How I do it - FAQs von Prof. Dr. Henning Niebuhr
“We have experience with thirty fascia traction procedures performed so far with the fasciotens device for large loss of domain hernias with widths up to 40 cm (W III +++). Fascia traction with fasciotens presents itself to us as a simple procedure for the management of large loss-of-domain hernias and helps to avoid complicated and complicating component separations in some cases.”
The indication for the use of fasciotens®Hernia are complex primary abdominal wall hernias and scar hernias (large W2 and W3 hernias). In addition, fasciotens Hernia has also been successfully used in cases of florid mesh infection without adequate closure to avoid the use of alloplastic material.
We have had very good experience with a traction time of about 30 to 40 minutes.
The Botox injection is optional and represents an off-label use. In principle, a combination with fasciotens®Hernia is possible. One indication is the perioperative relaxation of the lateral abdominal wall muscles to reduce tension. The injection is controlled sonographically or electromyographically about 4-6 weeks preoperatively.
We use diagonal traction as a standard. If the loss-of-domain situation is very pronounced, vertical traction may be necessary to avoid cutting the sutures into the organ package. For this reason, we always protect the organs with several moist abdominal drapes during the traction phase.
Yes, definitely. Our declared goal is to be able to do without component separation by using the technique. However, a combination of both procedures is also possible for very large defects in order to enable direct closure of the abdominal wall fascia.
- In most cases we treat the hernia after successful traction using the sublay mesh technique. If additional lateral hernial orifices are present, widening of the mesh layer may be necessary.
- Primary closure by direct fascial suture without the use of alloplastic material would also be possible (e.g. in infectious situations).
- But of course the decision about the closure technique of the fascia is always in the hands of the treating surgeon (and is not limited by the use of fasciotens®Hernia).
fasciotens®Hernia enables me to close complex hernias in a controlled manner (with quantifiable traction) and relatively quickly (shortening the duration of the operation) and with significantly less trauma compared to reconstructive operations that may be fraught with complications.
For the patient, the use of fasciotens®Hernia means that the surgeon can work in a way that is gentle on the tissue and the integrity of the abdominal wall can be preserved, which in my experience will also have a positive influence on the healing process.
- Prior to the use of fasciotens®Hernia, a free preparation of the hernia as well as only a sparing preparation of the fascia margin must be carried out. If necessary, intra-abdominal adhesiolysis must be performed.
- Complete relaxation by anaesthesia during the traction phase is essential in my opinion.
Traction forces of up to 20 kg can be applied. It is up to the surgeon to decide which traction force to use. Depending on the patient’s weight and constitution, most users use a total traction force of approx. 12 kg.
- The fascia are intensively stretched and thus prepared for closure.
- Faster stretching of individual threads may occur, which may make it necessary to retighten the individual threads. Every 2 min. the individual threads should be checked for sufficient tension and, if necessary, sufficiently retightened. A total tensile force of 12-14 kg should not be exceeded.
- In our experience, all threads should be regularly retightened during the first 15 min of the traction phase. As soon as the individual threads can no longer be relevantly retightened, we usually increase the total tension to approx. 16 kg for the second part of the traction phase.
Even in the few very high epigastric W3 (EHS) hernias I was able to gain sufficient fascia length with fasciotens.
Applicability may be limited by local factors in the area of application and the general condition of the patient:
- lack of distance to the device e.g. due to fullness of the body
- necrotic or inflamed fascia tissue
- fixation and non-releasable adhesions to the abdominal wall
- Age ≤ 10 years
- An assumption of costs by the health insurance companies should be sought on the basis of an individual case assessment. An example application form for reimbursement is available.
- Important: A case-by-case assessment must be communicated to the health insurance companies before use and confirmed by telephone.
- The OPS code 5-98j describes the use of an external device for abdominal wall traction with definable force adjustment.
fasciotens®Hernia is used in combination with fasciotens®Carrier (see illustration above). fasciotens®Carrier is a reusable medical device and can be reprocessed by the CSSD. fasciotens®Hernia is a single-use product.
- An observational study by Prof. Niebuhr (21 cases) was published in Frontiers in Surgery.
- Significant gain in fascia length (on average 9.8 cm).
- Low-tension closure after traction in all cases
- No postoperative abdominal compartment syndrome
- Postoperative pain VAS 2.5 (range 0-6)
- A prospective randomised controlled trial in collaboration with the German Hernia Society is currently being planned.
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