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Table of Contents
ANTERIOR COMPONENT SEPARATION
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 13-20

eCST: The endoscopic-assisted component separation technique for (complex) abdominal wall reconstruction


1 Department of Surgery, Elkerliek Hospital Helmond, The Netherlands
2 Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
3 Department of Radiology, Maastricht University Hospital, The Netherlands

Date of Submission23-Jun-2021
Date of Decision29-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication23-Feb-2022

Correspondence Address:
Dr. Tammo Sasker de Vries Reilingh
Department of Surgery, Elkerliek Hospital Helmond
The Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_41_21

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  Abstract 

INTRODUCTION: In 1990, Ramirez introduced his component separation technique (CST) based on enlargement of the abdominal wall for reconstruction of large abdominal wall defects. CST is prone to postoperative wound complications which lead to modification of the technique to an endoscopic assisted CST. The details of the technique are described in detail with illustrations and report the results of a 36 patient cohort. MATERIALS AND METHODS: Between 2014 and 2018, patients with midline hernias without previous subcutaneous dissection underwent endoscopic-assisted anterior components separation technique (eCST) with retro-rectus mesh enforcement in an expert center for abdominal wall reconstructions. Prospective data were gathered during inpatient care and at least 2 years of follow-up. RESULTS: A total of 36 eCST procedures were performed. Eight patients (22%) had postoperative seroma in the dissection plan between external and internal rectus muscle, 3 (8%) had a hematoma, 1 (3%) had wound dehiscence. Clinical relevant SSEs were present in 4 patients (11%) and consisted of 3 (8%) puncture in seroma, 1 (3%) patient needed a blood transfusion due to large hematoma. One patient was re-operated within 90 days; however, this was the placement of a surgical tracheostomy. Three patients had a recurrence in a mean follow-up length of 24 months. CONCLUSION: eCST can be useful in selected patients.

Keywords: Abdominal wall reconstruction, components separation technique, endoscopic assisted, myofascial release


How to cite this article:
de Vries Reilingh TS, Nienhuijs SW, de Jong DL, Mommers EH, Wegdam JA. eCST: The endoscopic-assisted component separation technique for (complex) abdominal wall reconstruction. Int J Abdom Wall Hernia Surg 2022;5:13-20

How to cite this URL:
de Vries Reilingh TS, Nienhuijs SW, de Jong DL, Mommers EH, Wegdam JA. eCST: The endoscopic-assisted component separation technique for (complex) abdominal wall reconstruction. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2022 May 18];5:13-20. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/1/13/338070




  Introduction Top


Over 20% of midline laparotomies cause an incisional hernia within 10 years.[1],[2] Especially the larger ones can be challenging in preconditioning the patient, choosing, and performing an appropriate reconstruction. One of those options is the (anterior) components separation technique (CST) as described by Ramirez et al. in 1990.[3] This technique is based on an open enlargement of the abdominal wall surface by transection of the external oblique muscle to create a compound flap of the internal oblique and transverse muscle that can be advanced towards the midline. CST can be used to close hernias up to 20 cm width in the waistline, however, due to the large wound surface patients are prone to postoperative wound complications (52%).[4] Furthermore, reconstruction using the original technique (of Ramirez) without a mesh, resulted in a high recurrence rate in the long term.[4],[5] The high incidence of wound complications is probably caused by transection of periumbilicular perforators, large skinflaps, and wound surfaces.[4],[5 In an attempt to reduce postperative wound complications],[ an endoscopic-assisted version of the anterior component separation technique (eCST) was developed. Wound surface is hereby reduced and the periumbilicular perforators of the abdominal skin are spared. Ultimately],[ it was demonstrated that eCST was associated with a trend toward less wound complications compared to open anterior CST.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] More recently, 20 years after the development of the eCST, the posterior component separation technique with transversus abdominis release (PCS-TAR) was developed. The PCS-TAR technique has gained huge popularity, which is demonstrated by the high number of PCS-TAR citations, derived from Pubmed between 2014 and September 2019, compared to CST and ECST, respectively, 116, 13, and 11.

This study aims to define indications for the use of eCST within the palet of current component separation techniques.


