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296
M. Y. Nahabedian
techniques with interpositional mesh are usually required. Figures21.4, 21.5, 21.6,
21.7, 21.8, and 21.9 illustrate a patient having bilateral anterior component separa-
tion with biologic mesh underlay. In patients at high risk for delayed healing, an
incisional negative-pressure wound therapy device can be applied (Fig.21.10).
Fig. 21.4 Preoperative
image of a patient with a
recurrent right/ventral
incisional hernia
Fig. 21.5 The right
component separation is
complete
21 Component Separation: Outcomes andComplications
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Fig. 21.6 The left
component separation is
complete
297
Fig. 21.7 Underlay
biologic mesh is placed for
reinforcement
298
Fig. 21.8 Midline fascial
approximation is achieved
M. Y. Nahabedian
Fig. 21.9 Postoperative
image demonstrating no
hernia and improved
contour at 9months
Other modications of the anterior component separation technique have been
described that provide additional reinforcement to the midline repair [5, 18] or further improve the vascularity to the adipocutaneous layer [14, 15]. Following the
classic anterior component separation technique with an underlay mesh, the incised
edges of the external oblique fascia are left as is. A modication, known as the
21 Component Separation: Outcomes andComplications
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Fig. 21.10 Incisional
negative-pressure wound
therapy can be placed to
improve wound healing
299
“sandwich” technique, can be performed whereby the incised edges of the external
oblique fascia and muscle are bridged with an onlay mesh that can be synthetic or
biologic in nature [18]. This bilaminar repair will tend to minimize the lateral forces
that can attenuate or disrupt the midline closure as well as provide additional lateral
support to minimize the occurrence of a lateral bulge.
Minimally invasive component separation (MICS) is another recent advancement that preserves the perforating vessels to the anterior abdominal wall [14, 15].
The purpose of MICS is to optimize perfusion to the adipocutaneous layer of the
abdominal wall and minimize the incidence of wound-healing complications such
as necrosis and dehiscence. The technique involves the creation of 3cm wide horizontal subcutaneous tunnels that extend from the linea alba to the linea semilunaris
at the level of the costal margin. This is followed by the creation of a 3cm vertical
tunnel that extends from the costal margin to the pubic bone. The perforating vessels at the periumbilical level are undisturbed. The external oblique fascia and muscle is then incised throughout the length of the vertical tunnel lateral the linea
semilunaris. A blunt Yankauer suction handle is then inserted into the plane between
the external and internal oblique muscle. Following mobilization of the rectus
abdominis myofascial complex and placement of an underlay mesh, the midline
defect is re-approximated with nonabsorbable sutures.
Outcomes
Outcomes following anterior component separation will vary based on the specic
details and variables of each repair. These include whether or not a mesh was used
for reinforcement and where the mesh was placed. The nature of the mesh, biologic
or synthetic, can also affect certain outcome measures. Table21.2 is a compilation
300
Table 21.2 Recurrence, surgical site infection (SSI), and surgical site occurrences (SSO) are
tabulated in these studies evaluating outcomes following component separation without mesh
reinforcement
Author
Ramirez [1] 1990 11 None 0 0 0 4–42
Girotto [19] 1999 33 None 6.10% 8 (24.1%) Enterocutaneous
Shestak [2] 2000 22 None 5% 2 (9.1%) Seroma [1],
De Vries [23] 2003 43 None 12/38 (32%) 6 (13.9%) 17 (39.5%)
Ko [6] 2009 158 None 36 (22.8%) (see SSO) 25.3% (MI, PE,
Year Number Mesh Recurrence SSI SSO
stula [1]
death [1]
hematoma [5],
seroma [2] skin
necrosis [2],
death, infection,
seroma, skin
necrosis)
M. Y. Nahabedian
FU
(months)
21
52
15.6
9.6
of various studies in which a component separation repair was performed without
mesh for reinforcement. Table21.3 is a compilation of studies in which a component separation was performed with mesh reinforcement. This section will focus on
specic outcome measures that include recurrence, reoperation, and quality of life
issues.
Girotto reviewed the Johns Hopkins experience following three cohorts of
patients that included primary fascial closure without component separation
(n=110), component separation and fascial closure with onlay mesh (n=96), and
component separation with interposition graft (n=78) [19, 20]. Recurrence rate for
the smaller defects that were closed with primary fascial closure group without
component separation was 15%, whereas the recurrence for the two cohorts combined requiring component separation was 26% (43/164). Component separation
with and without primary fascial closure demonstrated recurrence rates of 22% and
29%, respectively. The risk of recurrence was independent of patient age, gender,
perioperative steroid use, wound infection, defect size, and preoperative enterocutaneous stula. However, prior hernia repair with the use of a mesh was predictive of
recurrence (odds ratio=2.2, p=0.01). Increasing the complexity of the repair was
also associated with an increased risk of recurrence (odds ratio=1.5, p=0.04).
