The American Journal of Surgery 194 (2007) 385389

Scientific paper

Laparoscopic versus open-component separation: a comparative

analysis in a porcine model
Michael J. Rosen, M.D.*, Christina Williams, M.D., Judy Jin, M.D.,
Michael F. McGee, M.D., Steve Schomisch, B.S., Jeffrey Marks, M.D., Jeffrey Ponsky, M.D.
Case Medical Center, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106, USA
Manuscript received December 19, 2006; revised manuscript March 20, 2007

Abstract
Background: The ideal surgical treatment for complicated ventral hernias remains elusive. Traditional
component separation provides local advancement of native tissue for tension-free closure without
prosthetic materials. This technique requires an extensive subcutaneous dissection with division of
perforating vessels predisposing to skin-flap necrosis and complicated wound infections. A minimally
invasive component separation may decrease wound complication rates; however, the adequacy of the
myofascial advancement has not been studied.
Methods: Five 25-kg pigs underwent bilateral laparoscopic component separation. A 10-mm incision was
made lateral to the rectus abdominus muscle. The external oblique fascia was incised, and a dissecting
balloon was inflated between the internal and external oblique muscles. Two additional ports were placed
in the intermuscular space. The external oblique was incised from the costal margin to the inguinal
ligament. The maximal abdominal wall advancement was recorded. A formal open-component separation
was performed and maximal advancement 5 cm superior and 5 cm inferior to the umbilicus was recorded
for comparison. Groups were compared using standard statistical analysis.
Results: The laparoscopic component separation was completed successfully in all animals, with a mean
of 22 min/side. Laparoscopic component separation yielded 3.9 cm (SD 1.1) of fascial advancement above
the umbilicus, whereas 4.4 cm (1.2) was obtained after open release (P .24). Below the umbilicus,
laparoscopic release achieved 5.0 cm (1.0) of advancement, whereas 5.8 cm (1.2) was gained after open
release (P .13).
Comments: The minimally invasive component separation achieved an average of 86% of the myofascial
advancement compared with a formal open release. The laparoscopic approach does not require extensive
subcutaneous dissection and might theoretically result in a decreased incidence or decreased complexity of
postoperative wound infections or skin-flap necrosis. Based on our preliminary data in this porcine model,
further comparative studies of laparoscopic versus open component separation in complex ventral hernia
repair is warranted to evaluate postoperative morbidity and long-term hernia recurrence rates. 2007
Excerpta Medica Inc. All rights reserved.
Keywords: Component separation; Laparoscopic; Minimally invasive; Ventral hernia

The repair of massive ventral hernias has remained a challenging problem for surgeons. Primary repair is rarely successful and has associated recurrence rates of 18% to 62%
depending on the defect size [1 4]. The addition of synthetic mesh decreases recurrence rates significantly to 2% to
32% [1,3 6]. However, the use of large sheets of synthetic
* Corresponding author. Tel.: 1-216-844-2763; fax: 1-216-8445888.
E-mail address: michael.rosen@uhhospitals.org

material for hernia repair often results in a rigid, noncompliant, adynamic abdominal wall and is contraindicated in
the setting of contamination. Several groups have reported
various options using only autologous tissue to deal with
these challenging hernias.
Ramirez et al described a technique in which the lateral
abdominal musculature was partitioned, allowing myofascial advancement and extension of the abdominal wall [7].
Several modifications have been described for this technique, but most involve elevation of large subcutaneous

0002-9610/07/$ see front matter 2007 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.amjsurg.2007.03.003