  Historical Overview Top


Lowe et al. were the first who described an eCST.[16] Using this technique of Lowe a dissection balloon was placed in the subcutaneous space ventral to the anterior rectus fascia and fascia of the external oblique muscle. After removal of the balloon, the transection of the external oblique muscle was performed by endoscopic scissors and under direct endoscopic vision (top-down). Although the periumbilicular perforator was not damaged, there was still a large wound surface in the subcutaneous plane resulting in seromas.[17] Maas et al. first described the technique where the dissection balloon was placed in the avascular plane between external and internal oblique muscle. After removal of the dissection balloon, an extra trocar was placed to dissect the insertion of the external oblique muscle by endoscopic scissors and under direct endoscopic vision (bottom-up).[17] Both Lowe et al. and Maas et al. described a hybrid technique which means that the myofascial release was performed using the endoscopic technique after a laparotomy was performed for adhesiolysis and removing former scar.[16],[17]


  Ethics committee approval Top


The study was approved by the Local Institutional Review Board (No.: 0492-595681).


  Performing eCST Top


Step 1) ‘Indication

Most important is proper patient selection. Only patients should be selected for an anterior (endoscopic assisted) CST with a longitudinal midline abdominal wall defect within the lateral borders of the rectus abdominus muscle.

Ideally, a multidisciplinary approach should define the general physical and mental condition of the patient, including pulmonary screening, radiological examination using abdominal CT-scans is a prerequisite [Table 1], preoperative screening by an anesthesiologist, and discussed in a multidisciplinary team meeting.
Table 1: Preoperative CT-scan

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A preoperative prehabilitation protocol, including preoperative physical therapy, is used to optimize the patient by reducing preoperative risk factors. Patients with chronic obstructive pulmonary disease (COPD; Tiffenau index <70%) should receive pre- or perioperative pulmonary preparation to prevent exacerbation. There might be some suggestions that preoperative inspiratory muscle training (IMT) reduces pulmonary complications.[18] Patients with severe obesity should be stimulated to lose weight under supervision of a physical therapist, ideally, the body mass index (BMI) should be below 30 kg/m2 before surgery. Smoking should be stopped preoperatively at least for 4 weeks [Table 2].
Table 2: Patient related riskfactors

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Step 2) ‘Per-operative preparation

  • The patient is placed in a supine position, both arms are tucked in alongside the trunk using a cotton sheet to be able to approach the lateral side of the abdomen easily.


  • It can be very useful to position the patient with pelvis just above the angulation of the operation table.


  • The operation field is created using sterile drapings and extends from the thorax to the pubic area and as far lateral as possible.


  • Step 3) ‘Access the abdomen and perform adhesiolysis

  • The midline scar is excised and the hernia is reduced.


  • The hernia sac is removed.


  • Adhesiolysis was performed as far as the lateral peritoneal fold on both sides of the abdomen in order to investigate nonmidline defect (missed on pre-operative CT-scan), which could change the operative plane. To facilitate palpation of the abdominal wall from inside out (useful for trocar positioning) and for optimal sifting to the midline.


  • Step 4) ‘Create the lateral endoscopic pockets

    See [Figure 1] and [Figure 2] for optimal trocar placement of two trocars and position of the “endoscopic pocket.”
    Figure 1: Trocar position eCST

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    Figure 2: Trocar position eCST

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    Lower the legs by smooth “hyper” extension in the pelvis and angulate the patient a little bit to the opposite side.

    A small 1.5 cm incision is made 2 cm subcostal, in line with the superior anterior iliac spine approximately 5 cm laterally from the rectus muscle. This can easily be checked by palpation “around” the rectus muscle. The fascia of the external oblique muscle is identified and incised, the muscle fibers are spread and a blunt tip balloon trocar (10 mm AutoSuture BTT, Metronic®) is placed in the plane between the external and internal oblique muscle. Insufflation commences, a 5 or 10 mm 30° endoscope is introduced and used to separate the loose connective tissue between the external and internal oblique muscle, thus creating the “endoscopic pocket.” One 5 mm trocar with balloon is placed under direct vision 3 cm distal to the blunt-tip trocar. Using (electrocoagulation) scissors the pocket is extended cranially 5 cm above the costal margin, distally toward the inguinal ligament and laterally to the aponeurosis of the external oblique muscle [Figure 1]. Being careful on top of the costal margin for small vessels on the lateral side. The external oblique muscle is now released, using dissection hoke in combination with coagulation, approximately 1 cm lateral to the rectus abdominal muscle 5 cm cranial of the costal margin until the inguinal region in order to create a compound flap consisting of the internal oblique and transverse muscle. See [Figure 3] for an endoscopic view inside the endoscopic pocket after the external oblique muscle has been transacted. The same procedure is performed on the contralateral side. The trocars are removed and the external oblique fascia is closed with a single resorbable suture.
    Figure 3: Trocar position eCST following Jorgenson

