Skip to main content
SpringerLink
Log in

Open transversus abdominis release in incisional hernia repair: technical limits and solutions

  • Review
  • Published:
Hernia Aims and scope Submit manuscript

Abstract

Introduction

Incisional hernias with a defect width of more than10 cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique.

Methods

A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions.

Results

The standard PCSTAR can generally be used for a defect width of up to 15–17 cm. For defects greater than 17 cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0–97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used.

Summary

For a defect width greater than 17 cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on friendly request.

References

  1. Capoccia Giovannini S, Podda M, Ribas S, Montori G, Botteri E, Agresta F, Sartori A, Charvatova H, Aiolfi A, Antoniou SA, Arvieux C, Berrevoet F, Boermeester MA, Campanelli G, Chintapatla S, Christoffersen MW, Dahlstrand U, De la Croix H, Dietz UA, Ferreira A, Fortenly RH, Gaarder C, Garcia Urena MA, Gok H, Hernandez-Granados P, Jisova B, Laver O, Lerchuk O, Lopez-Cano M, Mega M, Mitura K, Muysoms F, Oliva A, Ortenzi M, Petersson U, Piccoli M, Radu VG, Renard Y, Rogmark P, Rosin D, Senent-Boza A, Simons M, Slade D, Smart N, Smith SR, Stabilini C, Theodorou A, Torkington J, Vironen J, Woeste G, De Beaux A, East B (2023) What defines an incisional hernia as ‘complex’: results from a Delphi consensus endorsed by the European Hernia Society (EHS). Br J Surg. https://doi.org/10.1093/bjs/znad346

    Article  Google Scholar 

  2. Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, Berrevoet F, de Beaux AC, East B, Henriksen NA, Klugar M, Langaufova A, Miserez M, Morales-Conde S, Montgomery A, Pettersson PK, Reinpold W, Renard Y, Slezakova S, Whitehead-Clarke T, Stabilini C (2023) Midline incisional hernia guidelines: the European Hernia Society. Br J Surg 11012:1732–1768. https://doi.org/10.1093/bjs/znad284

    Article  Google Scholar 

  3. Ramirez OM, Ruas E, Dellon AL (1990) “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 863:519–526. https://doi.org/10.1097/00006534-199009000-00023

    Article  Google Scholar 

  4. Oprea V, Toma M, Grad O, Bucuri C, Pavel P, Chiorescu S, Moga D (2023) The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysis. Hernia 273:503–517. https://doi.org/10.1007/s10029-023-02745-8

    Article  Google Scholar 

  5. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2045:709–716. https://doi.org/10.1016/j.amjsurg.2012.02.008

    Article  Google Scholar 

  6. Grover K, Korenblit N, Babu A, Podolsky D, Carbonell A, Orenstein S, Pauli EM, Novitsky Y, Madani A, Sullivan M, Nieman D (2023) Understanding how experts do it: a conceptual framework for the open transversus abdominis release procedure. Ann Surg 2773:498–505. https://doi.org/10.1097/SLA.0000000000005756

    Article  Google Scholar 

  7. Zolin SJ, Fafaj A, Krpata DM (2020) Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia 242:333–340. https://doi.org/10.1007/s10029-020-02150-5

    Article  Google Scholar 

  8. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB (2016) Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 2642:226–232. https://doi.org/10.1097/SLA.0000000000001673

    Article  Google Scholar 

  9. Jones CM, Winder JS, Potochny JD, Pauli EM (2016) Posterior component separation with transversus abdominis release: technique, utility, and outcomes in complex abdominal wall reconstruction. Plast Reconstr Surg 1372:636–646. https://doi.org/10.1097/01.prs.0000475778.45783.e2

    Article  CAS  Google Scholar 

  10. Kushner B, Holden S, Blatnik J (2021) Surgical “error traps” of open posterior component separation-transversus abdominis release. Hernia 256:1703–1714. https://doi.org/10.1007/s10029-020-02321-4

    Article  Google Scholar 

  11. Siegal SR, Pauli E (2019) Posterior component separation/transversus abdominis release. Plast Aesth Res 6:25. https://doi.org/10.20517/2347-9264.2019.35

  12. Gibreel W, Sarr MG, Rosen M, Novitsky Y (2016) Technical considerations in performing posterior component separation with transverse abdominis muscle release. Hernia 203:449–459. https://doi.org/10.1007/s10029-016-1473-y

    Article  Google Scholar 

  13. Hodgkinson JD, Leo CA, Maeda Y, Bassett P, Oke SM, Vaizey CJ, Warusavitarne J (2018) A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias. Hernia 224:617–626. https://doi.org/10.1007/s10029-018-1757-5

    Article  Google Scholar 

  14. Wegdam JA, Thoolen JMM, Nienhuijs SW, de Bouvy N, de Vries Reilingh TS (2019) Systematic review of transversus abdominis release in complex abdominal wall reconstruction. Hernia 231:5–15. https://doi.org/10.1007/s10029-018-1870-5

    Article  Google Scholar 

  15. Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosenblatt S, Rosen S, Thompson R, Fafaj A, Thomas JD, Huang LC, Rosen MJ (2023) Long-term clinical and patient-reported outcomes after transversus abdominis release with permanent synthetic mesh: a single center analysis of 1203 patients. Ann Surg 2774:e900–e906. https://doi.org/10.1097/sla.0000000000005443

