Reconstruction of the abdominal wall with posterior component separation; With and without transversus abdominis release

Authors

Abstract

Aim This study aims to evaluate the effectiveness and advantages of performing posterior component separation (PCS) with or without transversus abdominis release (TAR) in abdominal wall reconstruction for large incisional hernias.
Materials and Methods A total of 444 patients underwent elective incisional hernia repair at our center. Ninety patients with large midline hernias (>5 cm) were treated using a PCS technique. Of these, 71 patients with defects <10 cm underwent PCS without TAR (Group 1), and 19 patients with defects ≥10 cm underwent PCS with TAR (Group 2). Perioperative outcomes, postoperative pain (visual analog scale, VAS), seroma formation, and hernia recurrence were recorded and compared between groups with at least 1 year of follow-up.
Results PCS without TAR (Group 1) was associated with a shorter operative time, a less complex procedure, fewer seromas, and a shorter learning curve compared to PCS with TAR (Group 2). Group 1 patients also reported lower postoperative pain scores, and their abdominal wall defects were successfully reconstructed without deformity. Patients in Group 2 had larger hernia defects (≥10 cm) and underwent the more extensive TAR procedure.
Discussion Midline closure with PCS is a well-established technique, but the optimal use of TAR in addition to PCS for large hernias is not clearly defined in the literature. Our findings suggest that PCS without TAR can be safely and effectively performed for large incisional hernias under 10 cm, with TAR reserved for larger or more complex cases.

Keywords

Introduction

Midline abdominal wall repair frequently relies on component separation strategies as a key method for addressing extensive incisional hernias. Such approaches support fundamental goals of abdominal wall surgery, including restoring the linea alba and achieving fascial closure without tension [1]. Carbonell et al. [2] described the posterior component separation (PCS) technique, which involves a lateral division of the posterior rectus sheath (pRS) to create a plane between the internal oblique and transversus abdominis muscles. This technique permits broad myofascial mobilization, supporting central fascial closure and enabling adequate retromuscular mesh positioning. In Carbonell’s report, postoperative wound complications occurred in 15% of patients, and only one patient experienced hernia recurrence. One recognized limitation of the initial PCS method is the interruption of the rectus abdominis neurovascular supply, which may result in muscle denervation and related functional impairment. In response to these challenges, Novitsky et al. introduced the transversus abdominis release (TAR) technique [3]. TAR is a refinement of the posterior component separation approach for complex abdominal wall reconstruction, particularly in large or complex ventral hernias [4, 5]. TAR provides a nearly avascular dissection, enabling the creation of an expansive retromuscular pocket by accessing the preperitoneal layer. Novitsky’s initial series reported a 24% rate of wound-related complications and a 4.7% hernia recurrence rate with TAR. It facilitates approximation of both the posterior sheath and anterior fascia, permits large mesh placement in the pretransversalis plane (also known as the TAR plane), and crucially maintains rectus abdominis neurovascular integrity [6]. The role of TAR as an adjunct to PCS for various sizes of hernia defects is still not well defined. In this study, we compared outcomes of large incisional hernia repairs performed with PCS with versus without TAR, focusing on operative time, postoperative pain, seroma formation, and recurrence rates.

