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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 21-25

The open perforator sparing anterior component separation

1 Department of Plastic and Reconstructive Surgery, Guy’s & St. Thomas Hospital, London, UK
2 School of Medicine, University of Dundee, Scotland, UK

Date of Submission03-Aug-2021
Date of Decision20-Aug-2021
Date of Acceptance26-Aug-2021
Date of Web Publication23-Feb-2022

Correspondence Address:
Mr. David Ross
Department of Plastic and Reconstructive Surgery, Guy’s & St. Thomas Hospital, London.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_52_21

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Hernia surgery, and intra-abdominal surgery in general, have been accompanied by an increased risk of complications, largely due to a combination of operative complexity and obesity. Advances in care following major abdominal trauma, infections and complex abdominal procedures has led to the advent of several techniques that can allow dependable closure of these wider, more difficult defects. Anterior component separation (ACS) is a well-established technique used to achieve fascial closure in complex abdominal wall reconstruction (AWR). Wound related complications in the traditional ACS procedure have been reported to occur in 24%-50% of cases. In a quest to reduce complications and improve wound healing rates, methods have evolved in order to limit the anatomical injury caused by lateral elevation of flaps in the conventional techniques. These techniques involve preservation of the abdominal wall perforators. Thus ensuring appropriate perfusion of the overlying skin flaps. Perforator-sparing techniques have become increasingly important as they reflect greater understanding of how pre-operative planning can aid reduction of surgical risk, wound infection and improve wound healing in patients with complex abdominal wall hernias.

Keywords: Abdominal wall reconstruction, component separation, perforator sparing techniques

How to cite this article:
Mughal M, Ross D, Ross D. The open perforator sparing anterior component separation. Int J Abdom Wall Hernia Surg 2022;5:21-5

How to cite this URL:
Mughal M, Ross D, Ross D. The open perforator sparing anterior component separation. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Mar 24];5:21-5. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/1/21/338074

  Introduction Top

Hernia surgery, and intra-abdominal surgery in general, have been accompanied by an increased risk of complications, largely due to a combination of operative complexity and obesity.[1],[2] Difficulties in achieving durable wound closure, or catastrophic wound breakdown and infection, can result in long-term compromise of wound healing, exposure of underlying tissues, and recurrent herniation. Advances in mesh technology have aided support of the post-surgical abdominal wall, but these can be expensive and still prone to wound breakdown and recurrent herniation. Wound management is made further challenging if underlying mesh becomes exposed and infected.[3] Such complications produce significant patient morbidity and are difficult and expensive to treat.

Part of the challenge comes from treating a chronically exposed wound or trying to achieve closure in patients with a wide defect and the potential for tight wound closure. Advances in care following major abdominal trauma, infections, and complex abdominal procedures have led to the advent of several techniques that can allow dependable closure of these wider, more difficult defects. Anterior component separation (ACS) is a well-established technique used to achieve fascial closure in complex abdominal wall reconstruction (AWR).

The principles of surgical technique for what is now termed component separation were described by Gibson[4] in 1920, where he gained laxity of the abdominal wall by incising the lateral anterior sheath. This was followed by Albanese[5] and Young[6] describing an incision in the external obliques in 1951 and 1960s, respectively. The technique described by Ramirez et al.[7] included mobilization of the rectus abdominis muscle to the midline utilizing release of the external oblique muscle and fascia. The attachments of the external oblique muscle at the costal margin superiorly and the groin inferiorly restrict medial mobilization resulting in a 2 cm advancement at the epigastrium, a 4 cm advancement at the midline, and 2 cm at the groin on each side; however, division of the external oblique fascia 2 cm lateral to the linea semilunaris from the costal margin to the inguinal ligament with elevation of the external oblique from the internal oblique muscles allows 3 cm at the epigastrium, 5 cm at the midline, and 2 cm inferiorly, thus allowing 10 cm of medial migration.

Such advancements allowed surgeons to close defects that had previously been amenable to a bridging repair only. The addition of a mesh in the retrorectus plane is added to this technique as the main goal in treating ventral hernias is to achieve primary fascial closure, reinforce attenuated tissue, and reduce tension along the midline scar. These techniques were popularized by Ramirez et al.[7] in 1990 and termed anterior component separation and have become the key method of obtaining durable repair of the complex anterior abdominal defect.

