Component separation repair of large or complex abdominal wall defects
- John Cone, MD
John Cone, MD
- Professor, Department of Surgery
- University of Arkansas for Medical Sciences
An increasing number of patients have large or complex abdominal wall defects. Such defects may result from incisional hernia related to multiple abdominal operations, surgical resection of the abdominal wall, necrotizing abdominal wall infections, or therapeutic open abdomen. The component separation technique, which was first described in 1990 for midline abdominal wall reconstruction, is a type of rectus abdominis muscle advancement flap that allows reconstruction of such large ventral defects. The advantages of the component separation technique are that it restores functional and structural integrity of the abdominal wall, provides stable soft tissue coverage, and optimizes aesthetic appearance.
Component separation technique is reviewed here. Other techniques for ventral hernia repair are reviewed elsewhere. (See "Overview of abdominal wall hernias in adults" and "Management of ventral hernias".)
Large or complex abdominal wall defects may be associated with problems such as chronic back pain, respiratory compromise, and altered body image. Patients with symptoms related to these defects or incisional hernias should ideally be repaired. Whether to repair asymptomatic incisional hernias is reviewed separately. (See "Principles of abdominal wall closure" and "Management of ventral hernias".)
Large or complex abdominal wall defects are a particularly challenging surgical problem. Various methods of abdominal wall hernia repair (simple suture repair, mesh repair) using either open or laparoscopic approaches can be used to manage abdominal wall defects, which are most commonly related to incisional hernia. The relative merits of these hernia repairs are reviewed elsewhere. (See "Management of ventral hernias", section on 'Ventral hernia repair'.)
The component separation technique, which was first described in 1990, is a very effective method for reconstructing large or complex midline abdominal wall defects in a manner that restores innervated muscle function without tension [1-3], often without the need for mesh [4,5]. Indications for a component separation technique include the following:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- de Vries Reilingh TS, van Goor H, Rosman C, et al. "Components separation technique" for the repair of large abdominal wall hernias. J Am Coll Surg 2003; 196:32.
- Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000; 105:731.
- De Silva GS, Krpata DM, Hicks CW, et al. Comparative radiographic analysis of changes in the abdominal wall musculature morphology after open posterior component separation or bridging laparoscopic ventral hernia repair. J Am Coll Surg 2014; 218:353.
- Vargo D. Component separation in the management of the difficult abdominal wall. Am J Surg 2004; 188:633.
- Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990; 86:519.
- Diaz JJ Jr, Cullinane DC, Khwaja KA, et al. Eastern Association for the Surgery of Trauma: management of the open abdomen, part III-review of abdominal wall reconstruction. J Trauma Acute Care Surg 2013; 75:376.
- Poulakidas S, Kowal-Vern A. Component separation technique for abdominal wall reconstruction in burn patients with decompressive laparotomies. J Trauma 2009; 67:1435.
- van Eijck FC, de Blaauw I, Bleichrodt RP, et al. Closure of giant omphaloceles by the abdominal wall component separation technique in infants. J Pediatr Surg 2008; 43:246.
- Garvey PB, Bailey CM, Baumann DP, et al. Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction. J Am Coll Surg 2012; 214:131.
- Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012; :CD003769.
- Abramov D, Jeroukhimov I, Yinnon AM, et al. Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study. Eur J Surg 1996; 162:945.
- Aufenacker TJ, Koelemay MJ, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 2006; 93:5.
- de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial. World J Surg 2007; 31:756.
- Eriksson A, Rosenberg J, Bisgaard T. Surgical treatment for giant incisional hernia: a qualitative systematic review. Hernia 2014; 18:31.
- Nguyen V, Shestak KC. Separation of anatomic components method of abdominal wall reconstruction--clinical outcome analysis and an update of surgical modifications using the technique. Clin Plast Surg 2006; 33:247.
- Shell DH 4th, de la Torre J, Andrades P, Vasconez LO. Open repair of ventral incisional hernias. Surg Clin North Am 2008; 88:61.
- Ramirez OM. Inception and evolution of the components separation technique: personal recollections. Clin Plast Surg 2006; 33:241.
- Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: a comparative analysis. Am J Surg 2012; 203:318.
- DiCocco JM, Fabian TC, Emmett KP, et al. Components separation for abdominal wall reconstruction: the Memphis modification. Surgery 2012; 151:118.
