Transversus Abdominis Muscle Release (TAR) for Incisional Hernia Repair

Transversus Abdominis Muscle Release (TAR) for Incisional Hernia Repair

What is Incisional Hernia?

An incisional hernia can be understood as a hole in the abdominal wall through which the organs present beneath the skin bulge out. All abdominal surgeries carry some risk of the development of an incisional hernia. 1 in every 3 persons going for an abdominal surgery might develop an incisional hernia. After abdominal surgery, an incisional hernia can develop because of weakening in one or more abdominal muscles produced by the surgical incision. Muscular weakness causes the muscle layers that typically cover, support, and retain the abdominal organs to open up. The abdominal lining or abdominal organs may emerge directly beneath the skin through this hole.

Incisional hernia: What causes it?

Incisional hernias can occur after abdominal surgery. The abdominal wall usually recovers nicely following the surgery. A cut in the abdominal wall, on the other hand, does not always heal as well as it should. This indicates that the abdominal wall is weaker around the scarred area and is unable to withstand the abdominal pressure. The weakening region may allow abdominal tissue, intestines, or organs to protrude.

Incisional hernia: How to Diagnose?

Your doctor can diagnose your incisional hernia with a physical examination, and it doesn't usually require a diagnostic test. During your physical examination, your healthcare practitioner may ask you to cough or exert pressure so they may see the hernia.

Incisional hernias that are smaller may arise and vanish. Coughing, sneezing, straining to have a bowel movement, or moving a heavy object may cause this hernia to only be evident during actions that raise abdominal pressure. Testing may be necessary to discover which organs are impacted if the hernia is severe enough to enable more than the lining of the abdominal cavity to pop through.

Management of Incisional hernia

The best course of treatment for an incisional hernia is determined based on a variety of factors, including your general health, anatomy, location, and extent of the hernia, as well as how much physical activity you will be able to continue. The following options are there for the management of incisional hernia:

Non-surgical therapy: At times your doctor may advise you on a truss. A truss is a garment that is similar to a weight belt or girdle that applies constant pressure to a hernia. Typically, trusses treat symptomatically rather than treating the hernia itself. The only curative treatment is surgical repair.
Surgical therapy: An incisional hernia may need surgical repair to prevent it from getting larger, and to prevent incarceration or strangulation. An incisional hernia may require surgery if:

It continues to enlarge over time
It is a very large
It is cosmetically unappealing
No matter how relaxed or how long you lie, the bulge remains
The hernia causes pain

The surgical repair technique may be divided into two types depending upon the size, complexity, and chances of recurrence two types

Simple or convention technique: In this surgical procedure, the surgeon makes an incision in the abdomen above the hernia, pushes any protruding intestine back into the abdomen, and repairs the opening in the muscle wall. For large defects, simple suturing might not be adequate. Hernias are closed with mesh grafts and the hole is covered with a mesh graft in such cases. The mesh aid in reinforcing the weaker area and prevents the hernia from returning. Once the mesh is in place or the muscle has been sewn, the skin incision is closed. Dissolvable sutures are commonly used to seal the wound.

Limitation: The most suitable position for mesh placement is the retromuscular space. In regards to retromuscular rives mesh implantation, one of its major disadvantages is that it is limited to the rectus compartment. In cases of excessively large hernias and abdominal wall defects, mesh confinement to the rectus compartment can be accompanied by insufficient mesh overlap and defects that are not bridged, which increases the risk of recurrence. Sometimes when this approach is extended to the lateral sides it may result in lead an injury to the segmental nerves of the rectus abdominis muscle.

Advanced surgical techniques: There are several cases where a simple conventional technique is not a viable option. To attempt an incisional hernia repair in such cases several advanced techniques and approaches have been advised. The most common of these is a component separation technique (CST). With time this has been advanced to component separation technique with Transversus Abdominis Muscle Release. This is the most advanced technology that offers several advantages over conventional techniques in the management of complex incisional hernias.

Transversus Abdominis Muscle Release (TAR) For Incisional Hernia Repair

The concept of component separation technique (CST) for the treatment of very large primary and incisional abdominal wall hernias was developed because the traditional suture and mesh techniques without relaxing the musculofascial flaps lead to unfavourable results. TAR is a novel technique of abdominal wall reconstruction which is a modification of a posterior component separation for the repair of complex incisional hernia.

Transversus Abdominis Release (TAR) is a newly developed technique used in abdominal wall reconstruction that delivers a lasting solution to various complex incisional hernias. Incisional hernia formations are an ever-increasingly problematic development that presents difficult challenges to the patient and surgeon. While traditional reconstruction treatments typically fail to produce long-lasting results, Transversus Abdominis Release provides a long-lasting, dependable answer to difficult repair. It is the only technique that treats complicated incisional hernias at their source. A midline-long incision to the pubis is done in TAR surgery to open the hernia and liberate its sides. In the closure, a retro-rectus plane is created and the rectus muscle is elevated anteriorly.

Indication of Transversus Abdominis Release (TAR)

Large and complex ventral hernias
Subxiphoid hernias
Parastomal hernia
Flank hernias
Suprapubic hernia
Recurrent hernias

Advantages of Transversus Abdominis Release (TAR)

The use of the Transverse Abdominis Release (TAR) technique has demonstrated several advantages over traditional techniques when addressing complex abdominal deficiencies.

Low perioperative morbidity
Decrease in wound-related complications
Appears to be a safe and effective method for complex incisional hernia repair.
Allows for a safer, more comprehensive repair while maintaining the benefits of an open approach.
Low recurrence rate.
Avoids large skin flaps with damage to perforator vessels, thus reducing the risk of skin necrosis and infection
Allows the closure of abdominal wall defects of up to 20 cm in width
Allows implantation of very large uncoated standard alloplastic meshes in the most suitable retro muscular sublay plane

What are the different ways in which the TAR procedure can be done?

Open Surgical Technique
Laparoscopic TAR
Robotic TAR
e-TEP approach: e-TEP TAR
Unilateral TAR: either Open, Laparoscopic, e-TEP, or Robotic

After TAR Surgery: Things to Remember

While recovering from an incisional hernia repair one should carefully follow these:

Avoid heavy lifting, strenuous exercise, or any activity that strains the abdomen
Stop smoking if applicable, as this can slow healing
Manage excess weight, as this can help reduce pressure on the abdominal wall
Make sure to manage any existing medical conditions, such as diabetes.

Recovery after Transversus Abdominis Release (TAR)

Most persons who have hernia repair surgery can resume normal activities within three weeks of the procedure. The abdomen will be sore during the first week following surgery. Patients who undergo Transverse Abdominis Release (TAR) are off intravenous pain medications by day 2, allowed to go home by day 4, and no longer taking pain medication and performing at their baseline activity level 7 days after surgery. Short-term follow-ups frequently reveal no signs of recurrence or wound complications.

Conclusion

Incisional hernia repair with Transversus Abdominis Release has proven to be an effective means of treating complex abdominal wall defects and has demonstrated the potential to decrease the time that patients stay in the hospital, reduce pain, and facilitate a quick recovery.

Why Medanta – The Medicity?

The mission of Medanta institute of Digestive and Hepatobiliary Sciences is to provide state-of-the-art diagnostic and therapeutic services for patients of digestive, liver and pancreatobiliary diseases. Along with that, we have the finest surgeons and gastroenterologists who provide treatment as well as disease management guidelines to patients suffering with Herni

Dr. Vikas Singhal Senior Consultant