Materials and Methods

This single-center cohort study included 444 patients who underwent elective incisional hernia reconstruction at our institution between 2021 and 2024. Among these, 90 patients with large midline incisional hernias (defined as >5 cm in width, according to European Hernia Society criteria [7]) met the inclusion criteria and were treated using a posterior component separation technique. These 90 cases were divided into two groups based on hernia size and repair method:
Group 1 consisted of 71 patients with defects <10 cm who underwent PCS without TAR, and Group 2 consisted of 19 patients with defects ≥10 cm who underwent PCS with TAR.
All patients underwent thorough preoperative evaluation, including physical examination, abdominal ultrasonography to detect any intra-abdominal pathology, and computed tomography (if needed). Data from these patients were collected prospectively.
Surgical Technique
After excision of the old scar tissue, the hernia sac was carefully dissected free and opened, and the abdominal cavity was examined. During the lateral suprafascial dissection, perforating vessels were identified, meticulously isolated, and preserved to maintain blood supply. A longitudinal incision was made in the posterior rectus sheath approximately 5 mm from the midline on each side to enter the retrorectus (Rives–Stoppa) plane. This incision was extended cranially and caudally along the length of the defect, allowing the creation of a wide retromuscular pocket (Figure 1). Blunt dissection was then used to further develop the plane laterally toward the linea semilunaris. An assistant retracted the rectus abdominis (RA) muscle to improve exposure during this dissection. Small perforating vessels between the RA muscle and the posterior sheath were divided as needed until reaching the lateral border of the rectus (the linea semilunaris marked by the neurovascular bundles). These steps achieve the myofascial release of the posterior elements, constituting the PCS.In cases requiring TAR (Group 2 patients with hernias ≥10 cm), the dissection was continued with release of the transversus abdominis(TA) muscle. The lateral neurovascular bundles at the linea semilunaris were first identified to avoid injury. An incision was made in the posterior lamella of the internal oblique aponeurosis, approximately 5 mm medial to the neurovascular bundles, to expose the underlying TA muscle. The TA muscle was then incised along its length to enter the proper pre-transversalis plane (TAR plane). This muscle release was performed using short, controlled bursts of monopolar cautery to divide the muscle fibers bloodlessly. Following completion of the PCS (and TAR, in Group 2), the posterior rectus sheaths were brought together and closed in the midline. A large self-gripping mesh was then placed in the retromuscular space (sublay position) beneath the rectus muscles to reinforce the repair (Figure 2). Closed-suction drains were placed in the retromuscular space on each side. Finally, the anterior rectus sheath (linea alba) was reapproximated and closed using a small-bite technique to minimize tension and reduce wound complications. Operative time, intraoperative blood loss, and postoperative drain duration were recorded for all patients. Postoperative pain was assessed using the Visual Analog Scale (VAS). The presence of seroma and any wound complications (such as infection or dehiscence) was evaluated on postoperative days 1, 7, and 15. Patients were followed at regular intervals (approximately at 1, 3, 6, and 12 months postoperatively) to monitor for late complications and hernia recurrence. Outcome data, including operative time, VAS pain scores, duration of drainage, incidence of seroma, wound complications, and hernia recurrences, were compiled and analyzed. Descriptive statistics (mean, standard deviation, median, and frequency percentages) were used to summarize the data. Statistical comparisons between Group 1 and Group 2 were conducted where appropriate, with a significance level of p < 0.05.
Ethical Approval
The study was approved by the Ethics Committee of Istanbul Göztepe Prof. Dr. Süleyman Yalçın City Hospital (Date: 2019- 06-19, No: 2019/0232).

Results

A total of 90 patients with large incisional hernias were included over the 3-year study period. There were 61 women and 29 men, with an average age of 63 years. Thirty patients (33%) were overweight, and 14 (16%) were obese. Comorbid conditions included diabetes in 8 patients, a history of smoking in 16 patients, and chronic pulmonary disease in 4 patients (see Table 1 for patient demographics and risk factors). The mean operative time was significantly shorter in Group 1 (PCS without TAR) at 90 minutes (range 60–230) compared to 130 minutes (80–290) in Group 2 (PCS with TAR) (p < 0.01). The mean postoperative pain score (VAS) was also lower in Group 1, at 5 (on a 10-point scale), versus 8 in Group 2 during the early postoperative period (p < 0.01). Group 1 patients had a shorter mean hospital stay (4 days) compared to Group 2 (7 days), and a shorter mean postoperative drainage duration (8 days vs. 13 days, respectively). (Table 1). By the 1-year follow-up, no patients in either group reported any residual chronic pain. Additionally, no patient experienced mesh-related sensations, mesh migration, or limitations in abdominal wall movement during the follow-up period. No hernia recurrences were observed in either group during a minimum of one year of follow-up. Group 1 (PCS without TAR) had 2 postoperative seromas and 4 cases of wound-related morbidity, whereas Group 2 (PCS with TAR) had 3 seromas and 6 wound-related complications. All seromas were small and resolved spontaneously without intervention. Among the wound complications noted in Group 2, two patients developed superficial wound infections, and one patient experienced a wound dehiscence. The superficial infections were managed successfully with surgical debridement and antibiotics, and the wound dehiscence was treated by allowing it to heal by secondary intention. In addition, a total of 5 patients (across both groups) had minor wound complications such as localized cellulitis or mild wound inflammation, which were effectively managed with antibiotics.(Table1) There were no instances of mesh removal or other major adverse events.

