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Siegal et al. Plast Aesthet Res 2019;6:25 I http://dx.doi.org/10.20517/2347-9264.2019.35 Page 15 of 20

Figure 12. Anterior fascia reapproximation: the anterior fascia is closed. In this case, it was closed with interrupted suture to offload
midline tension. A retromuscular drain is placed on the patient’s right side (blue arrow)

SPECIAL SITUATIONS
The transversus abdominis release technique can be utilized in unique hernias as well. We have found
TAR to be successful for the management of parastomal hernia (or for large midline hernias occurring
in patient with an ostomy adjacent to the defect) [33,34] . If the stoma does not warrant relocation, a TAR is
carefully performed around the stoma as described above. Next, the posterior sheath defect for the stoma
is intentionally extended laterally. The bowel proximal to the stoma is delivered into the retroperitoneal
plane and posterior sheath defect is closed lateralizing the bowel within the retromuscular space. Mesh is
positioned around the bowel in a Sugarbaker fashion, which permits wide overlap of hernia defects without
[33]
the need to cut the mesh or relocate the stoma .
[35]
Another special situation is a hernia recurrence after ACS, reported in 7%-32% of cases . As stated
previously, the concern in performing a TAR after ACS centers on the potential for lateral hernia
formation. Previous evaluation of TAR after EO release resulted in hernia recurrence in only 3% of patients
[12]
after 11-month follow-up, suggesting the method may be utilized successfully in experienced hands .

MINIMALLY INVASIVE APPROACHES TO TAR
In the era of new surgical technologies, much attention is paid to developing minimally invasive
approaches to TAR. The following subsections briefly describe some of the novel techniques.

Mini or less-open sublay operation
[36]
The mini or less-open sublay operation (MILOS) technique was developed by Dr. Reinpold et al. out of
a desire to minimize complications and pain related to open repair, but allow a large sublay mesh to be