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Rives – Stoppa Repair


Rives – Stoppa Repair.

The Retro-Rectus repair has stood the test of time, since it was introduced in the early Seventies.

History:

Rene Stoppa first put forth the concept of Preperitoneal placement of a large Prosthesis Mesh of 16 by 24 cms, termed as Giant Preperitoneal Prosthetic Repair, in 1965. .
( Stoppa R, Petit J, Abourachid H, Henry X, Duclaye C, Monchaux G, et al. Original procedure of groin hernia repair: interposition without fixation of Dacron tulle prosthesis by subperitoneal median approach. Chirurgie. 1973;99(2):119–23. ).

This was later modified by Wantz who called it as Giant Prosthetic Reiforcement of Visceral Sac (GPVRS).

Jean Rives introduced the concept of Retro-Rectus Mesh Repair in 1966, and thus today, the Retro-Rectus Mesh Repair is being used for repair of Midline Hernias and is now called as the Rives-Stoppa repair.
(Rives J, Lardennois B, Pire JC, Hibon J. Large incisional hernias. The importance of flail abdomen and of subsequent respiratory disorders. Chirurgie. 1973;99(8):547–63)

Indications:

1. Midline Hernias
2. Midline Incisional Hernias
3. Midline Hernias with large defects in combination with Component Separation.

Technique:

1. The Skin and Hernial Sac is incised to the full extent of the Hernia.
2. Contents of the Hernia Sac are reduced into the Abdomen
3. Part of the Hernial sac at the lateral edges is preserved as far as possible
4. Adhesiolysis is done releasing the adhesions to the Anterior Abdominal wall and Sac, limiting the adhesiolysis to Anterior Abdominal wall upto midclavicular line beyond Linea Semilunaris: Interloop Bowel adhesions are tackled as per the necessity and history of Obstruction only.
5. The Rectus Sheath is incised near the midline, on the posterior aspect, as close to the the junction of Anterior and Posterior Rectus Sheath, to preserve largest possible area of Posterior Rectus Sheath.
6. The Posterior Rectus Sheath is separated leaving the Rectus muscle attached to the anterior Rectus Sheath: This is the Retromuscular plane.
Care is taken not to separate the Epigastric Vessels leaving them with the Rectus muscle. The Posterior Rectus Sheath is separated far laterally upto but stopping short of its junction with Anterior Rectus Sheath laterally: here the Neurovascular Bundles traveliing towards and entering the rectus Muscle have to be identified and preserved and dissection limited to the extent of their uninjured course. This Retro Rectus dissection is done throught the Extent of Hernia: Here in the Lower Abdomen, the Rectus Sheath ends at the Arcuate Ligament and thee is natural progression of the dissection into Retroperitoneal space exposing the Sympysis Pubis and both the Coopers Ligaments and Cave of Retzius: This dissection is essential in all lower midline Hernias in order to late fix the Mesh to Coopers ligaments.
In the upper Abdomen: the dissection prcooeds to the Xiphistenum where the Posterior Rectus sheath ends and will have to be incised to lay open the triangle of RetroXiphoid space.
The similar dissection is carried out on both the sides.

7. Closure of Posterior Rectus Sheath: this is done with delayed absorbable suture in a continuous or horizintal mattress fashion: the suture bites include the Posterior Rectus Sheath along with the Peritoneum/Sac and the the Peritoneal cavity is closed in the entire length.
8. Placement of Mesh: Measurement is taken and a nonabsorbable, Macroporous Mesh is placed on the closed Posterior Rectu Sheath, behind the Rectus Muscles: in the Lower Abdomen, the Mesh is placed into the cave of Retzius ( Retropubic space) or onto to the Coopers Ligaments.
9. Fixation of the Mesh:
Many ways are used: Central Hernias : no fixation may be required.
Lower Abdomen: Mesh is always fixed to Both the Coopers Ligaments
Posterior Rectus Sheath Fixation: This can be done by Preplacing the sutures before the Posterior Sheath is closed.
Anterior Rectus Sheath fixation: this necessitates passing the sutures through Rectus Muscle and should be done to the minimum.
Use of Glue : this is very elegant technique
Use of self fixing Mesh.

10. Closure of the Anterior Rectus Sheath: this closure should be done meticulously with nonabsorbable or delayed absorbable sutures
11. Skin is closed after excising the scar, or excess skin;
12. Drains Subcutaneous drains are placed if dissection appears extensive
Retrorectus Drains on the Mesh are used in some centres .

Postoperative Care:

1. Abdominal Support
2. Care of wound
3. Care of drains if any

Complications:

1. Surgical Site Infection
2. Seromas are rare in this repair
3. RetroRectus Haematoma
4. Mesh Infection
5. Intestinal Obstruction is rare due to lack of conact of Mesh with the Bowel.
6. Recurrence

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