- Heller L, McNichols CH, Ramirez OM. Component separations. Semin Plast Surg 2012; 26:25.
- Butler CE, Baumann DP, Janis JE, Rosen MJ. Abdominal wall reconstruction. Curr Probl Surg 2013; 50:557.
- Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2012; 204:709.
- Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am 2013; 93:1111.
- Novitsky YW, Fayezizadeh M, Majumder A, et al. Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement. Ann Surg 2016; 264:226.
- Blatnik JA, Krpata DM, Novitsky YW. Transversus Abdominis Release as an Alternative Component Separation Technique for Ventral Hernia Repair. JAMA Surg 2016; 151:383.
- EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002; 235:322.
- Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002; :CD002197.
- de Vries Reilingh TS, Bodegom ME, van Goor H, et al. Autologous tissue repair of large abdominal wall defects. Br J Surg 2007; 94:791.
- Rosen MJ, Krpata DM, Ermlich B, Blatnik JA. A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 2013; 257:991.
- Richmond BK, Chong B. Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair. Surgery 2013; 153:741.
- Patel KM, Nahabedian MY, Albino F, Bhanot P. The use of porcine acellular dermal matrix in a bridge technique for complex abdominal wall reconstruction: an outcome analysis. Am J Surg 2013; 205:209.
- Samson TD, Buchel EW, Garvey PB. Repair of infected abdominal wall hernias in obese patients using autologous dermal grafts for reinforcement. Plast Reconstr Surg 2005; 116:523.
- Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg 2007; 205:654.
- Maas SM, van Engeland M, Leeksma NG, Bleichrodt RP. A modification of the "components separation" technique for closure of abdominal wall defects in the presence of an enterostomy. J Am Coll Surg 1999; 189:138.
- Jensen KK, Henriksen NA, Jorgensen LN. Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and meta-analysis. Surg Endosc 2014; 28:3046.
- Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 2010; 199:342.
- Butler CE, Campbell KT. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 2011; 128:698.
- Ghali S, Turza KC, Baumann DP, Butler CE. Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg 2012; 214:981.
- Lowe JB, Garza JR, Bowman JL, et al. Endoscopically assisted "components separation" for closure of abdominal wall defects. Plast Reconstr Surg 2000; 105:720.
- DiBello JN Jr, Moore JH Jr. Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias. Plast Reconstr Surg 1996; 98:464.
- Moore M, Bax T, MacFarlane M, McNevin MS. Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese. Am J Surg 2008; 195:575.
- Clarke JM. Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique. Am J Surg 2010; 200:2.
- Sailes FC, Walls J, Guelig D, et al. Synthetic and biological mesh in component separation: a 10-year single institution review. Ann Plast Surg 2010; 64:696.
- Sailes FC, Walls J, Guelig D, et al. Ventral hernia repairs: 10-year single-institution review at Thomas Jefferson University Hospital. J Am Coll Surg 2011; 212:119.
- Hood K, Millikan K, Pittman T, et al. Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh. Am J Surg 2013; 205:322.
- Morris LM, LeBlanc KA. Components separation technique utilizing an intraperitoneal biologic and an onlay lightweight polypropylene mesh: "a sandwich technique". Hernia 2013; 17:45.
- Criss CN, Petro CC, Krpata DM, et al. Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery 2014; 156:176.
- Levi B, Zhang P, Lisiecki J, et al. Use of morphometric assessment of body composition to quantify risk of surgical-site infection in patients undergoing component separation ventral hernia repair. Plast Reconstr Surg 2014; 133:559e.
- HERNIA ASSESSMENT
- PREOPERATIVE EVALUATION AND PREPARATION
- ANATOMIC CONSIDERATIONS
- Abdominal wall musculature
- Skin and subcutaneous tissues
- COMPONENT SEPARATION TECHNIQUE
- General technique
- - Anterior component separation
- - Posterior component separation
- - Choosing a technique
- - Use of mesh
- - Presence of a stoma
- - Use of laparoscopy
- Placement of drains
- POSTOPERATIVE CARE AND FOLLOW-UP
- Recurrent hernia
- Functional results
- Surgical site infection
- Skin flap necrosis
- SUMMARY AND RECOMMENDATIONS