    Article  Google Scholar 

  16. Christopher AN, Morris MP, Barrette LX, Patel V, Broach RB, Fischer JP (2023) Longitudinal clinical and patient-reported outcomes after transversus abdominis release for complex hernia repair with a review of the literature. Am Surg 894:749–759. https://doi.org/10.1177/00031348211038580

    Article  Google Scholar 

  17. Carbonell AM (2008) Interparietal hernias after open retromuscular hernia repair. Hernia 126:663–666. https://doi.org/10.1007/s10029-008-0393-x

    Article  Google Scholar 

  18. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ (2012) Posterior and open anterior components separations: a comparative analysis. Am J Surg 2033:318–322; discussion 322. https://doi.org/10.1016/j.amjsurg.2011.10.009

  19. Winder JS, Majumder A, Fayezizadeh M, Novitsky YW, Pauli EM (2018) Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation. Hernia 222:303–309. https://doi.org/10.1007/s10029-018-1732-1

    Article  Google Scholar 

  20. Robin-Lersundi A, Blazquez Hernando L, López-Monclús J, Cruz Cidoncha A, San Miguel Méndez C, Jimenez Cubedo E, García-Ureña MA (2018) How we do it: down to up posterior components separation. Langenbecks Arch Surg 4034:539–546. https://doi.org/10.1007/s00423-018-1655-4

    Article  Google Scholar 

  21. Alkhatib H, Tastaldi L, Krpata DM, Petro CC, Olson M, Rosenblatt S, Rosen MJ, Prabhu AS (2019) Outcomes of transversus abdominis release in non-elective incisional hernia repair: a retrospective review of the Americas Hernia Society Quality Collaborative (AHSQC). Hernia 231:43–49. https://doi.org/10.1007/s10029-019-01878-z

    Article  Google Scholar 

  22. Punjani R, Arora E, Mankeshwar R, Gala J (2021) An early experience with transversus abdominis release for complex ventral hernias: a retrospective review of 100 cases. Hernia 252:353–364. https://doi.org/10.1007/s10029-020-02202-w

    Article  Google Scholar 

  23. Posielski NM, Yee ST, Majumder A, Orenstein SB, Prabhu AS, Novitsky YW (2015) Repair of massive ventral hernias with “quilted” mesh. Hernia 193:465–472. https://doi.org/10.1007/s10029-015-1375-4

    Article  Google Scholar 

  24. Garcia-Urena MA, Lopez-Monclus J, Cuccurullo D, Blazquez Hernando LA, Garcia-Pastor P, Reggio S, Jimenez Cubedo E, San Miguel Mendez C, Cruz Cidoncha A, Valle R, de Lersundi A (2019) Abdominal wall reconstruction utilizing the combination of absorbable and permanent mesh in a retromuscular position: a multicenter prospective study. World J Surg 431:149–158. https://doi.org/10.1007/s00268-018-4765-9

    Article  Google Scholar 

  25. San Miguel-Méndez C, López-Monclús J, Munoz-Rodriguez J, de Lersundi ÁRV, Artes-Caselles M, Blázquez Hernando LA, García-Hernandez JP, Minaya-Bravo AM, Garcia-Urena M (2021) Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias. Surgery 1704:1112–1119. https://doi.org/10.1016/j.surg.2021.04.007

    Article  Google Scholar 

  26. Cornette B, De Bacquer D, Berrevoet F (2018) Component separation technique for giant incisional hernia: a systematic review. Am J Surg 2154:719–726. https://doi.org/10.1016/j.amjsurg.2017.07.032

    Article  Google Scholar 

Download references

Author information

Author notes

  1. H. Riediger and F. Köckerling are contributed equally to this publication.

Authors and Affiliations

  1. Hernia Center, Vivantes Humboldt Hospital, Academic Teaching Hospital of Charité University Medicine, 13509, Berlin, Germany

    H. Riediger & F. Köckerling

Authors
  1. H. Riediger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. F. Köckerling
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to H. Riediger.

Ethics declarations

Conflict of interest

Prof. Dr. Köckerling reports grants to fund Herniamed from Johnson&Johnson, Norderstedt, Karl Storz, Tuttlingen, MenkeMed, Munich, DB Karlsruhe and personal fees from BD Karlsruhe. Dr. H. Riediger has nothing to disclose.

Ethical approval

Only cases of routine hernia surgery were documented in the Herniamed Registry and all patients have signed a special informed consent declaration agreeing to participate. The Herniamed Registry has ethical approval (BASEC No. 2016 - 00.123, 287/2017 BO2).

Human and animal rights

This article does not contain any Study with animals performed by any of the authors.

Informed consent

All patients with routine hernia surgery documented in Herniamed Registry have signed an informed consent declaration agreeing to participate.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Riediger, H., Köckerling, F. Open transversus abdominis release in incisional hernia repair: technical limits and solutions. Hernia (2024). https://doi.org/10.1007/s10029-024-02994-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10029-024-02994-1

Keywords

Search

Navigation