banner

Component Separation

When is Component Separation required?


What is Component Separation?

Component Separation is release of a group of Abdominal muscles so that, they can be pulled towards midline to help in closing the Hernia or Abdominal wall defect.

This concept was first proposed by Ramirez in 1990 (Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg (1990) 86(3):519–26). This was in fact an “Anterior Component Separation” This procedure involves taking an incision on External oblique aponeurosis lateral to the Rectus sheath ( Linea Semilunaris) from Costal margin to Inguinal region. It then  involves separating the two cut edges of External oblique aponeurosis.

This releases the underlying Internal Oblique and Transversus Abdominis muscle with its combined attachment to Linea Semilunaris, preserving the nerves passing between them intact. Then the Rectus sheath, Rectus Abdominis muscle can be pulled towards midline, and linea alba can be recreated by closing them in midline.

This restores the anatomical structural integrity of the Abdominal wall and also the functions.

Later, many other types of Component separation were described and constituted ” Posterior Component separation” Carbonell described the posterior Component separation through the Retro-rectus approach, but that involved dissection between Internal Oblique and Transversus Abdominis which in fact is damaging to the nerves traveling between them. The real revolution happened when Yuri Novitsky described TAR: the Transversus Abdominis release procedure. This TAR procedure has now become synonymous with “Posterior Component separation”.

The Anterior Component Separation Surgery can be done with an open surgery technique, or an Endoscopic Technique.

The Open surgery involves raising of large skin flaps to Anterior Axillary line this can lead to necrosis of surrounding edges causing prolonged healing issues.

Endoscopic component separation on the other hand, can be done without raising skin flaps : Thus the incidence of skin flap necrosis is almost negligible and patients can go home early.

The TAR procedure which started as an open surgical procedure, now is also done through many different approaches like Laparoscopic, Robotic, e-TEP etc.

 

Technique of Endoscopic Anterior Component Separation:

This can be done either as a Subcutaneous technique or Sub- External oblique technique.

Subcutaneous Technique:

  1. A camera port is inserted in the subcutaneous space either in subcostal region or lateral iliac fossa, lateral to the Linea Semilunaris
  2. The subcutaneons space in expanded using a Balloon, Co2 or Telescopic dissection
  3. Once the space in developed from costal margin to Inguinal region, additional working port is inserted
  4. Then The External Oblique aponeurosis is incised (cut) lateral to the Linea Semilunaris, from costal margin to Inguinal Region.
  5. The edges of cut External Oblique are separated.
  6. Additional dissection done between External & Internal Oblique.
  7. This procedure is repeated on both sides.

 

This releases the underlying muscles so that closure of midline becomes possible

The Sub- External Oblique approach/Technique:

  1. A small incision in taken generally in the subcostal region, lateral to the Linea Semilunaris
  2. External Oblique muscle is identified and incised between sutures.
  3. The space between External and  Internal Oblique is dissected with a balloon or finger dissection.
  4. A 11 mm Trocar is introduced between External and  Internal oblique.
  5. Telescope is introduced and  Co2 insufflation started.
  6. The space between External and Internal Oblique in further expanded by blunt Telescopic dissection and  a working port is introduced laterally.
  7. The External Oblique aponeurosis is incised 1 to 2 cms lateral to the Linea Semilunaris from costal margin to the Inguinal region.
  8. The cut edges are separated from each other.
  9. Further dissection is done between External and  Internal oblique
  10. The procedure is repeated on the other side and completed  bilaterally.

 

How wide a defect can be closed by this Anterior Component Separation:

A defect of as wide as 16cms can be closed in Umbilical region.

At the Xiphisternum and pubic region the defect of maximum 8 to 10cms can be closed.

 

Advantages of Endoscopic Anterior Component Separation:

It can be done in open as well as Laparoscopic Repair.

The Endoscopic Technique can be combined with open Ventral Hernia Repair as well as Laparoscopic Repair.

Skin flap necrosis is prevented to a large extent.

logo

Useful Links

www.sages.org
www.websurg.com

Contact us

Email ID

awrsurgeons@gmail.com

Phone No

+91 8379083799 / +91 97182 36969

Designed by LBM INFOTECH