Anterior Component Separation: Open Surgery Technique


Complex Abdominal Hernias with large defects have been repaired with various techniques: However, Midline closure of Abdominal wall in defects more than 8 cms, has always been a problem, till Ramirez came up with his paper in 1990, describing Anterior Component Separation. This technique made it possible to mobilise the anterior Abdominal wall and close the defect. Soon many modifications came up to obviate the need to avoid the necrosis of skin flaps.


1. Large midline defects more than 6 to 8 cms
2. Closure of Abdominal wall (Midline)defects due to Trauma, Sepsis or Malignancy
3. Abdominal Compartment Syndrome either to treat or prevent raised IAH.


1. Opening the Abdomen with excision of diseased skin, Bad scar, previous Skin Graft, or Ulcer.
2. Reduction of Hernial Contents to Abdominal Cavity.
3.Adhesiolysis: it is important to free the Abdominal Wall completely uptill the Anterior Axillary line

4. Raising the skin flaps: the skin flaps have to be raised beyond the Linea Semilunaris till Anterior Axillary line and sometimes even beyond that, to expose the External Oblique Aponeurosis. The Flaps have to be raised from Costal Margin to inguinal region.

5.The External Oblique Muscle is now incised 1 to 2 cms Lateral to the Linea Semilunaris, from the Costal Margin to Inguinal Region: in Upper Abdominal defects, the Incision shoud be extended above the Costal margin.

6. Separation of Extenal Oblique from the Internal Oblique Muscle: this plane is avascular: this dissection can be extended all the way upto Mid-Axillary line. This will release the underlying Internal Oblique and Transversus Abdominis Muscle so that the Rectus Muscle, Sheath and the Linea Alba can be pulled towards midline for closure

7. The same Procedure is repeated on the Other side.

8.Mesh placement: this can be done either in the Retrorectus Plane or as an Onlay: In the Onlay method, a large Mesh is used to cover entire Abdominal wall from the lateral cut edge of External Oblique Aponeurosis to the other.

9. Reconstitution of Midline:The Linea Alba is recreated by Suturing the Medial Edge of Rectus Sheath to each other in the Midline by using a Nonabsorbable Suture: in Case of RetroRectus Mesh placement, the Posterior Rectus Sheath and the Anterior Rectus Sheath is closed separately.
10. Skin closure is done after placing drains to drain the large Subcutaneous space.

Precautions to be taken during the Surgery:
1. Skin flaps vascularity should be preserved as far as possible by limiting dissection, preserving subcutaneous fat with the Skin, deliberate preservation of Perforators, Tunnel technique etc.
2. Watch for raised Intra-Abdominal Pressures during closure by monitoring the peak Airway Pressures.
3. Use Macroporous Mesh
4. Prevent contact of Mesh with the Skin.


1. Raised IAP
2. Wound Infection SSI
3. Skin flap Necrosis
4. Mesh Infection
5. Intestinal Obstruction
6. Peritonitis due to missed/delayed Intestinal Perforation
7. Recurrence


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