Hernia Surgery pp 159-168 | Cite as

Open Anterior Component Separation with Perforator Preservation

  • Gregory A. DumanianEmail author


Repair of midline incisional hernias is a common procedure for which two related problems need to be solved. First, how can this high-tension internal closure best be achieved without the sutures cheesewiring through the fascia over time? Meshes are commonly used to distribute tension, but the optimal location of the mesh, its size, and the method of fixation are hotly debated. Equally argued is the optimal handling of the soft tissues required to place the mesh. This chapter will describe a means to reliably close a midline abdominal wall defect using a well-fixed narrow retrorectus mesh and a perforator-sparing anterior components release.


Components release Perforator preservation Macroporous mesh Force distribution Suture tissue interface 

Supplementary material

Video 16.1

Perforator Preserving Open ACS, by Dumanian (MP4 368,919 kb)


  1. 1.
    Raines JK, Jaffrin MY, Rao S. A non-invasive pressure-pulse recorder: development and rationale. Med Instrum. 1973;7:245.PubMedGoogle Scholar
  2. 2.
    Gibbons GW, Wheelock FC, Hoar CC, et al. Predicting success of forefoot amputations in diabetics by noninvasive testing. Arch Surg. 1979;114:1034.CrossRefPubMedGoogle Scholar
  3. 3.
    Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation on musculocutaneous and random pattern flaps. Plast Reconstr Surg. 1982;70:1.CrossRefPubMedGoogle Scholar
  4. 4.
    Feng LF, Price D, Hohn D, Mathes SJ. Blood flow changes and leukocyte mobilization in infection: a comparison between ischemia and well-perfused skin. Surg Forum. 1983;34:603.Google Scholar
  5. 5.
    Abbott DE, Halverson AL, Wayne JD, Kim JY, Talamonti MS, Dumanian GA. The oblique rectus abdominis myocutaneous flap for complex pelvic wound reconstruction. Dis Colon Rectum. 2008;51:1237–41.CrossRefPubMedGoogle Scholar
  6. 6.
    Dumanian GA. Discussion: minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg. 2011;128:710–2.CrossRefPubMedGoogle Scholar
  7. 7.
    Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE. Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast Reconstr Surg. 2000;105:720–9.CrossRefPubMedGoogle Scholar
  8. 8.
    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;189:138–40.CrossRefPubMedGoogle Scholar
  9. 9.
    Saulis A, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “Separation of Parts” hernia repairs. Plast Reconstr Surg. 2002;109:2275.CrossRefPubMedGoogle Scholar
  10. 10.
    Ghali S, Turza K, 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;214:981–9.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Armananzas L, Ruiz-Tovar J, Arroyo A, et al. Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia: a randomized clinical trial. J Am Coll Surg. 2014;218:960–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Alexander CH, Prudden JF. The causes of abdominal wound disruption. SGO. 1966;122:1223–9.PubMedGoogle Scholar
  13. 13.
    Rodeheaver GT, Nesbit WS, Edlich RF. Novafil, a dynamic suture for wound closure. Ann Surg. 1986;204:193–9.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Israelsson LA, Millbourn D. Closing midline abdominal incisions. Langenbecks Arch Surg. 2012;397:1201–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Playforth MJ, Sauven PD, Evans M, Pollock AV. The prediction of incisional hernias by radio-opaque markers. Ann Royal Col Surg Eng. 1986;68:82–4.Google Scholar
  16. 16.
    Pollock AV, Evans M. Early prediction of late incisional hernias. Br J Surg. 1989;76:953–4.CrossRefPubMedGoogle Scholar
  17. 17.
    Burger JW, Lange JF, Halm JA, Kleinrensink G-J, Jeekel H. Incisional hernia: early complication of abdominal surgery. World J Surg. 2005;29:1608–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Xing L, Culbertson EJ, Wen Y, Franz MG. Early laparotomy wound failure as the mechanism for incisional hernia formation. J Surg Res. 2013;182:e35–42.CrossRefPubMedGoogle Scholar
  19. 19.
    Ellis H, Gajraj H, George CD. Incisional hernias: when do they occur? Br J Surg. 1983;70:290–1.CrossRefPubMedGoogle Scholar
  20. 20.
    Hoes J, Fischer L, Schachtrupp A. Laparotomy closure and incisional hernia prevention—what are the surgical requirements. Zentralbl Chir. 2011;136:42–9.CrossRefGoogle Scholar
  21. 21.
    Klink CD, Binnebosel M, Alizai PH, Lambertz A, von Trotha KT, Junker E, et al. Tension of knotted surgical sutures shows tissue specific rapid loss in a rodent model. BMC Surg. 2011;11:36–45.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Cheesborough JE, Dumanian GA. Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs. Plast Reconstr Surg. 2015;135:268–76.CrossRefPubMedGoogle Scholar
  23. 23.
    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;228:3046–52.CrossRefGoogle Scholar
  24. 24.
    Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Slater NJ, van Goor H, Bleichrodt RP. Large and complex ventral hernia repair using “components separation technique” without mesh results in a high recurrence rate. Am J Surg. 2015;209:170–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Souza JM, Dumanian GA. Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intraabdominal midweight polypropylene mesh for ventral hernia repair. Surgery. 2013;153:393–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Iqbal CW, Pham TH, Joseph A, Mai J, Thompson GB, Sarr MG. Long-term outcome of 254 complex incisional hernia repairs using the modified Rives-Stoppa technique. World J Surg. 2007;31:2398–404.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Northwestern Feinberg School of MedicineNorthwestern Memorial HospitalChicagoUSA

Personalised recommendations