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CLINICAL PAPER

Comparison of Outcome After Mesh-Only Repair, LaparoscopicComponent Separation, and Open Component Separation

Winnie M. Y. Tong, MD,* William Hope, MD,† David W. Overby, MD,‡and Charles S. Hultman, MD, MBA*§

Abstract: Component separation (CS) has been advocated as the technique

of choice to reconstruct complex abdominal hernia defects, especially in the

setting of gross contamination. However, open CS was reported to have

relatively high incidences of wound complications. Minimally invasive

approaches to CS were proposed by several surgeons to reduce wound

morbidity. To date, there are limited comparative data between minimally

invasive CS (MICS) versus open CS. In this article, we reviewed existing

literature on open CS versus MICS with respect to their recurrence and

complication rates. Our analysis appeared to show that MICS has compara-

ble recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of com-

plications after MICS, we reported our experience of using MICS to repair

a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.

Key Words: component separation, ventral hernia repair, laparoscopy

( Ann Plast Surg 2011;66: 551–556)

Complex ventral hernia repair in the presence of infection pres-ents unique challenges for reconstruction. The use of autolo-

gous tissue to reconstruct complex defects has been advocated in thesetting of gross contamination in which prosthetic biomaterial iscontraindicated. In 1990, Ramirez et al1 first described component

separation (CS) by releasing the lateral abdominal wall myofascialunit to achieve up to 10 cm of unilateral rectus advancement. CScreates a dynamic repair of muscles along the midline by medial-ization of the rectus, thereby restoring a functional innervated abdominal wall in a tension-free closure. Case series have docu-mented wound complications namely seromas, subcutaneous ab-scess, and flap necrosis in up to 40% of cases.2 The extensivedissection and the division of the abdominal perforators necessary toraise large lipocutaneous flaps to access the lateral abdominalmusculature was thought to contribute to the high wound morbidityin open CS. Recognizing the limitations of open CS, attempts have

been made to use less invasive approaches. Minimally invasive CS(MICS) directly access the lateral abdominal wall by utilizing

balloon dissectors and laparoscopic or endoscopic visualization.

Several authors3–5 recently published their experience with MICSwith variable outcomes.

STUDY AIMSIn this study, we will review the literature on open CS and

MICS to determine whether there is a benefit to perform MICS for complex ventral hernia repair. We will also present a patient with arecurrent, incisional hernia who underwent MICS for hernia repair for definitive closure and describe how the postoperative complica-tion was managed.

METHOD

We reviewed the literature on open CS and MICS, withspecial attention paid to the hernia recurrence and complicationrates, to determine a better surgical option for complex ventralhernia repair.

Search StrategyElectronic databases on PubMed were searched between 2000

and 2010, and studies were identified using the words “componentseparation and hernia.”

Selection CriteriaStudies on either open CS or MICS for ventral or incisional

hernias, which were written in the English language, were included.Mixed studies that included other types of hernia repairs such asopen repairs with sutures alone or different prosthetic mesh wereincluded. We excluded studies that reported CS as part of a staged hernia repair. The primary outcome for the review was the number of patients who developed a recurrent incisional hernia. The sec-ondary outcomes for the review included length of follow-up;overall complication rate; and individual complications such asseroma, hematoma, enterocutaneous fistula, superficial infection,mesh infection, or dehiscence. Overall complication was defined asany systemic or wound complications that occurred postoperativelyas reported in the study.

Data AnalysisA list of studies on open CS is shown in Table 1, whereas

Table 2 shows the studies on MICS. Statistical analysis was not performed on the data.

RESULTSA total of 29 publications were retrieved and 6 studies were

excluded because the described operations did not involve ventral/incisional hernia repairs with the CS technique by either the MICSor open CS approach. Two studies were excluded because they did not contain any outcome data. The remaining 21 publications con-sisted of 927 patients who underwent one of the following opera-tions: open CS (803 patients), MICS (41 patients), mesh repair (66

patients), or suture repair (17 patients). Open CS can be further categorized into following 2 groups: open CS alone (75 patients, 11studies) and open CS with mesh (728 patients, 9 studies). Bothsynthetic and biologic meshes were included in the open CS with

mesh group. Among the 5 studies on MICS, there was 1 comparativestudy with open CS and the remaining 4 were case series. All thecase series report on MICS exclusively. The 16 studies on open CS

Received November 30, 2010, and accepted for publication, after revision,December 10, 2010.

