Ramirez component separation technique - general and visceral surgery
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Marking the landmarks
Skin incision
Scar excision
Adhesiolysis
To free any adherent intestinal loops from the abdominal wall, perform lateral adhesiolysis either in parallel with the skin excision or after the latter has been completed. Here, too, the intestinal loops must be spared because otherwise the surgical field will be contaminated, thereby exposing the mesh implant to the risk of infection.
Freeing the posterior rectus sheath/peritoneum
After extensive adhesiolysis free the posterior lamina off the medial margin of the rectus sheath. This dissection runs from the costal arch or far (here 7 cm) along the posterior aspect of the xyphoid process to the retropubic space and should reach the lateral margins of the rectus sheath.
Note: Opening up the retroxyphoidal space requires sharp dissection of the posterior lamina of the rectus sheath off the xyphoid process. On both sides of the white line, the posterior lamina of the rectus sheath must then be transected transversely for 5 cm. This opens up the preperitoneal space. The preperitoneal fatty tissue appears in the “fatty triangle”. Also, see the article of incisional hernia repair with subfascial mesh augmentation
Freeing the subcutis
Incising the aponeurosis of the external oblique
Separating the external oblique muscle
Closing the posterior rectus sheath/peritoneum
Mesh augmentation
Closing the anterior rectus sheath
Wound closure
Applying the NPWT
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