Teaching Model for Reconstruction of the Abdominal Wall via the Separation of Anterior and Posterior Components Technique
Authors: Barros Mirna Duarte , Roll Sergio , Silva Rodrigo Altenfelder , Mendes Carlos José Lazzarini 
Published: November 2023

Introduction

Hernias in the anterolateral wall of the abdomen, principally the giant ones, with an orifice greater than or equal to 10cm, do not offer the opportunity to be closed primarily by suturing, considering the high rate of recurrence. Tactics such as relaxing incisions in aponeuroses, with or without the interposing of prosthetics, comprise part of the alternatives for the reconstruction of the wall. The detailed anatomical knowledge of the stratigraphy of the abdominal wall allow the surgeon to deconstruct it, to repair defects and to re‐establish the morphofunctional equilibrium. The sectioning of the aponeurosis in the external oblique muscle, parallel to the lateral border of the rectus abdominis muscle, promoting the detachment of the internal oblique muscle, was described in 1990, as the Anterior Components Separation (ACS) and the sectioning of the transversal abdominal muscle, followed by detachment of the transversal fascia, called the Transversus Abdominis Muscle Release (TAR), described in 2012, are alternatives for the reconstruction of the wall. The objective of this study is to present a reproducible teaching method using a cadaver in a structured manner, allowing for the use of a small number of anatomical specimens.

Method

Two cadavers were dissected, preserved in a modified Larsen solution. On the first, we performed: a medial xiphopubic incision to the linea alba and two auxiliary transversal incisions at the xiphoid process and pubic symphysis; subcutaneous detachment of the aponeurosis; sectioning of the aponeurosis of the external oblique m., longitudinally and in parallel with the lateral edge of the rectus abdominis m.; detachment of the external oblique m. from the internal oblique m., so as to slide the musculature, allowing the approach to the medial line (Fig. 1 a, b). On the second, we performed: medial xiphopubic incision, followed by the opening of the linea alba, exposing the rectus abdominis m.; anterior tractioning of the rectus abdominis m., exposing the posterior lamina from its sheath, and the transverse abdominal m. in its supraumbilical portion; sectioning of the transverse abdominal m. from the costal border to the iliac crest, exposing the transversal fascia and retroperitoneum, permitting approach to the medal line (Fig. 1 c, d, e, f, g).

Results

The dissection model provided reproducibility by both techniques of approach to the abdominal wall and permitted the identification of anatomical structures on various stratigraphic planes, as well as the visualization of the anatomical region with its morphology intact.

Discussion and conclusion

The ACS and the TAR were performed perfectly, so that the surgery residents would have the opportunity to study and clear up doubts many times. The method employed in the dissections, preserving all the layers of the abdominal wall, allowed the student to visualize the stratigraphy of the wall and the modifications imposed by hernia correction techniques, as well as to preserve the excellent quality of the specimens repeatedly dissected for many consecutive students.