From the *Divisions of Plastic Surgery, University of North Carolina, Chapel Hill, NC; †Division of Gastrointestinal Surgery, New Hanover Regional MedicalCenter, Wilmington, NC; and Divisions of ‡Gastrointestinal Surgery and §Burn Surgery, University of North Carolina, Chapel Hill, NC.

Supported in part by the Ethel and James Valone Plastic Surgery ResearchEndowment of the UNC Division of Plastic Surgery.

Presented at (as a poster) the 53rd Annual Scientific Meeting of the SoutheasternSociety of Plastic Surgeons, June 2010, Palm Beach, FL.

Reprints: Winnie Mao Yiu Tong, MD, Division of Plastic Surgery, University of North Carolina, 7040 Burnett Womack Building, CB 7195, Chapel Hill, NC27599–7195. E-mail: [email protected].

Copyright © 2011 by Lippincott Williams & WilkinsISSN: 0148-7043/11/6605-0551DOI: 10.1097/SAP.0b013e31820b3c91

Annals of Plastic Surgery • Volume 66, Number 5, May 2011 www.annalsplasticsurgery.com | 551

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TABLE 1. A List of Studies on Open Component Separation (CS)

ReferencePatient Characteristics,

Size of Defect Type of RepairNo.

PatientsComplications

(Complication Rate)

Hernia

RecurrenceRate

Mean

Follow-upin Months

6 Fistula, NA Open CS 2 Total 50% 0% 12

7 Recurrent hernia, NA Open CS bilaminar alloderm 16 Seroma 12%Superficial dehiscence 6%

0% 16

8 Recurrent hernia, NA Open CS onlay mesh 545 Hematoma 0.08%Seroma 5%Infected mesh 1.8%Enterocutaneous fistula 1%

18.3% NA

9 Hernia, 780 cm2 CS alloderm onlay/alloderminterposition/alloderm

prolene mesh

27 Total 22.2% None, but 7 withlaxity of alloderm

6.7

10 Burn patient decompressivelaparotomy, 750–1000 cm2

CS 3 Death 66% NA 3.5

11 Damage control celiotomyopen abdomen, NA

CS 8 Infection 25% 0% NA

CS mesh 3 Wound infection 33%Mesh infection 33%

33%

Mesh 4 Mesh infection 25%

Fistula 50%

0%

Primary closure 5 Seroma 25%Total 0%

0%

2 Temporary abdominalclosure, NA

CS 8 Intraoperative 28.6% 25% NA

CS mesh 2 Postoperative 66.7% 50%

CS tissue transfer 2 (No data on types of complications) 50%

Mesh 10 40%

Mesh tissue transfer 1 0%

Primary closure 7 43%

12 Hernia, 96 cm2 CS 1 Total 100% 0% NA

13 Hernia, NA Mesh 9 Total 30% 22% 56

Open CS 14 Seroma 22%Wound infection 9%

7%

14 Herniated gravid uterus, NA Open CS 1 Total 0% 0% 12

15 Morbid obese, NA Open CS mesh 90 Wound dehiscence 9%Deep infection 10%Mesh erosion 1%Hematoma 1%Seroma 3%Death, MI 1%

5.5% 50

16 Hernia, NA Open CS alloderm 22 NA 13% 22.2

Alloderm 15 NA 60%

17 Open abdomen or recurrenthernia, NA

Mesh (ePTFE) 18 Total 72%Wound infection 10%Skin necrosis 5%Hematoma 5%

22% 36

Open CS 19 Mesh removal 35%Total 52%

Wound infection 16%Skin necrosis 11%Hematoma 5%Seroma 21%

52%

18 Contaminated wound, NA Direct repair 3 Total 47% 0% 14

Mesh 5 40%

Open CS 2 0%

Open CS mesh 9 0%

19 Renal transplant, NA Direct repair 2 0% 50% 26

Mesh 5 0% 0%

Open CS 14 Total 14% 21%

20 Morbid obese, NA CS dermal graft from panniculectomy

2 Total 100%Abscess 50%Wound infection 50%

0% 16

ePTFE indicates expanded polytetrafluoroethylene; NA, not available; MI, myocardial infarction.

Tong et al Annals of Plastic Surgery • Volume 66, Number 5, May 2011

552 | www.annalsplasticsurgery.com © 2011 Lippincott Williams & Wilkins





included 1 randomized controlled study and 15 retrospective studies.Among these 15 retrospective studies on open CS, comparative datawere available for other types of hernia repair in 6 studies. Therewere 7 studies on mesh repair and 4 on suture repair. Results aresummarized in Table 3.