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M.J. Rosen et al. / The American Journal of Surgery 194 (2007) 385389

flaps to provide access to the lateral abdominal wall musculature [79]. Using these techniques, up to 10 cm of
unilateral advancement can be achieved, providing a tension-free abdominal closure with medialization of the rectus
abdominus muscle in large ventral hernias [7]. Several large
series have reported recurrence rates from 5% to 30%
[8 10]. Despite these very respectable recurrence rates for
complex ventral hernia repair, this procedure does not seem
to be widely used by most surgeons.
Critics of the component-separation technique for abdominal wall reconstruction cite certain disadvantages. The
extensive dissection necessary to elevate the lipocutaneous
flaps necessitates division of abdominal wallperforating
vessels and creates large potential spaces, which can result
in skin-flap necrosis, seromas, hematomas, and massive
wound infections. A review of the available literature found
serious wound morbidity occurring in up to 40% of patients
[8,11]. Recently, endoscopically assisted component separation has been described in an attempt to decrease postoperative wound morbidity [11,12]. Although these approaches have decreased the incidence and severity of
wound complications, the adequacy of myofascial advancement has not been studied. To date, no comparative data
exist evaluating standard open-component separation versus
laparoscopic-assisted component separation. We hypothesize that laparoscopic component separation can result in
substantial myofascial advancement compared with open
release in a porcine model.
Materials and Methods
Five healthy pigs, weighing an average of 25 kg, were
studied. Each animal was sedated with Telazol (teletamine
HCl and zolazepam; Fort Dodge Animal Health, Fort
Dodge, Iowa) and then placed under general anesthesia
using isoflurane (.5% to 2%; AErrane; Baxter, Deerfield,
Illinois). A midline incision was made, and the peritoneum
was opened from the xyphoid process to the symphysis
pubis.
The laparoscopic component separation of parts began
with a 1-cm incision made just below the costal margin
lateral to the rectus abdominus muscle. The subcutaneous
tissues were bluntly divided to expose the external oblique
aponeurosis. The external oblique was grasped with Kocher

Fig. 1. Cross-section of anterior abdominal wall with balloon dissector in

place in between the external and internal oblique muscles.

Fig. 2. Port positioning for laparoscopic component separation.

clamps and sharply incised. The fibers were split in their

natural orientation and the internal oblique muscle exposed.
The potential space between the internal and external
oblique was created using a bilateral laparoscopic inguinal
hernia balloon dissector (United States Surgical, Norwalk
Connecticut) (Fig. 1). A structural balloon port was then
placed in this space to maintain insufflation pressures of 12
mm Hg. A 10-mm, 30 laparoscope was used to bluntly
dissect the space under direct vision. Two additional 5-mm
ports were then placed: 1 at the level of the umbilicus at the
posterior axillary line and another just above the inguinal
ligament lateral to the rectus (Fig. 2). The space was then
completely dissected from cephalad to the costal margin to
the inguinal ligament and the posterior axillary line using
laparoscopic visualization. The external oblique was then
released from the 5-cm cephalad to the costal margin to the
inguinal ligament using coagulating scissors (Fig. 3).

Fig. 3. Laparoscopic release of external oblique aponeurosis lateral to the

linea semilunaris.

M.J. Rosen et al. / The American Journal of Surgery 194 (2007) 385389

Fig. 4. Depiction of the technique used to measure abdominal wall advancement. (A) Clamps of 1 kg weight secured to the linea alba above and
below the umbilicus, with Prolene suture placed in midline. (B) Abdominal
wall advancement. Measurements taken at points A and A1 represent
abdominal wall advancement past the midline above and below the umbilicus.

Despite an extensive literature review, there is no standard method to measure abdominal wall advancement after
component separation. In fact, the majority of series define
maximal advancement based on excessive tension to bring
the fascia back to the midline. Recognizing these limitations, we devised a standardized method to obtain reproducible measurements of abdominal wall advancement
(Fig. 4). This technique was particularly chosen with only
2 kg of weight to determine the maximal advancement
without undue tension. Measurements of maximal abdominal wall advancement were recorded as follows. The midline of the abdomen was marked with a suture secured from
the symphysis pubis to the xyphoid process. The location of
the umbilicus was noted, and towel clips were placed 5 cm
superior and 5 cm inferior to the umbilicus. These towel
clips were then attached to a 1-kg weight using umbilical
tape. The weights were dropped over the edge of the surgical table. The amount of fascial advancement was calculated based on the distance past the previously placed Prolene suture at each of the 2 points. The procedure was then
repeated for the contralateral side and similar measurements
recorded.
Bilateral open-component separation of parts was then performed by elevating the subcutaneous flaps laterally to the
external oblique muscle. The external oblique fascial release
was evaluated for completeness of release. A complete release
was defined as complete transection of the entire external
oblique fascia from 5 cm cephalad to the costal margin and
extending to the inguinal ligament. If the release was deemed
inadequate, it was completed using open techniques before
measurements were taken. Final measurements of maximal
abdominal wall advancement were then recorded from each
side. Groups were compared for statistical significance using
paired Student t test; P .05 was considered significant.
Results
The laparoscopic component separation was completed
successfully in all animals in an average of 22 min/side

