Relieving the Tension: A Quantitative Assessment of Decreased Force Required for Fascial Closure After Component Separation
Jaime L. Bernstein, MD1, Adam S. Levy, MD2, Karel-Bart Celie, BA1, Jason A. Spector, MD2.
1NewYork-Presbyterian Cornell and Columbia, New York, CT, USA, 2NewYork-Presbyterian Cornell and Columbia, New York, NY, USA.
BACKGROUND:When defects in large ventral hernias are unable to be closed, a component separation (CS) is performed to restore the functionality of the abdominal wall with a tension free closure. Although this technique is widely practiced, almost no clinical literature exists that describes the actual decrease in tension experienced following CS. Quantification of this data could help better predict where excessive tension exists and therefore where the hernia is most likely to recur. Here we aim to develop an accurate and simple technique for intra-operatively measuring the tension of the fascia on closure during hernia repair and how CS reduces this tension at various points.
METHODS:A simple tensiometer was created using a spring with a known recoil constant (k) hooked to a Kocher clamp, attached to a fascial defect and pulled until the fascia reached midline. By measuring the change in length of the spring, the resulting tension on the fascia could be calculated by Hooke's Law (Force=kX; k=spring constant, x=spring displacement). This method was tested on the anterior abdominal fascia of 8 fresh cadaver hemi-abdomens over a range of simulated hernia defects, 0-18cm wide. When the fascia could no longer be approximated to midline, a CS was performed. Measurements were taken in triplicate for each defect size by 2 observers at 3 points along the craniocaudal axis of closure. Measurements were plotted as force versus defect size, resulting in values of tissue stiffness. Reduction in tension following CS was calculated.
RESULTS:A linear relationship between defect size and tension was observed, with mean R2 values of 0.91 (p=0.01; all values significant), demonstrating the precision of this methodology in quantifying fascial tension. Defects ranged from 1-18cm in diameter with average midline force of 36.1N (range 17-48) prior to CS and 8.2N (range 5-11) after CS, a mean 436% decrease (range 327 to 677). CS most significantly reduced the tension at midline by 436%, while reducing that at the superior and inferior aspect by only 284% and 316%, respectively.
CONCLUSIONS:We have developed a low cost, simple, and precise method of assessing fascial tension on the hernia suture line before and after CS. This technique may be rapidly translated into the operating room, requiring only a Kocher and a spring. Quantifying the fascial tension at the time of hernia repair would provide significant objective data to surgeons critical for intraoperative decision-making, leading to improved outcomes and reduced incidence of recurrent hernia.
Back to 2018 Abstracts