Fascial closure provides structural and functional restoration of this crucial anatomical composite and is further assisted by repositioning of the recti to the midline. However, in achieving repair of the abdominal corset, it is essential to also ensure robust and durable skin cover. In the classical method described by Ramirez et al., access to the external oblique aponeurosis is obtained by elevation of large skin flaps. The skin edge is elevated from the immediate medial wound edge at the junction between the rectus fascia and overlying sub-Scarpa’s fat. In essence, a large laterally based flap is raised, effectively over the majority of each side of the abdomen. As these flaps are elevated, the defect and the displaced rectus fascia become exposed and allow access to the lateral rectus fascia, prior to release.

Flap elevation by this conventional route thus entails dividing musculocutaneous perforators that pass vertically through the recti and disrupting vascularity to this large area of anterior abdominal skin. Such wide de-gloving creates significant dead space that can also increase susceptibility to seroma or abscess formation. Wound-related complications in the traditional ACS procedure are thus common and reported to occur in 24%-50% of the cases.[5],[6],[7]

In a quest to reduce complications and improve wound healing rates, methods have evolved in order to limit such additional anatomical injury by looking to preserve perforators and their associated perfusion of the crucial overlying skin flaps. As such, perforator sparing techniques have become increasingly important as they reflect greater understanding of how pre-operative planning can aid reduction of surgical risk in this crucial aspect of abdominal surgery.

  Anatomical Considerations Top

The blood supply to the anterior abdominal wall is largely dependent upon musculocutaneous perforators arising from deep vessels [Figure 1]. The zones of Huger guide planning in AWR; the central zone, Huger Zone I, is supplied by the deep inferior epigastric and superior epigastric vessels, and the lower abdominal wall, Zone II, is supplied by the superficial inferior epigastric, superficial external pudendal, and superficial circumflex iliac arteries. Zone III, the lateral abdominal wall, is supplied by the intercostal, subcostal, and lumbar arteries.{Figure 1}

An analysis of the vascular anatomy of the anterior abdominal wall shows that the perforating branches of the deep inferior epigastric artery provide the main blood supply to the abdominal skin flap.[8] In a traditional ACS approach, the perforators to zone I are entirely disrupted, forming a potential area of reduced vascularity to the central part of the wound. Ideally, when undermining the skin and subcutaneous tissue where possible, efforts should be made to identify and preserve remaining perforators [Figure 2].
Figure 2: A: This patient has undergone MICS. (A) Perforators to the anterior abdominal wall spared during lateral dissection and (B) shows the tunnel to gain access to the lateral rectus margin. B: (A) Perforators supplying the anterior abdominal wall

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More specifically, the periumbilical perforators (PUPs), mostly inferior and lateral to the umbilicus, contribute as a significant source of vascularity to the medial abdominal wall skin flap.[9] As the midline closure is the area of highest tension, loss of these PUPs can lead to ischemia and consequently soft tissue necrosis. The plastic surgery literature has a number of references that show that maintaining epigastric perforators can sustain large myocutaneous flaps and resist tissue necrosis and infection.[8],[9],[10]

  Perforator Preserving Techniques Top

The described perforator preserving techniques can be categorized into four types:

  • Open release with preservation of the PUPs;

  • Endoscopic CS;

  • Open release with additional costal margin release; and

  • Minimally invasive component separation (MICS).

  •   Open release with preservation of the PUPs Top

    This technique, first described by Dumanian et al., involves dissection of the supra-umbilical skin and fat off the anterior rectus sheath for a width of 8 cm to identify the linea semilunaris. Lateral dissection continues till the linea semilunaris is visualized. A second infra-umbilical access is created with supra-fascial dissection, and the two spaces are connected for better visualization of the linea semilunaris. The PUPs are carefully preserved [Figure 1]. Some surgeons have described leaving a wedge of periumbilical fat undisturbed while the dissection is continued laterally.[11],[12] In preserving the PUPs, this technique requires extensive undermining, creating a large dead space, that may predispose to seroma formation and wound complications.

      Endoscopic CS Top

    In the endoscopic technique, the component separation is performed with an endoscope, while the remaining procedure is performed via an open approach.[13],[14] This technique is further discussed in another article in detail.

      Open release with additional costal margin release Top

    Saulis and Dumanian[12] also described an alternative to the open approach, utilizing supplemental subcostal transverse incisions through which the external oblique is longitudinally incised while preserving the PUPs. This technique involves less undermining than the above-described non-endoscopic open method.

