Approaching the Complex Abdominal Wall Hernia: General Principles of Component Separation Techniques

Abstract

Abdominal wall hernias represent a clinical spectrum ranging from a small defect in the abdominal wall causing minimal interruption to patients up to massive defects with severe impairment in abdominal wall function and physiology. Principles of successful hernia repair rely on re-approximation of fascial defect edges to achieve primary closure in a tension free manner and subsequent reenforcement of the repair with a mesh. In the case of large defects, especially in the incisional hernia scenario, advanced fascial release techniques with separation of components is often required to recreate normal anatomy. Relevant techniques are anterior component separation with or without sparing of periumbilical vascular perforators and posterior component separation with transverse abdominis release, representing an expansion of the retrorectus Rives-Stoppa repair. With regards to surgical planning, preoperative imaging, standardization of techniques according to patient and hernia defect characteristics as well as prehabilitation of the abdominal wall with botulinum toxin (“chemical component separation”) represent significant weapons in the armamentarium of the complex abdominal wall reconstruction surgeon. The scope of this chapter is to attempt to unify pathophysiologic concepts of hernias with anatomic-based advanced repairs.