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The technique for component separation hernia repair com­mences in a manner similar to a ventral hernia repair, gener­ally through a midline laparotomy incision, although a transverse abdominal incision may also be employed. The abdominal cavity is entered and the viscera are dissected from the posterior abdominal wall. The first step involves the creation of skin flaps from the anterior abdominal wall mus­culature (Fig. 31.1). The skin and subcutaneous tissues are dissected from the anterior rectus sheath and the external oblique to the approximate level of the anterior axillary line (Fig. 31.2). Dissection is extended laterally to a distance sev­eral centimeters lateral to the linea semilunaris laterally, cra­nially to a distance at least 5 cm above the costal margin, and inferiorly to the level of the inguinal ligament. The creation of these large undermining skin flaps will result in several centimeters of abdominal wall advancement. Next, the rectus abdominis muscle is separated from the posterior rectus sheath, resulting in elongation of the rectus abdominis mus­cle. This is achieved by incising the posterior rectus sheath 1 cm medial to its insertion into the linea alba. The use of Kocher clamps on the linea alba is often helpful to provide traction to the abdominal wall musculature. Once the poste­rior rectus is incised, the rectus abdominis muscle may be identified anterior the posterior rectus sheath. The posterior rectus sheath incision is extended to the level of the costal margin superiorly and inferiorly to the pubic symphysis.

The technique for a perforator preserving component separa­tion begins similarly to an open component separation by performing a laparotomy and lysing adhesions between the viscera and abdominal wall. The skin and subcutaneous fat are then dissected off the anterior rectus fascia to clearly identify the edge of the rectus muscles at the semilunar line. Just lateral and parallel to the semilunar lines, over the exter­nal oblique fascia, a subcutaneous pocket is bluntly created superiorly and inferiorly. A second access to the semilunar line is then created inferior to the periumbilical rectus abdominis perforators, just above the suprapubic area. This is accomplished in the same manner by dissecting subcuta­neous fat off the rectus fascia until the linea semilunaris is identified. The inferior access site is then connected with the superior access site by creating a subcutaneous tunnel lateral to the periumbilical rectus abdominis perforator vessels. The external oblique aponeurosis is then incised lateral to the linea semilunaris to access the space between the internal and external oblique muscles. A Yankauer suction is intro­duced into the inter-oblique space and is utilized to retract the linea semilunaris medially, thus allowing for division of the external oblique aponeurosis laterally. Once isolated, the length of the external oblique muscle and aponeurosis is incised from above the costal margin to the inguinal liga­ment. The incised lateral external oblique edge is then bluntly separated from the internal oblique to allow maximal medial advancement of the rectus musculature. Following advance­ment, the fascia is closed. Butler and Campbell [12] described fascial closure with interrupted braided nylon sutures, place­ment of three closed-suction drains, debridement of redun­dant or ischemic skin, and skin closure. Alternative closure techniques include slowly resorbable or permanent monofil­ament sutures placed in an interrupted or running fashion.