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    Step 4) ‘Create the lateral endoscopic pockets using a dissection balloon’ following Jorgensen

    Alternative is the technique as described by Jorgenson.[19] The first step is a small incision at the costal margin and splitting the external oblique muscle. [Figure 3] A dissection balloon is placed in distal direction and in the avascular plane between external and internal oblique muscle. Under video endoscopic vision the balloon is insufflated with care and kept in place for several minutes. After desufflation of the dissection balloon it can be changed for a blunt tip trocar and regular insufflation started. A second 5 mm trocar places just below and entrance to the pocket. The external oblique muscle is now released approximately 1 cm lateral to the rectus abdominal muscle. The last step in this approach is dissection of the external oblique muscle in the region using a clamp and electro-coagulation after removing the trocar. The trocars are removed and the external oblique fascia cannot be closed.

    Step 6) ‘Primary fascia closure

    The newly created compound flap consisting of the rectus muscle, internal oblique muscle, and transverse abdominal muscle (see enlargement in [Figure 4]) can now be advanced approximately 6–8 cm toward the midline on either side. Closing gaps between 10 and 15 cm in width. The posterior rectus fascia is opened and dissected following Rives–Stoppa for xyfoid until the pubic bone.[20] The fatty triangle must be fully opened. Care not to damage the neurovascular bundles on the lateral side of posterior rectus sheath.
    Figure 4: Retromuscular mesh placing after eCST

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    The posterior rectus abdominis fascia is in most patients of good quality and can be closed in the midline using a continues slowly resorbable running 2/0 suture with small steps, small bites principle. A sublay position of the prosthetic lightweight mesh (underneath the rectus abdominis muscle, on top of the posterior rectus fascia) is preferred due to the reduced risk of bowel adhesions. In our opinion, it is not necessary to fixate the mesh. It diminishes the changes of bowel lesions or postoperative pain. The anterior rectus abdominis fascia is closed using a continues slowly resorbable running 2/0 suture with small steps, small bites principle.[stich trial] The subcutaneous plane is always closed using resorbable 2/0 sutures. No drains are used. The skin is closed and the wounds are dressed.


      Tips and Tricks Top


    Tip 1) ‘Presence of a uro- or enterostomy

    The presence of a uro- or enterostomy limits the surgical techniques that can be used for ventral hernia repair. However, eCST can be used in these patients if a “sublay” position of the mesh is feasible. Most important is the location of uro- or enterostomy in relation to the lateral border of the rectus (located in the center of the rectus muscle) in order to have sufficient mesh overlap. An ECST should not be used if the uro- or enterostomy must be replaced or if a parastomal hernia is present. In these situations, a myofascial release using transversus abdominal release (TAR) should be recommended.[21]

    Tip 3 ‘Monitor position

    During eCST orientation inside the endoscopic pocket may be difficult for the performing surgeon. In order to assist the surgeon with orientation during the endoscopic release two endoscopic video monitors are used, one at the head of the operating table and one at the bottom end of the operating table. If the surgeon points the endoscope toward the head of the patient, the monitor located at that side of the table is used and vice versa if the endoscope is pointed towards the feet of the patient.

    Tip 4 ‘Creating the endoscopic pocket

    The “space” between the external and internal oblique muscle may be difficult to identify due to its resemblance to the “space” between the transverse and the internal oblique muscle. However, after placement of the balloon trocar and insufflation of the “endoscopic pocket,” the surgeon can quickly check if he is creating the endoscopic pocket between the external and internal oblique muscle or (by mistake) in between the internal oblique and the transverse abdominal muscle since the first is an avascular plane and shouldn’t be accompanied by any bleeding during dissection of the connective tissue and the later is not.