387

(range 20 to 29). Each animal underwent bilateral laparoscopic component separation without any intraoperative
complications. When the release of the external oblique
obtained laparoscopically was examined during the open
portion of the procedure, 2 animals had an incomplete
unilateral release. These 2 animals had only 2 cm of external
oblique fascia released above the costal margin. These inadequate releases were secondary to crowding of the laparoscopic ports. In these 2 animals, the initial laparoscopic
port was placed too medial near the edge of the rectus
muscle, which interfered with our ability to reach the upper
portion of the release. After modifying our initial port placement to be further lateral, all subsequent laparoscopic releases were deemed complete.
The laparoscopic component separation resulted in 3.9
cm 1.1 cm advancement (range 2.8 to 5.5) above the
umbilicus versus 4.4 cm 1.2 cm (range 3.0 to 6.2) (P
.24) after open-component separation (Table 1). The laparoscopic component separation resulted in 5.0 cm 1.2 of
advancement (range 3.1 to 6.8) below the umbilicus versus
5.8 cm 1.0 (range 4.1 to 7.5) (P .13) after opencomponent separation. In other words, the laparoscopic
component separation achieved an average of 86% of
the myofascial advancement obtained after formal opencomponent separation both above (range 70% to 100%) and
below (range 73% to 94%) the umbilicus.
Comments
Large abdominal hernias continue to be a vexing problem for general surgeons. The traditional component-separation technique provides tension-free closure without the use of
permanent prosthetic material for large, complicated hernia
repairs. However, this approach carries significant wound morbidity for the large subcutaneous dissection necessary to complete the procedure. We have evaluated the adequacy of a
minimally invasive component separation to obtain myofascial
advancement. The minimally invasive component separation
achieved an average of 86% of the myofascial advancement
obtained by the open technique. Although the current study did
not evaluate wound morbidity, based on the theoretic advantages of avoiding extensive subcutaneous dissection and division of the abdominal wall blood supply, one might expect a
decrease in postoperative wound morbidity. There was no
Table 1
Absolute advancement (in cm) both above and below the umbilicus per
animal
Above umbilicus

Below umbilicus

Laparoscopic

Open Release (%) Laparoscopic Open Release (%)

2.8
3.0
3.5
5.5
3.0
4.0
4.3
3.3
5.5
3.5

4.0
3.0
4.0
5.8
3.2
5.5
4.9
3.5
6.2
4.0

70
100
88
95
94
73
88
94
89
88

5.3
3.1
4.0
6.8
4.0
6.0
5.3
4.0
6.2
4.7

5.6
4.1
5.3
7.2
5.5
6.5
6.0
4.4
7.5
5.3

95
76
75
94
73
92
88
91
83
89

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M.J. Rosen et al. / The American Journal of Surgery 194 (2007) 385389

