title: Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.
abstract: BACKGROUND
  Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias.
  
  
  METHODS
  The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement.
  
  
  RESULTS
  The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations.
  
  
  CONCLUSIONS
  Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.
authors.affiliation: Hershey, Pa. From the Divisions of Plastic Surgery and Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Jones
authors.forename: Joshua S
authors.initials: JS
authors.lastname: Winder
authors.forename: John D
authors.initials: JD
authors.lastname: Potochny
authors.forename: Eric M
authors.initials: EM
authors.lastname: Pauli
mesh_terms: D000009:Abdominal Muscles / Q000601:surgery*; D034861:Abdominal Wall / Q000601:surgery*; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D016896:Treatment Outcome; D014945:Wound Healing
references.citation: Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg. 1990;86:519–526
references.citation: Souza JM, Dumanian GA. An evidence-based approach to abdominal wall reconstruction. Plast Reconstr Surg. 2012;130:116–124
references.citation: Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg. 2014;133:688e–701e
references.citation: Sailes FC, Walls J, Guelig D, et al. Synthetic and biological mesh in component separation: A 10-year single institution review. Ann Plast Surg. 2010;64:696–698
references.citation: Ghazi B, Deigni O, Yezhelyev M, Losken A. Current options in the management of complex abdominal wall defects. Ann Plast Surg. 2011;66:488–492
references.citation: de Vries Reilingh TS, van Goor H, Charbon JA, 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;31:756–763
references.citation: Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: A novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204:709–716
references.citation: Raigani S, Criss CN, Petro CC, Prabhu AS, Novitsky YW, Rosen MJ. Single-center experience with parastomal hernia repair using retromuscular mesh placement. J Gastrointest Surg. 2014;18:1673–1677
references.citation: Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ. Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia. 2015;19:285–291
references.citation: Petro CC, Como JJ, Yee S, Prabhu AS, Novitsky YW, Rosen MJ. Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen. J Trauma Acute Care Surg. 2015;78:422–429
references.citation: Petro CC, Orenstein SB, Criss CN, et al. Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients. Am J Surg. 2015;210:334–339
references.citation: Stoppa R, Petit J, Abourachid H, et al. Original procedure of groin hernia repair: Interposition without fixation of Dacron tulle prosthesis by subperitoneal median approach. Chirurgie. 1973;99:119–123
references.citation: Rives J, Pire JC, Flament JB, Palot JP, Body C. Treatment of large eventrations: New therapeutic indications apropos of 322 cases. Chirurgie. 1985;111:215–225
references.citation: Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13:545–554
references.citation: Wantz GE. Giant prosthetic reinforcement of the visceral sac: The Stoppa groin hernia repair. Surg Clin North Am. 1998;78:1075–1087
references.citation: Novitsky YW, Porter JR, Rucho ZC, et al. Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias. J Am Coll Surg. 2006;203:283–289
references.citation: Iqbal CW, Pham TH, Joseph A, Mai J, Thompson GB, Sarr MG. Long-term outcome of 254 complex incisional hernia repairs using the modified Rives-Stoppa technique. World J Surg. 2007;31:2398–2404
references.citation: Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia. 2008;12:359–362
references.citation: Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am. 2013;93:1111–1133
references.citation: Cobb WS, Burns JM, Peindl RD, et al. Textile analysis of heavy weight, mid-weight, and light weight polypropylene mesh in a porcine ventral hernia model. J Surg Res. 2006;136:1–7
references.citation: Shankaran V, Weber DJ, Reed RL II, Luchette FA. A review of available prosthetics for ventral hernia repair. Ann Surg. 2011;253:16–26
references.citation: Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg. 2013;217:991–998
references.citation: Jones CM, Potochny JD, Pauli EM. Posterior component separation with transversus abdominis release: Technique and utility in challenging abdominal wall reconstruction cases. Plast Reconstr Surg. 2014;134:116
references.citation: Zuvela M, Galun D, Djurić-Stefanović A, Palibrk I, Petrović M, Milićević M. Central rupture and bulging of low-weight polypropylene mesh following recurrent incisional sublay hernioplasty. Hernia. 2014;18:135–140
references.citation: Petro CC, Nahabet EH, Criss CN, et al. Central failures of lightweight monofilament polyester mesh causing hernia recurrence: A cautionary note. Hernia. 2015;19:155–159
references.citation: Hope WW, Hooks WB III. Atypical hernias: Suprapubic, subxiphoid, and flank. Surg Clin North Am. 2013;93:1135–1162
references.citation: Kim HS, Kim KB, Hwang HY, Chang HW, Park KJ. Subxiphoid incisional hernia development after coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg. 2012;45:161–165
references.citation: Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg. 2003;90:784–793
references.citation: Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction: Lessons learned from 200 “components separation” procedures. Arch Surg. 2009;144:1047–1055
references.citation: Tong WM, Hope W, Overby DW, Hultman CS. Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation. Ann Plast Surg. 2011;66:551–556
references.citation: Hultman CS, Tong WM, Kittinger BJ, Cairns B, Overby DW, Rich PB. Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center. Ann Plast Surg. 2011;66:504–507