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1. Abdominal Wall Reconstruction
Anterior and Posterior Component
Separation
Jin S. Yoo M.D.
Assistant Professor of Surgery
Duke University Medical Center
Jin.S. Yoo@duke.edu

2. Disclosures
Page 2
• The discussion will focus on hernias that are big
enough and/or warrant an AWR approach
NON-ELECTIVE
SMALL HERNIA
ELECTIVE
SMALL HERNIA
NON-ELECTIVE
LARGE HERNIA
ELECTIVE
LARGE HERNIA

3. AWR techniques
• External component separation (ECS)
- “Ramierz CS”
- can also be performed endoscopically
• Posterior component separation (PCS)
- “Transversus abdominis muscle release” (TAR)
- can also be performed laparoscopically or robotically
• Chemical component separation (CCS)
Page 3

4. Page 4

5. AWR Techniques
External CS
Page 5

6. Open Anterior Component Separation

7. Page 7
SLIDE courtesy of Robert Martindale

8. Page 8
SLIDE courtesy of Robert Martindale

9. Page 9
SLIDE courtesy of Robert Martindale

10. Page 10
SLIDE courtesy of Robert Martindale

11. Page 11
Anterior CS VIDEO

12. AWR Techniques
Posterior CS
TARS
Page 12

13. Posterior Component Separation
• Minimizes subcutaneous
dissection
• Allows for wide overlap of
mesh in the
extraperitoneal position
• Difficult to perform
• Less pull (6-8 cm) than
Ramirez’s CST
Page 13
Carbonell AM et al. . Hernia 2008; 12 (4); 359-62

14. Starts off as a Rives-Stoppa
rectrorectus repair…
Page 14

15. Rosen MJ. Atlas of Abdominal Wall Reconstruction
Gain access to retro-rectus space at midline

16. Dissect to linea semilunaris
Rosen MJ. Atlas of Abdominal Wall Reconstruction

17. Coverage of the defect at the midline which
provides space for wide mesh overlap
Rosen MJ. Atlas of Abdominal Wall Reconstruction

18. Ideal position for mesh with well vascularized
tissue on both sides
Rosen MJ. Atlas of Abdominal Wall Reconstruction

19. But if you need more (1) mesh
overlap or (2) tension off the
anterior rectus fascia closure,
then continue on with transversus
abdominis muscle release…
Page 19

20. Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed
Exposure of posterior sheath

21. Rosen MJ. Atlas of Abdominal Wall Reconstruction
Incision of the posterior rectus sheath

22. Anatomy of the posterior sheath and landmarks
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

23. Rosen MJ. Atlas of Abdominal Wall Reconstruction
Transversus abdominis release

24. Exposure of transversus abdominis
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

25. Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

26. Release of transversus abdominis muscle
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

27. Development of preperitoneal space
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

28. Completion of release and midline advancement
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

29. Subxyphoid exposure
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

30. Page 30

31. Rosen MJ. Atlas of Abdominal Wall Reconstruction
Reapproximation of the posterior sheath

32. Rosen MJ. Atlas of Abdominal Wall Reconstruction
Mesh placement

33. Mesh fixation with transfacial sutures
Rosen MJ. Atlas of Abdominal Wall Reconstruction 2ed

34. Page 34
Posterior CS VIDEO
COURTESY OF Dr. Daniel Guerron

36. AWR Techniques
Chemical CS
Page 36

37. “Chemical” component separation
Botulinum toxin A
• Administered pre-op (1-4
weeks)
• Total dose 100 - 500 U
• 3-5 sites on each side
• Each muscular layer gets
injected
Page 37
Soltanizadeh S et al. PRS Global Open 2017

38. “Chemical” component separation
Botulinum toxin A
Page 38
Soltanizadeh S et al. PRS Global Open 2017

39. • Role as an adjunct for the larger hernias
Small  medium  large  very large
• Role for patients who recurred after previous CS
• Limiting factor – how are you going to do it?
- cost of Botox ($9-20 per unit)
- ultrasound
- skill set – radiologist? surgeon?
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“Chemical” component separation
Botulinum toxin A

40. AWR Techniques
Laparoscopic / Robotic CS
Page 40

41. You can do it, but…
• There is a learning curve…
- start small… (don’t do the “ultimate robotic hernia repair you
eventually want to do” right off the bat)
• Only proven benefit right now is less wound Cx (due
to avoiding larger incision)
• Trouble with reimbursement
- lesson learned from laparoscopic external CST experience
• Will it catch on?
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42. Summary of all 4 AWR approaches
ECS PCS CCS LAP/ROBOTIC
Difficulty
(technical)
4 2 --- 1 (most difficult)
Difficulty
(physical)
2 1 (most difficult) --- 3
Mesh overlap 2 1 (most overlap) 2 ---
Mesh location Onlay,
Rectrorectus,
Sublay
Preperitoneal Onlay,
Sublay
Rectrorectus,
Preperitoneal,
Sublay
Amount of
release
1 (most release) 2 2/3 1/2
Repeatable ? ? YES ?
Cost 3 3 1 (most
expensive)
2
Reimbursement 1 1 3 (least likely to
be reimbursed)
2
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