    Tip 5 ‘Postoperative care

    The patient is advised to wear an abdominal binder for at least 4 weeks and avoid heavy lifting for 6 weeks, although there is a lack of evidence to support this.[22]


      Experience Top


    Our current practice is a single-center (regional referral center for abdominal wall surgery), retrospective series of patients who underwent elective incisional hernia repair through an eCST (n = 36) with retro-rectus mesh position between September 2014 and December 2018 with a follow-up of at least 2 years. Data are collected prospectively in a hospital-based database. All patients received standard preoperative workup and are discussed preoperatively in a multidisciplinary setting with several hernia-specialized surgeons, pulmonologist, anesthetist, intensive care physician, and specialized abdominal wall case manager. Together, they set up a patient-tailored treatment plan and discuss the most suitable surgery.

    Patients are included if they met the following criteria: age >18 years, hernia size confirmed by abdominal computed tomography (CT) scan; hernia repair with a sublay mesh; use of a lightweight polypropylene mesh or poly-4-hydroxybutyrate mesh in a contaminated situation (since 2016).

    [Table 3] summarizes their demographics, which are assessed preoperatively.
    Table 3: Per- and postoperative data

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    [Table 4] describes the operative and postoperative characteristics. A postoperative SSO rate of 25%, some patients had multiple SSOs. However, a small amount was clinically relevant surgical site events. Eight patients (22%) had postoperative seroma in the dissection plan between external and internal rectus muscle, 3 (8%) had a hematoma, 1 (3%) had wound dehiscence. Clinical relevant SSEs were present in 4 patients (11%) and consisted of 3 (8%) puncture in seroma, 1 (3%) patient needed blood transfusion due to large hematoma. One patient was re-operated within 90 days; however, this was the placement of a surgical tracheostomy.
    Table 4: Patient demographics and hernia characteristics

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    Three patients had a recurrence in a mean follow-up length of 24 months. One patient was diabetic, smoked, and had a previous hernia repair and was classified as HPW stage 2; one patient smoked and had a previous hernia repair; one was obese and had a stoma.


      Discussion Top


    e CST can be used to reconstruct midline abdominal wall hernias with a defect of 7–15 cm at the waistline even in patients with a uro- or enterostomy. If an anterior myofasciale release is used to reconstruct a large abdominal wall defect the endoscopic assisted CST seems superior to the classical open anterior CST with respect to SSO.[19]

    Our technique to perform the endoscopic release differs from previously published methods such as those performed by Lowe et al.[16] In our opinion using a distension balloon to create a subcutaneous space has little advantage over the original technique described by Ramirez et al. because of trauma to the skin vascularization.[3] Rosen et al. and Fox et al. described an endoscopic method using the plane between the internal and external oblique muscles, though they lack full endoscopic control since a dissection balloon is used and the external oblique fascia is incised in three places because an extra trocar is needed to complete transection of the external oblique muscle.[9],[23],[24],[25] The use of full video-endoscopic guidance to create a space in the avascular plane between the internal and external oblique muscle and transect the external oblique aponeurosis is a safe-operative technique and causes less trauma to the skin vascularization. Although the dissection in the technique described by Jorgenson is quite elegant, especially for the ergonomics of the surgeon, it is not that controlled because the balloon can easily damage small vessels. These small bleeding can be difficult to control by coagulation.

    As the complexity of the abdominal hernias increases, the discussion about surgical techniques evolves.

    A systematic review by Cornette et al. compared the SSO rates in eCST and PCSTAR surgery.[26] They found a SSO rate of 23.7% (n = 761) for PCSTAR and 20.3% (n = 193) for eCST which did not differ significantly. It is hard to compare our study outcomes with these outcomes because of the large heterogeneity in baseline patient characteristics in the studies used in the systematic review. Several of the included studies showed patients’ age, contaminated wound status, and hernia width to be possible predictors of a surgical site infection and thus SSO.[26]

    Recent systematic review of Balla et al. about eCST + laparotomy (hybrid) vs. complete eCST (endoscopy in combination with laparoscopy) vs. Robot PCS-TAR shows some superiority of de-PCS-TAR considering SSO, the main difference between the techniques is the midline laparotomy which is necessary for the eCST. This midline laparotomy is sometimes unavoidable, which makes the groups not completely comparable.[27]