Discussion

Large incisional hernias can be repaired with a posterior component separation approach, either with or without a transversus abdominis release. The TAR modification of PCS offers certain theoretical and reported advantages. By placing the mesh in a well-vascularized retromuscular plane, TAR may enhance mesh integration and reduce the risk of infection [8]. TAR also facilitates a greater medial mobilization of the rectus abdominis muscles, allowing closure of very large defects, and it can be especially beneficial in patients with significant comorbidities such as obesity or diabetes [9–11]. Moreover, because TAR is performed in a plane that avoids extensive subcutaneous dissection, it has been associated with lower rates of wound complications in some studies [12]. On the other hand, TAR is a more invasive extension of the PCS technique. In our series, this was reflected by a higher number of wound complications in the TAR group (6 in Group 2 vs. 4 in Group 1), despite the TAR group’s patients having larger hernia defects by selection criteria. Seroma formation is one of the most common postoperative complications in abdominal wall reconstruction. TAR, due to the larger dissection plane and tissue rearrangement, can result in seromas, wound infections, or even recurrence, although reported rates for TAR remain generally favorable compared to other complex hernia repair techniques [5]. In our comparison, the PCS without TAR (Group 1), which involves less extensive dissection, had a lower incidence of seroma than the TAR group. This suggests that minimizing dissection (as in PCS without TAR) may help reduce seroma formation, whereas the added dissection required for TAR could increase that risk slightly, even though all seromas observed were minor and self-limited. Another important consideration is the level of surgical expertise required for TAR. The TAR technique demands a high level of familiarity with abdominal wall anatomy and advanced reconstructive skill, typically limiting its use to specially trained hernia surgeons [13]. The learning curve for TAR is steep, requiring substantial training and experience, which can impede widespread adoption of the technique [14]. TAR often also entails longer operative times and may need specialized equipment or materials, making it relatively resource-intensive [4]. In contrast, PCS without TAR is a more straightforward procedure. Consistent with these differences, our findings showed that the mean operative time was significantly longer in the TAR group by about 40 minutes. Thus, while TAR can achieve additional medial mobilization of the fascia, it comes at the cost of increased operative duration and complexity. It is crucial that when TAR is employed, it is performed by surgeons with appropriate specialized training and experience in complex hernia repair in order to optimize outcomes and minimize complications [11, 15, 16]. Chronic postoperative pain is a known issue following ventral hernia repairs, and its causes are likely multifactorial. Iatrogenic nerve injury or entrapment, chronic inflammatory reactions to the mesh, and excessive mesh fixation tension (from sutures or tacks) can all contribute to long-term pain. A study in the literature reported that approximately 31% of patients experienced some degree of pain 2–3 years after abdominal wall reconstruction, with about 6% reporting pain that interfered with daily activities [17–20]. In our study, patients in the TAR group had higher pain scores in the immediate postoperative period compared to the non-TAR group (median early VAS 8 vs. 5, p < 0.01), which is not unexpected given the larger dissection and muscle release. Importantly, however, by one year after surgery, all patients in both groups were entirely pain-free, and hernia-specific quality of life was excellent. This suggests that while TAR may be associated with greater short-term pain, diligent pain management and the benefits of durable hernia repair can result in excellent long-term outcomes for patient comfort.

Limitations

Our study has some limitations. First, the sample size (especially for the TAR group) is relatively small, reflecting the fact that only a subset of incisional hernias require such complex reconstruction. Similar studies in the recent literature have also been limited to smaller cohorts due to the specialized nature of these cases. Second, the follow-up period in our study (a minimum of 1 year) is relatively short for detecting long-term recurrences or late complications, compared to some other series. A longer follow-up will be important to ensure that the no-recurrence findings in both groups hold over time. Finally, as with many studies in complex hernia repair, our study was not randomized; the choice of performing TAR was guided by hernia size and surgeon judgment, which could introduce selection bias. Despite these limitations, our data provide useful insight into how PCS with or without TAR can be applied based on hernia size, with encouraging outcomes in both approaches.

Conclusion

Complex incisional hernia repair is a specialized field that often requires individualized, case-specific solutions, making large randomized trials difficult. Based on our experience, posterior component separation without TAR can be safely and effectively used for the reconstruction of large midline hernias up to 10 cm in width, achieving excellent outcomes with fewer perioperative complexities. The decision to add a transversus abdominis release for abdominal wall reconstruction should be tailored to the patient’s hernia characteristics; for defects under about 10 cm, TAR may not be necessary, whereas for larger or more complex hernias, TAR provides additional mobilization that can facilitate a tension-free closure. In the absence of clear guidelines in the literature, our results help inform this decision- making process, suggesting that PCS alone is sufficient for many large hernias, with TAR reserved for the most extensive cases.

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