Patient satisfaction scores were obtained in 108 patients demonstrating improvements in abdominal appearance, postoperative emotional state, abdominal strain,
ability to lift objects and lift themselves from a chair and bed, and exercise.
Ko and Dumanian performed primary component separation on 200 patients
demonstrating a recurrence rate of 21.5% [6]. Of these 200 patients, 158 (79.0%)
had primary component separation without mesh, and 42 (21.0%) had primary component separation with underlay mesh. Of the underlay mesh cohort, 6 (3.0%) had
polypropylene mesh, 18 (9.0%) had human acellular cadaveric dermis, and 18
(9.0%) had soft polypropylene mesh. Comparison based on reinforcement material
21 Component Separation: Outcomes andComplications
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Table 21.3 Recurrence, surgical site infection (SSI), and surgical site occurrences (SSO) are
tabulated in these studies evaluating outcomes following component separation with mesh
reinforcement
Author
Ko [
Ko [
Morris [5] 2013 51 Porcine +
Gallud
[18]
Garvey
22]
[
Year Number Mesh Recurrence SSI SSO
6] 2009 18 Human 33.30% (See
6] 2009 24 Polypropylene 4.10% (See
polypropylene
2017 351 Polypropylene,
DynaMesh
2017 191 Porcine 57.1%,
bovine 31.4%,
human 11%
3.90% 1
8.20% 7.20% Seroma
13.60% 8.40% 25.1%: Bulge
SSO)
SSO)
(1.9%)
22.2% (MI,
PE, death,
infection,
seroma, skin
necrosis)
16.7 (MI, PE,
death,
infection,
seroma, skin
necrosis)
SSO– 39%
(partial mesh
excision 7,
skin necrosis,
death)
35.1%,
hematoma
9.1%, skin
necrosis
8.8%, SBO
1.5%
6.3%,
dehiscence
16.8%,
hematoma
2.1%, seroma
3.7%
301
FU
(months)
14.7
5.4
20.6
31.6
52.9
demonstrated a recurrence rate of 0 with a polypropylene mesh compared to 33%
with human acellular dermal matrix. The recurrence rate using soft polypropylene
mesh was signicantly less compared with the other groups (P=0.04). The failure
of human dermis as a reinforcement material is notable in these complex cases due
to the inherent elasticity of the human dermis [21]. Obesity was associated with a
signicant increase on hernia recurrence (odds ratio=1.06, P=0.003) [6]. Previous
hernia repair by another surgeon approached signicance with an odds ratio of 1.87
(P=0.08). Factors that were not associated with an increased risk of recurrence
included hernia width, diabetes mellitus, tobacco use, and contamination.
In a more recent review, Garvey studied 191 patients having component separation with a median follow-up of 52.9months (range 36–104months) [22]. Hernia
recurrence was documented in 26/191 (13.6%). The cumulative recurrence rates
were 11.5% at 3years and 14.6% at 5years demonstrating relatively stable repairs
over time. Interestingly, at 7 years, the hernia recurrence rate remains stable at
302
M. Y. Nahabedian
14.6%. Factors associated with hernia recurrence included a lack of primary fascial
closure, bridged repair, incisional dehiscence, and the use of a human
ADM. Performing a component separation was associated with less recurrence
compared to no component separation. The authors found that when the analysis
was adjusted to exclude patients with a bridged repair or those that had human
ADM, the cumulative hernia recurrence rate was 6.4% at 3 years and 8.3% at
5years. The authors noted no difference in recurrence following component separation with either a porcine or bovine acellular dermal matrix.
In another recent review, Torregrosa-Gallud evaluated 351 patients with complex
ventral hernias with over 10-year follow-up that were managed with a modied
component separation [18]. The primary modication was the application of an
onlay synthetic mesh in addition to the underlay biologic mesh aka sandwich repair.
Other modications included preoperative botulinum toxin and progressive pneumoperitoneum in patients with giant hernias in whom the volume ratio between the
incisional hernia (VIH) and the abdominal cavity (VAC) was 20%. The recurrence
rate following this modied component separation was 8.2% (29/351). The mean
follow-up was 32months (range 24–60months). Twenty-four (83%) of the patients
that had a recurrence had a secondary repair that included a posterior component
separation (n = 11), preperitoneal repair (n =9), and primary suture repair with
onlay polypropylene mesh (n=4).