      Minimally invasive component separation Top

    MICS was described and popularized by Butler and Campbell[15] in 2011; this technique avoids the use of endoscopic instruments and additional access incisions and involves less undermining and tissue elevation than the aforementioned open techniques. MICS was originally described using a bioprosthetic mesh or synthetic mesh, placed in the retrorectus, pre-peritoneal, or intraperitoneal plane.[15] Following hernia reduction and adhesiolysis, two horizontal subcutaneous tunnels (3 cm wide and 2 cm inferior to the costal margin) are dissected superficial to the anterior rectus sheath from the midline to the linea semilunaris.

    Through these access tunnels, the external oblique aponeurosis is vertically incised 1.5 cm lateral to the linea semilunaris. The tip of a metal Yankauer suction handle, without suction, is inserted through the opening in the avascular plane between the external oblique and internal oblique aponeurosis to separate them at their junction with the rectus sheath. The internal and external oblique aponeurosis is separated using sweeping motions of the Yankauer sucker in this plane. A narrow (2.5 cm wide) subcutaneous tunnel is created with electrocautery superficial to the external oblique aponeurosis, using a lighted retractor. The external oblique fascia is incised 1.5–2 cm lateral to the linea semilunaris. The midline soft tissues are then elevated off the anterior sheath laterally to the medial row of rectus abdominus muscle perforators.

    A bioprosthetic or synthetic mesh is placed as an underlay in the pre-peritoneal plane, retrorectus plane deep to the posterior rectus sheath, and anchored with polypropylene sutures. The rectus muscle is approximated over the midline using interrupted or running polypropylene sutures. The dead space is reduced by placing quilting sutures between the anterior rectus sheath and the overlying abdominal wall subcutaneous tissue. Drain placement is between the underlay mesh and the fascial closure, the CS donor sites, and along the subcutaneous plane of the midline closure.[15],[16]

      Discussion Top

    ACS has proven to be a very effective and reliable method of achieving wound closure and hernia repair in the face of significant defect and deformity. The original descriptions illuminated a method by which abdominal tissues of key layers can be isolated or released and then mobilized medially to cover wound gaps of more than 15–20 cm in some cases. In order to access the lateral fascia, it was necessary to widely elevate the abdominal skin flaps laterally and divide perforators that otherwise act as important sources of blood supply to the overlying skin and fat. Blood supply to the wound surface and edge may be further compromised by any closure under tension, and the thickness of the skin flaps themselves. Wound breakdown following such large procedures can prove incredibly expensive to both the patient and the health system caring for them. Wound breakdown may require a considerable degree of specialist wound and nursing time in order to achieve wound healing in a poorly vascularized milleu, but the main risk is one of deeper wound infections, possibly involving mesh, and recurrent herniation.[1],[2],[3],[17],[18]

    Over the last decade, a number of modifications to the traditional open technique for CS have emerged, which are directed to limiting these limitations and lead to improved vascularity to the soft tissue, reduce dead space, and decrease wound complications. Wound complications are the main morbidity of complex AWR, expensive, and a major predictor of hernia recurrence.[3],[17],[18] Current literature reports a wound complication figure of almost 50%, following standard ACS.[1],[2],[3],[17],[18],[19] Ghali et al.,[19] in their study comparing standard CS with perforator sparing MICS, observed a wound complication rate of 44% in the open CS approach vs. 26% in the MICS cohort, with a statistically greater incidence of wound healing complications in the open CS group.

    More recently, Elhage et al.[20] compared wound complications and infection rates in patients undergoing conventional and perforator sparing ACS. The rate of wound complications was observed to be much lower in the perforator sparing groups when compared with conventional ACS (20.8% vs. 46.1%). Wound infection rates were also lower for the perforator sparing technique (9.1% vs. 21.1%).

    However, although not statistically significant, the hernia recurrence rate in the PS ACS group was lower at 4.4%, compared with 7% recurrence rate in the conventional ACS group. They also note that the PS group had hernias with higher rates of VHWG grading.[20]

    In addition, a review of 107 patients who underwent[20] either an open technique or the MICS technique showed that, despite a larger mean hernia defect size, patients undergoing the MICS technique had a significantly lower rate of skin dehiscence (11% vs. 28%) and wound healing complications (14% vs. 32%).[21]

    A key outcome measure of the success of AWR is the rate of hernia recurrence. However, previous studies in perforator preserving techniques have not shown a decrease in hernia recurrence rates. Saulis and Dumanian[12] observed wound breakdown rate of 8.3% (1/12), infection in 8.3% (1/12), and no statistically significant difference in recurrence rates using open perforator sparing component separation. Giurgius et al.[22] reviewed their data following endoscopic CS and observed a significantly reduced wound complication rate (19% vs. 57%) using this relatively minimally invasive method. However, again, they reported a similar rate of hernia recurrence as compared to open methods. Lowe et al.[13] described their experience of using endoscopic balloon dissection to maintain PUPs; in this limited cohort, they reported a hernia recurrence in 14% of the cases. Clarke[23] continued endoscopic dissection to spare PUPs and their cohort observed a 13.8% recurrence rate.

