Background
The stable and dynamic muscular support provided by the component separation technique has lead to lower rates of recurrence in comparison to other techniques for complex abdominal hernia repair. Despite the success in reduction of hernia recurrence, local wound complications have been prevalent with this method of repair (i.e. wound dehiscence, ischemia, necrosis, infection, and seroma, etc.) Component separation, as initially described by Ramirez, necessitates extensive undermining of subcutaneous tissue, which can adversely interrupt the arterial perforators supplying the overlying skin. The purpose of the study is to demonstrate a novel, minimally invasive method for component separation.
Methods
A retrospective case series of three patients, who underwent midline ventral hernia repair via a minimally invasive component separation technique, was reviewed. Clinical outcomes of particular interest included wound dehiscence, wound infection, seroma rates, skin necrosis, and hernia recurrence. The minimally invasive component separation of parts technique utilized was as follows: 1) after completion of midline incision, excision of underlying hernia sac, and hernia reduction, two 3-4cm transverse incisions were made lateral to the semilunar lines within the waistline bilaterally (Figure 1A-1B). 2) A 300cc balloon dissector (Spacemaker, Covidien, Mansfield, MA) was then inserted into the subcutaneous plane and advanced superiorly to the costal margin (Figure 1C). 3) Utilizing lighted fiberoptic retractors, the external oblique fascia was then identified, and the overlying fascia as well as underlying external oblique muscles were incised under direct visualization (Figure 1D). 4) Bilateral myofasciocutaneous flaps were then created, with minimal subcutaneous undermining. Complete preservation of the perforating vessels from the deep epigastric arcade was accomplished. 5) Finally, adequate release of the flaps was achieved to allow for low-tension approximation of the rectus abdominis edges during closure.
Results
A total of three patients have undergone ventral hernia repair utilizing this technique. No significant complications such as wound dehiscence, infection, seromas, or recurrences have been observed. Follow-up has ranged from 3-12 months.
Discussion
Complex abdominal ventral hernias have become an increasingly common problem encountered by plastic surgeons. The component separation method for ventral hernia repair has been well established. However, this method does have significant morbidities associated with the large flaps typically employed in hernia repair. In this paper, a novel minimally invasive component separation technique has been described. By minimizing the size of the subcutaneous wounds created when raising large flaps, the method described in this study provides many of the established advantages traditionally seen in previously reported endoscopic separation of parts methods. However, unlike endoscopic techniques, this method stands as a more practical and cost-effective adaptation. Direct visualization utilized in this technique relinquishes the need for advanced endoscopic visual equipment and specialized endoscopic surgical training. Given the utilization of routine operating room equipment and a more simplified approach, plastic surgeons currently performing traditional component separation could begin to offer this procedure following a short learning curve.