Morris reviewed a series of 51 patients that had abdominal wall reconstruction
utilizing component separation with bilaminar mesh reinforcement [5]. Hernia
recurrence was observed in 3.9% of patients (2/51), and surgical site occurrence
occurred in 39% (20/51). Of the two patients that developed a recurrence, one sustained a mesh infection 2months postoperatively and required complete mesh excision that resulted in recurrence. The second patient also sustained a mesh infection
and failed negative-pressure wound therapy developing a recurrence.
Complications
Complications following anterior component separation include surgical site infections and other occurrences that include seroma, hematoma, delayed healing, death,
pulmonary emboli, enterocutaneous stula, myocardial infarction, and others.
In the Ko and Dumanian study evaluating 200 patients following component
separation, major complications were documented in 48 patients (24.0%) and
included hematoma, infection requiring incision and drainage, reoperation, as well
as myocardial infarction, pulmonary embolus, and death [6]. Minor complications
were documented in 38 patients (19.0%) and included cellulitis, seroma, and
delayed healing. The type of mesh used did not correlate with postoperative morbidity. Factors associated with major complications included contamination at time of
surgery (odds ratio=2.26, p=0,04) as well as a preoperative enterocutaneous stula (odds ratio = 3.67, P = 0.02). Factors associated with minor complications
included obesity (odds ratio=1.06, P=0.01) and diabetes mellitus (odds ratio=2.38,
P=0.04). Figures21.11 and 21.12 illustrate a patient with delayed healing managed
with a vacuum-assisted closure device.
21 Component Separation: Outcomes andComplications
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Fig. 21.11 Complex
wound following
simultaneous component
separation and
panniculectomy
Fig. 21.12 Vacuumassisted closure application
to facilitate wound healing
303
In the Garvey study evaluating 512 patients following anterior component separation of which 191 had greater than 3-year follow-up, the overall incidence of
adverse events was 38.7% (74/191) [22]. Surgical site occurrences related to the
abdominal wall occurred in 25.1% (48/191). Factors associated with the development of a surgical site occurrence were analyzed using a multivariable logistic
regression model and demonstrated that BMI>30 (odds ratio=4.4, p<0.01) and
at least 1 medical comorbid condition (odds ratio = 4.5 p < 0.02), and defect
width > 15 cm (odds ratio = 2.1, p < 0.01) were all signicant, independent
predictors.
In the Torregrosa-Gallud study evaluating 351 patients following anterior component separation using a synthetic mesh over 10 years, major complications
included bowel evisceration (n=3, 0.9%), small bowel stula (n=4, 1.1%), and
mesh infection (n=11, 3.1%) [18]. Reoperation and total or partial mesh excision
was required in 6 patients that had mesh infection. Salvage of the infected mesh was
possible in 5/11 patients (45%) using conservative measures and antibiotics. Minor
304
M. Y. Nahabedian
surgical site occurrences included seroma (35.1%), hematoma (9.1%), skin necrosis
(8.8%), and wound infection (7.2%). Medical complications occurred in 20 patients
(5.6%) and included a prolonged postoperative ileus (n = 9, 2.5%), pneumonia
(n=5, 1.4%), and urinary tract infection (n=3, 0.9%) patients. Anterior compartment syndrome occurred in two patients with a bladder pressure of 31mmHg. One
patient with anterior compartment syndrome died due to multisystem organ failure
and the other required a biologic interposition graft.
Ghali and Butler studied 57 patients following MICS and 50 patients following
open component separation with a mean follow-up of 15.2months [15]. The mean
fascial defect size was larger in the MICS cohort compared to the open component
2
separation cohort (405.4cm
vs. 273.8cm2, p=0.002). It was demonstrated that the
incidence of dehiscence (11% vs. 28%; p=0.011), wound-healing complications
(14% vs. 32%; p= 0.026), abdominal wall laxity/bulge (4% vs. 14%; p=0.056),
and hernia recurrence (4% vs. 8%; p=0.3) was lower in the MICS cohort compared
to the open component separation cohort.
Conclusion
Component separation is a useful technique for complex abdominal wall reconstruction. The use of mesh is an effective means of minimizing recurrence. Mesh
placement can be as an underlay, onlay, interposition (bridge), or bilaminar.
Primary fascial closure is recommended to minimize the risk of recurrence. Risk
factors for recurrence include but not limited to prior hernia repair, obesity, and
prior mesh repair. Risk factors for surgical site occurrence include but not limited
to obesity, poorly controlled patient comorbidities, tobacco use, and poor tissue
perfusion.
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