Length of Follow-up

The average length of follow-up was 29.3 months for openCS, 12.6 months for MICS, 31 months for mesh repair, and 18.8months for suture repair. When open CS was further categorized intoopen CS with mesh and open CS alone, the average length of follow-up was 33 months and 27 months, respectively. Data wereavailable on length of follow-up in 12 studies (75%) for open CS, 5studies (100%) for MICS, 5 studies (71%) for mesh repair, and 2studies (50%) for suture repair.

Hernia RecurrenceHernia recurrence was as follows: 21%, 17%, 33%, and 24%

for open CS, MICS, mesh repair, and suture repair, respectively.Open CS with mesh seemed to have lower recurrence rate than openCS alone (16.7% vs. 27%, respectively). Data on hernia recurrence

were reported in all studies on MICS, mesh repair, and suture repair,whereas 91% of the studies reported on open CS documented herniarecurrence rate.

ComplicationsOverall complication rates were as follows: 56% for mesh

repair, 35% for open CS, and 32% for MICS. There were insufficientdata to determine the complication rate on suture repair alone. Datawere available on overall complications in 11 studies (91%) for openCS, 5 studies (100%) for MICS, 2 studies (28%) for mesh repair, and 2 studies (50%) for suture repair. The rate of seroma among thegroups was 5.1%, 4.8%, 0%, and 0% for open CS, MICS, meshrepair, and suture repair, respectively. There were 2 hematomas inopen CS and 1 hematoma in mesh repair. There were 6 cases of enterocutaneous fistulas in open CS. There was 1 dehiscence in open

CS. There were 17 superficial infections and 21 mesh infections inopen CS. There were 8 mesh infections with mesh repair and 8wound infections in laparoscopic CS.

Minimally Invasive CS Versus Open CSA comparison between MICS and open CS showed compa-

rable hernia recurrence rates between the 2 groups (MICS 17%;open 21%). Overall complications were also similar in MICS(32%) and open CS (35%).

CS Versus Mesh RepairWhen hernia recurrence rates were compared between the

open CS method and the mesh repair method, the open CS rate(21%) appeared to fare better than mesh repair rate (33%). Similarly,the recurrence rate for endoscopic CS (17%) appeared to be lower than that of the mesh repair (33%). Comparative data on complica-tions for open CS and mesh repair were limited to a single random-ized study that showed comparable complication rate between the 2groups.

Open CS Alone Versus Open CS With MeshOpen CS was further divided into following 2 groups: open

CS with mesh and open CS alone. Patients who had open CS withmesh appeared to do better than those who had open CS alone.Fewer hernia recurrence (with mesh: 16.7% vs. without mesh: 27%)

and overall complication (with mesh: 21% vs. without mesh: 59%)appeared to be seen in open CS with mesh compared with open CSalone.

TABLE 2. A List of Studies on Minimally Invasive Component Separation (MICS)

ReferencePatient Characteristics,

Size of Defect Type of RepairNo.

PatientsComplications

(Complication Rate)

Hernia

RecurrenceRate

Mean

Follow-up inMonths

21 Hernia 382 cm2 MICS 22 Total 27% 27% 15

416 cm2

Open 22 Total 52% 32%22 Obese stoma, 367 cm2 Pannieculectomy MICS 3 Total 0% 0% 41.5

3 Hernia, 306 cm2 MICS laparoscopic hernia repair 4 Total 50%Seroma 50%

0% 1

23 Recurrent hernia, NA MICS mesh (FlexHD, Surgisis) 5 Total 40%Abscess 20%Hematoma 20%

20% 6

5 Infected mesh, 338 cm2 MICS 7 Total 43%Wound infection 14%Hematoma 14%

0% 4.5

4 Cadaver, NA Laparoscopic release of transversesabdominus and posterior sheath

10 NA NA NA

24 Porcine, NA MICS Open CS 5 NA NA NA

CS indicates component separation; NA, not available.

TABLE 3. Comparison of Open CS, MICS, Mesh Repair,and Suture Repair for Hernia

Open CS

(With and

Without

Mesh)

Open

CS

With

Mesh

Open

CS

Without

Mesh MICS

Mesh

Repair

Suture

Repair

Mean follow-upin months

29.3 33 27 12.6 31 18.8

Hernia recurrencerate

21% 16.7% 27% 17% 33% 24%

Total complicationrate 35% 21% 59% 32% 56% NA

Seroma rate 5.1% NA NA 4.8% 0% 0%

CS indicates component separation; MICS, minimally invasive component separa-tion; NA, not available.

