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A posterior components separation is based on the retromuscular Rives-Stoppa approach to ventral hernia repair (Fig.17.16). Unlike the Ramirez components sep­aration focusing on external oblique aponeurosis release, the posterior components separation focuses on transversus abdominis aponeurosis release. As previously mentioned, the transversus abdominis aponeurosis actually forms the posterior rec­tus sheath in the upper two-thirds of the abdomen. By incising this myofascial apo­neurosis, the surgeon accesses the preperitoneal space. This provides substantial advancement of both the posterior fascial ap and the anterior myofascial compart­ment. The initial release is completed by incising the posterior rectus sheath approx­imately 1cm lateral to the linea alba, and the posterior rectus sheath is separated from the overlying rectus muscle. The transversus abdominis muscle is incised just medial to the intercostal nerves, and the underlying transversalis fascia and perito­neum are identied. This myofascial release is extended the entire length of the posterior rectus sheath. The potential space between the transversus abdominis muscle and the peritoneum is developed as far laterally as necessary, even to the psoas muscle if needed. This plane can be extended superiorly to the costal margin, retrosternally above the xiphoid, and inferiorly into the space of Retzius. The

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In general, abdominal wall reconstruction patients have prolonged postoperative healing periods due to the dynamic function and mobility of the abdominal mus­culature. Based upon specic unique indications, each patient’s postoperative care regimen should be individually tailored to allow for sufcient healing of the surgical site. Sequential compression devices and early ambulation should be uti­lized with low-molecular weight fractionated heparins administered postopera­tively for DVT prophylaxis as indicated [22]. Perioperative antibiotics are indicated with violation of the gastrointestinal tract and should include broad coverage for anaerobic as well as Gram-negative bacteria. For ventral hernia, closed-suction drains are used liberally and are kept in place on average 1–2weeks

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Estimated incidences of hernia recurrence have a wide range from 2 to 54%, depending on the type of repair (mesh 2–36% versus suture repair alone 25–54%), patient comorbidities, and surgical technique [12, 13, 25–27]. The number of prior attempts of hernia repair is predictive of the relative risk of recurrence. In a study of approximately 10,000 patients, 5-year reoperative rate was 23.8% after a pri­mary repair, 35.3% following a secondary repair, and 38.7% after a tertiary repair [28, 29]. There are few comparative data to suggest the superiority of one myofas- cial advancement approach over another, and likely each has a role in abdominal wall reconstruction. Open components separation often allows tension-free clo­sure of large defects, and recurrence rates as low as 20% have been reported with the use of open components separation and mesh reinforcement in large hernias. Recognizing the high recurrence rates with components separation alone, several authors have reported series of bioprosthetic or synthetic mesh reinforcement of these repairs, although to date, no randomized controlled trials have demonstrated lower hernia recurrence rates with a specic mesh type [30]. Comparative data have shown laparoscopic components separation to result in a lower rate of wound morbidity than open components separation. One series reported a signicant reduction in wound morbidity with the periumbilical perforator-sparing technique compared with the standard open components separation technique (2% vs 20%; p < 0.05) [31]. A controlled study demonstrated that patients had signicantly fewer wound-healing complications (32% vs 14%, p = 0.026) and skin dehis­cences (28% vs 11%, p=0.01) with MICS than with traditional open components separation [27]. These improved wound-healing outcomes are likely due to