt und bewertet. Resultate: Die Originaltechnik hat noch einen hohen Stellenwert, weil sie ein hohes Ausmaß zur Medialisierung des Rektusmuskelkomplexes erzielt. Zahlreiche Modifikationen der konventionellen Komponentenseparation mit unterschiedlichen Ergebnissen wurden beschrieben. Ein wesentlicher Entwicklungsschritt war die minimalinvasive anteriore Komponentenseparation mit Ballondilatationstrokaren, wodurch die generell hohe Wundmorbidität gesenkt werden konnte. In letzter Zeit hat sich die modifiziert posteriore Komponentenseparation durch Ablösung des M. transversus abdominis als Weiterentwicklung der Sublay-Technik als vielversprechende Alternative herauskristallisiert. Die einzelnen Techniken werden mit Implantation von synthetischen oder biologischen Netzen in intraperitonealer Onlay-Technik (IPOM), Sublay- oder Onlay-Technik kombiniert, wodurch sich generell die Rezidivraten senken ließen. Schlussfolgerung: Aus heutiger Sicht kann keine allgemeingültige Empfehlung zu einer der zahlreichen Methoden der Komponentenseparation ausgesprochen werden. Die neuen Ansätze der minimalinvasiven Zugänge und der posterioren Separation zielen auf eine Reduzierung der Komplikationen und Rezidivraten ab. Die operative Strategie hängt nach wie vor von der Komplexität des Bauchwanddefekts ab und wird individuell und gegebenenfalls interdisziplinär festgelegt.

Abstract

Background: The separation of autologous and functional active components of the lateral abdominal wall for closing large midline defects was introduced in 1990. The original components separation technique (CS) has undergone numerous modifications. The aim of this work is to summarise the essential steps of the development. Methods: Based on a literature review, the original technique, the modifications and advancements are presented and evaluated regarding indication, techniques and results. Results: The original technique still has a high status, because of the large extent of rectus complex medialisation. Numerous modifications of the anterior conventional component separation with different clinical results were described. The development of a minimally invasive technique with balloon dilatation trocars was an essential step and decreased wound morbidity. The modified posterior component separation by transverse abdominis release currently seems to be an encouraging alternative to be regarded as a widening of the sublay technique. All methods can be combined with implantation of prosthetic or biological implants in intraperitoneal, sublay or onlay technique, whereby the recurrence rate can be decreased. Conclusion: From where we stand today no single technique can generally be recommended. The latest methods aim for decreasing complications and recurrences by means of minimally invasive procedures. The surgical strategy still depends on the complexity and extent of abdominal wall defect and has to be determined according to individual aspects and sometimes requires an interdisciplinary approach.

Schlüsselwörter

Hernie - chirurgische Technik - Allgemeinchirurgie

Key words

hernia - surgical technique - general surgery

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