Annals of Plastic Surgery • Volume 66, Number 5, May 2011 Comparison of Outcome

© 2011 Lippincott Williams & Wilkins www.annalsplasticsurgery.com | 553





Suture RepairHernia recurrence rate was 24% for suture repair. There were

insufficient data to determine the complication rate after suturerepair of hernia.

Overall, the data collected from the literature review appeared to indicate that the complication rate was comparable between open

CS and MICS. To highlight the management of postoperativecomplication after repair of a recurrent ventral hernia by MICSapproach, the following case study is presented.

CASE STUDYA 63-year-old man with a history of multiple abdominal

surgeries presented to clinic with an incisional hernia in need of definitive abdominal closure. His medical history started approxi-mately 1 year before presenting to us with a perforated duodenalulcer that was repaired with an omental patch, but the abdominalwound dehisced. He was taken to the operating room for placementof a jejunostomy tube and “bridging” abdominal closure with anacellular human dermis (FlexHD, Musculoskeletal Transplant Foun-dation, Edison, NJ). The bridging repair failed as the human acel-

lular dermis tore away from the fascia leaving the patient with anopen abdomen. Subsequently, he underwent a split-thickness skingraft over the open abdominal wound. However, an enterocutaneousfistula developed through the skin graft at his old jejunostomy tubesite (Fig. 1). Ultimately, when the nutritional and functional status of the patient improved, the enterocutaneous fistula was taken downand the abdominal wound was closed primarily.

When we examined the patient on the preoperative visit prior to his MICS operation, the patient was afebrile, normotensive, and in sinus rhythm. Examination of the abdomen showed a closed abdomen with necrotic skin edges (Fig. 2). There was a loss of domain. The abdomen was soft, nontender without guarding, or rigid. Laboratory studies were normal.

We performed definitive closure of the 30 15 cm hernia

defect (Fig. 3) using a combination of MICS and Rives-Stopparepair with synthetic mesh. This was accomplished by making anincision below the costal margin lateral to the rectus abdominusmuscle to expose the external oblique aponeurosis. After the poten-tial space was created between the external and internal oblique witha laparoscopic inguinal hernia balloon dissector, the external obliquewas incised longitudinally using coagulating scissors (Fig. 4). The

external oblique was incised superior to the costal margin to theinguinal ligament on the side contralateral to the gastrostomy tube.The Rives-Stoppa method was used to repair the ventral hernia witha coated polypropylene mesh (Proceed, Ethicon, Inc., Sommerville,

NJ). Blood loss was estimated to be 100 mL. He was discharged on postoperative day 16. He had a small area of wound dehiscence withmesh exposed at a clinic visit 2 weeks postoperatively (Fig. 5). Withdressing changes, the open wound eventually closed without a meshinfection. At 13-month follow-up, there was no hernia recurrenceand the patient’s wound has healed (Fig. 6).

DISCUSSIONComplex ventral hernia repair, in the setting of loss of domain

and unstable coverage as demonstrated in the case we presented,remains a difficult problem for many reconstructive surgeons. Asdescribed by Ramirez et al,1 CS provides a viable option in such

FIGURE 1. A 61-year-old man with a recurrent incisional her-

nia that was covered with a skin graft. He developed an en-terocutaneous fistula (black solid arrowhead) through theskin graft.

FIGURE 2. The enterocutaneous fistula was taken down andthe abdominal wall was closed but patient developed skin

flap necrosis.

FIGURE 3. The necrotic skin flap was debrided and the her-nia defect measured 30 15 cm.







situation by using autologous tissue to recreate a functional dynamicabdominal wall. However, earlier studies of open CS showed arelatively high wound complication rate.2 In an attempt to reducewound complications, which were felt to be due to the extensivedissection, required to raise the lipocutaneous flaps in open CS, aminimally invasive approach to CS has been advocated.3–5 To date,there is still a paucity of comparative data between open CS and MICS. This study reports the most current review of the existingliterature on the 2 procedures.

