Complex Ventral Hernia Repair With Component Separation in High Risk Patient Population

Classic Surgical Teachings Hold True

Jordan N. Halsey MD; Nicholas C. Oleck MD; Farrah C. Liu MD; Sebastian Eid MD; Frank S. Ciminello MD


ePlasty. 2021;21(e5) 

In This Article

Abstract and Introduction


Background: Reconstructive techniques in complex abdominal wall reconstruction have evolved throughout the past decade. Improvements in mesh technology, along with the utilization of component separation, have allowed for the repair of massive hernia defects in complex cases involving patients with significant comorbidities. Notably, this procedure is often combined with panniculectomy.

Methods: The authors performed a retrospective review on all patients who underwent a complex ventral hernia repair with component separation with or without panniculectomy from 2015 to 2019 at Hackensack University Medical Center in Hackensack, New Jersey. Demographic data was obtained from medical records, including patient medical history, smoking status, and comorbidities, along with any prior hernia surgery.

Results: A total of 40 patients (27 females, 13 males) met inclusion criteria for the study. Every patient had at least 1 medical comorbidity. There were 3 active smokers and 13 former smokers. Hernia size ranged from 40 cm2 to 400 cm2 and component separation, either anterior or posterior, was performed on all patients. Mesh was included in 90% of cases, most commonly in a retrorectus position. Complications, including hematoma, late recurrence, pulmonary embolism, and closed-loop bowel obstruction, occurred in 5 patients. There were 13 patients with minor surgical site occurrences that resolved with local wound care. Concomitant panniculectomy, obesity, and higher American Society of Anesthesiologists (ASA) class were associated with a higher complication rate.

Conclusion: Complex hernia repair with component separation can be performed on high-risk patients safely with an acceptable outcome. This can be performed with panniculectomy with a potential increased risk of complications.


Abdominal wall reconstruction (AWR) has grown in both procedural variety and technical complexity over the last decade. Reconstructive techniques for complex ventral hernia repair (VHR) have improved dramatically over the past several years. The rise in the number of reconstructive options and the development of novel mesh technologies has led to an increase in durable hernia repairs with markedly improved surgical site occurrence rates and surgical outcomes.[1]

The advent of component separation, and its various iterations since inception, has allowed for closure of massive abdominal wall defects during VHR.[2] Cadaveric studies have demonstrated up to 10 cm of medial advancement of the abdominal musculature following an anterior component separation.[3] Posterior component separation with transverse abdominis release (TAR) may provide further advancement for even larger defects.[1] Hernia recurrence rates of 4% to 6% have been reported following TAR with sublay mesh reinforcement,[4,5] extending even to patients with significant comorbidities such as morbid obesity.[6] Perforator sparing dissection techniques have also been developed in order to preserve blood supply to the fasciocutaneous flaps created during component separation, decreasing postoperative wound complications and skin breakdown.[7,8]

Surgical mesh selection and the plane of mesh deployment also plays a significant role in VHR outcomes. While synthetic options are often preferred in clean surgical wounds, a clean-contaminated or contaminated field may require biological mesh, although significant controversy exists in the current literature regarding mesh selection.[2] The preferred site for mesh location is an under or sublay position, as lower hernia recurrence and postoperative complication rates have been demonstrated with this method when compared to onlay, inlay, or primary repair without mesh.[1,2]

Obesity is the most common comorbidity seen in patients presenting for VHR.[9] These patients are at an increased risk for both hernia recurrence and postoperative complications following AWR. This had been attributed in part to poor wound healing and decreased oxygen tension seen with excess subcutaneous fat of the abdominal wall.[10] In response, several studies have investigated concurrent panniculectomy following VHR.[11,12] While the results of these studies have varied considerably, the majority endorse that concurrent panniculectomy significantly reduces hernia recurrence rates but increases rates of wound complication.[11]

The variety of surgical options, mesh considerations, concurrent procedures, and frequency of medical comorbidities in the VHR population makes AWR a complex field which requires continued investigation. In this study, a single institution's experience with complex VHR over a three-year period is presented in order to elucidate the effect of medical comorbidities, reconstructive technique, and concomitant procedures on postoperative complication and hernia recurrence rates.