    AWR has multiple complex nuances which need to be understood and adjusted based on the clinical scenario. Preservation of the vascularity of the abdominal wall in complex abdominal reconstruction is an anatomical challenge. Patient optimization is vital in improving outcomes from modifiable risk factors such as diabetes, obesity, and smoking.

    Perforator sparing CS reduces wound complications in patients undergoing complex AWR, maintains similar recurrence rates, and does not increase the operative time. Hernia recurrence is an important outcome measure for successful AWR. However, further studies are required to assess the true significance of perforator sparing techniques in improving hernia recurrence. Current studies suggest that there is a decrease in recurrence rates in perforator sparing techniques, even in complex higher-grade hernias.[19],[20]

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    Conflicts of interest

    There are no conflicts of interest.

      References Top

    Girotto JA, Ko MJ, Redett R, Muehlberger T, Talamini M, Chang B. Closure of chronic abdominal wall defects: A long-term evaluation of the components separation method. Ann Plast Surg 1999;42:385-94; discussion 394-5.  Back to cited text no. 1
    Heniford BT, Ross SW, Wormer BA, Walters AL, Lincourt AE, Colavita PD, et al. Preperitoneal ventral hernia repair: A decade long prospective observational study with analysis of 1023 patient outcomes. Ann Surg 2020;271:364-74.  Back to cited text no. 2
    Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, et al Ventral Hernia Working Group. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544-58.  Back to cited text no. 3
    Gibson CL. Operation for cure of large ventral hernia. Ann Surg 1920;72:214-7.  Back to cited text no. 4
    Albanese AR. [Gigantic median xipho-umbilical eventration; method for treatment]. Rev Asoc Med Argent 1951;65:376-8.  Back to cited text no. 5
    Young D. Repair of epigastric incisional hernia. Br J Surg 1961;48:514-6.  Back to cited text no. 6
    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. 7
    Nahai F, Brown RG, Vasconez LO. Blood supply to the abdominal wall as related to planning abdominal incisions. Am Surg 1976;42:691-5.  Back to cited text no. 8
    Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32:32-8.  Back to cited text no. 9
    Shao JM, Alimi Y, Conroy D, Bhanot P. Outcomes using indocyanine green angiography with perforator-sparing component separation technique for abdominal wall reconstruction. Surg Endosc 2020;34:2227-36.  Back to cited text no. 10
    Dumanian GA. Abdominal wall reconstruction. Grabb and Smith’s Plastic Surgery. 7th ed. Wolters Kluwer Health Adis (ESP). Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2013. p. 933-40.  Back to cited text no. 11
    Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg 2002;109:2275-80; discussion 2281-2.  Back to cited text no. 12
    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; quiz 730.  Back to cited text no. 13
    Gonzalez R, Rehnke RD, Ramaswamy A, Smith CD, Clarke JM, Ramshaw BJ. Components separation technique and laparoscopic approach: A review of two evolving strategies for ventral hernia repair. Am Surg 2005;71:598-605.  Back to cited text no. 14
    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. 15
    Garvey PB, Bailey CM, Baumann DP, Liu J, Butler CE. Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction. J Am Coll Surg 2012;214:131-9.  Back to cited text no. 16
    Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, et al. Epidemiology and cost of ventral hernia repair: Making the case for hernia research. Hernia 2012;16:179-83.  Back to cited text no. 17
    Augenstein VA, Colavita PD, Wormer BA, Walters AL, Bradley JF, Lincourt AE, et al. CeDAR: Carolinas equation for determining associated risks. J Am Coll Surg 2015;221:S65-6.  Back to cited text no. 18
    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. 19
    Elhage SA, Marturano MN, Prasad T, Colavita PD, Kercher KW, Augenstein VA, et al. Impact of perforator sparing on anterior component separation outcomes in open abdominal wall reconstruction. Surg Endosc 2021;35:4624-31.  Back to cited text no. 20
    Kapur SK, Butler CE (December 2, 2019). Refinements and Advancements in Anterior Component Separation, Techniques and Innovation in Hernia Surgery, Angelo Guttadauro, IntechOpen, doi:10.5772/intechopen.90346.  Back to cited text no. 21
    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. 22
    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. 23


      [Figure 1: A], [Figure 2]


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