    In hernia surgery, one size does not seem to fit all. The eCST is well suitable in defects smaller than 15 cm because of the limited dissection. Therefore, the endoscopic approach is primarily for midline hernia defects that reach up to a maximum of 2 cm medial from the semilunar line.[14] For hernias located <2 cm of the semilunar line or passing it, the PCS-TAR has been shown to be an excellent option for abdominal wall repair. Large lateral and flank hernias should have a mesh overlap of at least 5–7 cm, which only can be achieved by a PCS-TAR procedure.[21] Besides, hernias near bony structures, like subxyphoid or suprapubic, do not benefit from anterior component release but are suited for PCS-TAR [Table 5].[21]
    Table 5: Indications for eCST and PCS-TAR

    Click here to view


    The trocar position and number of trocars depend on the surgeons' preference. In our opinion, two lateral trocars give the best exposure to perform the dissection. Trocar position at the costal margin probably has better ergonomics.

    In conclusion, reconstruction in complex abdominal wall defects is tailored surgery and demands skills of several techniques to reconstruct the abdominal wall. The choice of which techniques should be performed depends on hernia and patient characteristics. eCST can be useful in selected patients. The surgeons in any entre of excellence for hernia surgery should be familiar with the endoscopic assisted CST.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

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    Mudge M, Hughes LE. Incisional hernia: A 10 year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.  Back to cited text no. 2
        
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    Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26.  Back to cited text no. 3
        
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    de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, et al. Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: Interim analysis of a randomized controlled trial. World J Surg 2007;31:756-63.  Back to cited text no. 4
        
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    Albright E, Diaz D, Davenport D, Roth JS. The component separation technique for hernia repair: A comparison of open and endoscopic techniques. Am Surg 2011;77:839-43.  Back to cited text no. 6
        
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    Butler CE, Campbell KT. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 2011;128:698-709.  Back to cited text no. 7
        
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    Clarke JM. Incisional hernia repair by fascial component separation: Results in 128 cases and evolution of technique. Am J Surg 2010;200:2-8.  Back to cited text no. 8
        
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    Fox M, Cannon RM, Egger M, Spate K, Kehdy FJ. Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs. Am J Surg 2013;206:869-74; discussion 874-5.  Back to cited text no. 9
        
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    Ghali S, Turza KC, 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.  Back to cited text no. 10
        
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    Giurgius M, Bendure L, Davenport DL, Roth JS. The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 2012;16:47-51.  Back to cited text no. 11
        
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    Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 2010;199:342-6; discussion 346-7.  Back to cited text no. 13
        
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    Lipman J, Medalie D, Rosen MJ. Staged repair of massive incisional hernias with loss of abdominal domain: A novel approach. Am J Surg 2008;195:84-8.  Back to cited text no. 14
        
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    Switzer NJ, Dykstra MA, Gill RS, Lim S, Lester E, de Gara C, et al. Endoscopic versus open component separation: Systematic review and meta-analysis. Surg Endosc 2015;29:787-95.  Back to cited text no. 15
        
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    Lowe JBG, J. R.; Bowman, J. L.; Rohrich R. J.; Strodel W. E. Endoscopically assisted ‘components separation’ for closure of abdominal wall defects. Plast Reconstr Surg 105:720-9.  Back to cited text no. 16
        
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    Maas SM, de Vries RS, van Goor H, de Jong D, Bleichrodt RP. Endoscopically assisted “components separation technique” for the repair of complicated ventral hernias. J Am Coll Surg 2002;194:388-90.  Back to cited text no. 17
        
    18.
    Kendall F, Oliveira J, Peleteiro B, Pinho P, Bastos PT. Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: A systematic review and meta-analysis. Disabil Rehabil 2018;40:864-82.  Back to cited text no. 18
        
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    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;28:3046-52.  Back to cited text no. 19
        
    20.
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    Rosen MJ, Williams C, Jin J, McGee MF, Schomisch S, Marks J, et al. Laparoscopic versus open-component separation: A comparative analysis in a porcine model. Am J Surg 2007;194:385-9.  Back to cited text no. 23
        
    24.
    Rosen MJ, Jin J, McGee MF, Williams C, Marks J, Ponsky JL. Laparoscopic component separation in the single-stage treatment of infected abdominal wall prosthetic removal. Hernia 2007;11:435-40.  Back to cited text no. 24
        
    25.
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    26.
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        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



     

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      In this article
       Abstract
      Introduction
      Historical Overview
       Ethics committee...
      Performing eCST
      Tips and Tricks
      Experience
      Discussion
       References
       Article Figures
       Article Tables

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