Component separation technique for a very large abdominal wall hernia

• 28 years male.• Abdominal distention since 1 month.• P/A- Large Ventral Hernia with widely gappingrecti muscles, thinning of overlying skin, grossabdominal distention.• Past history: Ileostomy and Colostomy formegacolon with Crohn’s Colitis followed by closureof stoma.

Planned for Incisional hernia repair (component separation technique)

with mesh

Step 1. Incision planning Skin incision is planned considering the size of the defect and

the laxity of the overlying skin.

Step 2. Lateral dissection• Extensive lateral dissection is done on both sides beyond

the rectus muscle to expose the external oblique aponeurosis.

Step 3. Bilateral Lateral Incision on external oblique aponeurosis

Long vertical incisions areplaced on both sidesstarting from costalmargin up to the pelvicbone inferiorly on bothsides.

Step 4. Dissection between external and internal oblique muscles

• Extensive blunt dissection done in between the two muscles in an avascular plane to separate the components and gain 7-10 cm medial shift of the anterior component.

• If necessary posterior incision on posterior rectus sheath can also be placed to further gain a shift of 3-4 cm.

Step 5. Midline mass closure with interrupted sutures

Midline closure wasdone without tensionwith interrupted nonabsorbable no 1sutures

Step 6. Overlay repair with Polypropelene mesh

A large piece ofpolypropylene mesh (30* 15 cm) is placed overthe repair to have anadequate cover andoverlap all around thedefect and fixed toparities with sutures.

Step 7 Closure with negative suction drains

Post-operative Course

• Liquids were started on 2nd POD.• Semisolid diet on 3rd POD and normal diet on 4th POD.• Drains removed on 7th POD. • Discharged on 7th POD.

Conclusion

• Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. 10 cm on each side to cover the defect without tension.

• An overlay mesh repair is performed to reinforce the mass closure

• This technique can prevent intra-abdominal compartment syndrome and postoperative pain and can allow tension free repair of large hernias