difference above and below the umbilicus in the percentage

release obtained by the open versus laparoscopic method.
The goals of abdominal wall hernia repair include the
prevention of visceral eventration by recreation of a dynamic and functional abdominal wall using a tension-free
closure [10]. Ideally this involves reestablishing the linea
alba with autologous fascia [11]. Prosthetic materials are
widely used in ventral hernia repair and are associated with
decreased recurrence rates compared with primary repair.
Synthetic mesh does not result in innervated autologous
repair and therefore often results in adynamic noncompliant
repair. Prosthetic mesh is also associated with significant
morbidity, including infection, enterocutaneous fistula formation, and extrusion and in the setting of contamination is
contraindicated. Abdominal component separation is a
unique technique initially described by Ramirez et al in
1990 and accomplishes the basic principles of ventral hernia
repair [7]. This technique uses innervated vascularized tissue, recreating the linea alba in a tension-free manner.
Several investigators have reported large series with abdominal component separation performed for a variety of indications, with recurrence rates ranging from 5% to 30% in
challenging hernia repairs [8 10].
The basic principles of component separation involve
release of the external oblique muscle lateral to the linea
semilunaris and separation of the avascular plane in between the external and internal oblique to allow midline
advancement of the abdominal wall. If additional advancement is needed, the posterior rectus fascia is incised and
released. The lateral abdominal wall is typically accessed
after elevating large subcutaneous flaps. These flaps can
result in significant postoperative morbidity, with wound
complications occurring in more than one third of patients
in most series [9 11,13,14]. These complications likely
result from the large undermining of subcutaneous flaps that
result in interruption of the abdominal wall blood supply to
expose the external oblique fascia. Recognizing the importance of abdominal wall vascularity, Saulis et al described a
modified technique of elevating partial subcutaneous flaps,
thereby preserving periumbilical-perforating vessels [15].
By using this technique, these investigators noted a significant decrease in wound breakdown. However, large potential space is still created, which predisposes to postoperative
hematomas and seromas, which can in turn be particularly
problematic in the setting of contamination.
Several investigators have evaluated a variety of endoscopically assisted approaches to limit the wound morbidity
associated with open-component separation techniques.
Lowe et al recently reported 7 cases of endoscopically
assisted component separation [11]. These investigators
performed a modification of the component separation in
which the balloon dissector is placed above the external
oblique in the subcutaneous space, and after insufflation the
external oblique muscle is incised. Unlike our technique,
this space is not entirely avascular, and some perforating
vessels are divided. However, they noted no postoperative
wound complications in their series and were able to close
defects up to 15 25 cm with this method. In addition, they
noted a 50% decrease in postoperative length of stay. As
these investigators pointed out, this decrease in hospital stay
and postoperative wound care certainly justifies the initial

expense of the laparoscopic instrumentation. Maas et al

recently reported another series of endoscopically assisted
component separation for the repair of complicated ventral
hernias [12]. This group performed a technique, similar to
our approach, in which the balloon dissector is placed underneath the external oblique fascia, thus separating it from
the internal oblique. However, the actual release was not
performed using laparoscopic techniques and instead was
performed through several small counter incisions under
laparoscopic visualization. Despite these counter incisions,
they noted no postoperative wound complications and had
only 1 recurrence in their series of 5 patients. Interestingly,
this series had several patients with stomas, and these investigators pointed out that an endoscopic approach provided distinct advantages in the setting of concomitant stomas. Because
the dissection plane is lateral to the rectus muscle, the stomas
are not interfered with during the release.
Minimally invasive component separation provides direct access to the lateral compartment without large subcutaneous flap dissection and avoids undermining the skin,
dividing abdominal wall perforators, and creation of excessive potential space. As these small series have demonstrated, significant decrease in postoperative wound complications seems logical. However, no study to date has
compared the adequacy of the release when performed laparoscopically without elevation of the necessary skin flap
compared with a standard open approach. Our study demonstrates that there was no statistically significant difference
in the amount of abdominal wall mobilization achieved
between the laparoscopic and open-component separation
methods. Because on average an 86% release is accomplished using the laparoscopic release without the elevation
of skin flaps, any additional release can be achieved with
incision of the posterior rectus sheath if necessary. In the
setting of contamination, the laparoscopic approach provides unique advantages in providing the release in a clean
space not in continuity with the midline incision, thus decreasing the complexity of postoperative wound infections.
In this swine model, laparoscopic component separation
resulted in similar myofascial advancement compared with
standard open-component separation. Based on the potential
decrease in serious postoperative wound morbidity and
comparable fascial advancement, the laparoscopic approach
to component separation should be further evaluated in
clinical trials, with particular attention paid to postoperative
wound morbidity and long-term hernia recurrence rates.
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