Our literature review did not appear to show that MICSreduce wound morbidity when compared with open CS. The onlydirect comparative study evaluating MICS to open CS was recently

published by Harth and Rosen21 and reported a trend toward lower

wound complications in MICS relative to open CS (27% vs. 52%,respectively), although there was no statistical significance. SinceMICS is a relatively novel technique and our analysis included allexisting studies, it is conceivable that some data included in our analysis may be a reflection of the learning curve of the surgeons.Therefore, our reported complication rate for MICS may be higher than the true value. Learning curves have been reported in other minimally invasive procedures. For example, Suter et al25 per-formed their initial 100 cases of laparoscopic Roux-en-Y gastric

bypass and reported a complication rate of 25% in their first 70 patients versus 2.7% in the last 30 patients. Assuming data fromother minimally invasive studies is applicable to MICS, the compli-cation rate in MICS may decrease as the surgeon experience in-creases. If more long-term data are available on MICS, we may be

able to see a benefit from this less invasive approach over open CS.Existing data, albeit limited, showed that the long-term out-come of MICS is comparable to open CS. The single comparativestudy21 on MICS and open CS showed a similar hernia recurrencerate between the 2 groups (32% in open CS vs. 27% in MICS; P 0.99). The mean follow-up periods for the open and minimallyinvasive groups in that study were similar (16 vs. 14 months,respectively; P 0.65). These findings are supportive of our resultsthat demonstrated hernia recurrence rates to be comparable betweenMICS and open CS. Long-term prospective studies are needed toresolve this issue.

Preliminary data appeared to indicate that patients undergoingCS for complex hernia repair would benefit from reinforcement with

prosthetic material.26 Our study seemed to suggest a benefit in

outcome from open CS with mesh relative to open CS alone.Patients who had open CS alone had higher hernia recurrence and complication rates than those who had open CS with mesh. Aretrospective study by Espinosa-de-los-Monteros et al26 alsoshowed a significantly lower recurrence rate when CS wasreinforced with biologic repair material (0%) relative to CS alone(13%; P 0.006). Again, long-term prospective studies areneeded to resolve this issue.

How CS compares to mesh repair in complex hernia cases iscontroversial. Admittedly, this study was not designed to compareCS with mesh repair, and we did not include all published studies onmesh repair in this review. However, preliminary analysis from our study proposed a trend toward lower hernia recurrence in either openor MICS when compared with open mesh repair. The use of

autologous tissue to restore a functional innervated abdominal wallin a tension-free closure in CS by minimally invasive or openapproach may improve the long-term durability of the hernia repair.

FIGURE 4. An incision was made lateral to the rectus abdo-

minus muscle to expose the external oblique aponeurosis(not shown). The external oblique was incised from superior to the costal margin to the inguinal ligament using coagu-lating scissors to facilitate fascial closure without creation of skin flaps. A Rives-Stoppa incisional hernia repair is per-

formed with mesh placed in the retromuscular position (notshown).

FIGURE 5. Mesh was exposed requiring dressing changes.

FIGURE 6. Wound was healed at 13-months follow-up.

Annals of Plastic Surgery • Volume 66, Number 5, May 2011 Comparison of Outcome

© 2011 Lippincott Williams & Wilkins www.annalsplasticsurgery.com | 555





On the other hand, de Vries Reilingh et al conducted a randomized study comparing the use of open CS with expanded polytetrafluo-roethylene (ePTFE) mesh to reconstruct giant midline abdominalwall hernia. The study was terminated early because of an unac-ceptably high frequency of wound complications resulting in sub-sequent prosthetic loss in the ePTFE group. Although their

interim analysis showed that hernia recurrence was higher in theCS versus ePTFE group, they concluded that CS is better thanmesh repair for complex hernia cases because of the lower associated wound complications.17

There are several limitations in our study. Our analysisaggregates disparate methods and is limited by the quality of theincluded studies. Very few studies selected for this analysis arecomparative trials of techniques or randomized controlled trials.Almost all the studies selected for this report are limited by smallsample size, variable patient population, lack of a control group,short follow-up, nonstandardized operative technique, and variableoutcome measures. Our data were only limited to those studies that

performed MICS and did not include all existing data on other methods of hernia repairs. MICS as discussed earlier is still an

evolving technique, and the data may be biased by the learning curveof the reporting surgeons.

CONCLUSIONBased on mostly retrospective data from uncontrolled studies,

this review demonstrates that complication and hernia recurrencerates appear to be comparable between open CS and MICS. Morecomparative studies on the various surgical options for complexhernia repair will be important to delineate the optimal solution tothis complex problem.

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