Skip to main content

Advertisement

SpringerLink
Log in

Endoscopic versus open component separation: systematic review and meta-analysis

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies.

Methods

A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools.

Results

63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure.

Conclusion

This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Dholakia C, Reavis KM (2010) Component separation in the treatment of incisional hernias. J Long Term Eff Med Implants 20:129–132

    Article  PubMed  Google Scholar 

  2. Ramirez OM, Ruas E, Dellon AL (1990) “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 86:519–526

    Article  CAS  PubMed  Google Scholar 

  3. Maas SM, de Vries RS, van Goor H, de Jong D, Bleichrodt RP (2002) Endoscopically assisted “components separation technique” for the repair of complicated ventral hernias. J Am Coll Surg 194:388–390

    Article  PubMed  Google Scholar 

  4. Albright E, Diaz D, Davenport D, Roth JS (2011) The component separation technique for hernia repair: a comparison of open and endoscopic techniques. Am Surg 77:839–843

    PubMed  Google Scholar 

  5. Clarke JM (2010) Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique. Am J Surg 200:2–8

    Article  PubMed  Google Scholar 

  6. Ghali S, Turza KC, Baumann DP, Butler CE (2012) Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg 214:981–989

    Article  PubMed Central  PubMed  Google Scholar 

  7. Harth KC, Rosen MJ (2010) Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 199:342–346 discussion 346–347

    Article  PubMed  Google Scholar 

  8. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE (2000) Endoscopically assisted “components separation” for closure of abdominal wall defects. Plastic and reconstructive surgery 105:720–729 quiz 730

    Article  CAS  PubMed  Google Scholar 

  9. Giurgius M, Bendure L, Davenport DL, Roth JS (2012) The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 16:47–51

    Article  CAS  PubMed  Google Scholar 

  10. Lipman J, Medalie D, Rosen MJ (2008) Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach. Am J Surg 195:84–88

    Article  PubMed  Google Scholar 

  11. Parker M, Bray JM, Pfluke JM, Asbun HJ, Smith CD, Bowers SP (2011) Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair. J Laparoendosc Adv Surg Tech A 21:405–410

    Article  PubMed  Google Scholar 

  12. Bachman SL, Ramaswamy A, Ramshaw BJ (2009) Early results of midline hernia repair using a minimally invasive component separation technique. Am Surg 75:572–577 discussion 577–578

    PubMed  Google Scholar 

  13. Bogetti P, Boriani F, Gravante G, Milanese A, Ferrando PM, Baglioni E (2012) A retrospective study on mesh repair alone vs. mesh repair plus pedicle flap for large incisional hernias. Eur Rev Med Pharmacol Sci 16:1847–1852

    CAS  PubMed  Google Scholar 

  14. Dragu A, Klein P, Unglaub F, Polykandriotis E, Kneser U, Hohenberger W, Horch RE (2009) Tensiometry as a decision tool for abdominal wall reconstruction with component separation. World J Surg 33:1174–1180

    Article  PubMed  Google Scholar 

  15. Ekeh AP, McCarthy MC, Woods RJ, Walusimbi M, Saxe JM, Patterson LA (2006) Delayed closure of ventral abdominal hernias after severe trauma. Am J Surg 191:391–395

    Article  PubMed  Google Scholar 

  16. Garvey PB, Bailey CM, Baumann DP, Liu J, Butler CE (2012) Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction. J Am Coll Surg 214:131–139

    Article  PubMed  Google Scholar 

  17. Hood K, Millikan K, Pittman T, Zelhart M, Secemsky B, Rajan M, Myers J, Luu M (2013) Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh. Am J Surg 205:322–327 discussion 327–328

    Article  PubMed  Google Scholar 

  18. Li EN, Silverman RP, Goldberg NH (2005) Incisional hernia repair in renal transplantation patients. Hernia 9:231–237

    Article  PubMed  Google Scholar 

  19. Mazzocchi M, Dessy LA, Ranno R, Carlesimo B, Rubino C (2011) “Component separation” technique and panniculectomy for repair of incisional hernia. Am J Surg 201:776–783

    Article  PubMed  Google Scholar 

  20. Vargo D (2004) Component separation in the management of the difficult abdominal wall. Am J Surg 188:633–637

    Article  PubMed  Google Scholar 

  21. Satterwhite TS, Miri S, Chung C, Spain DA, Lorenz HP, Lee GK (2012) Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: the “Pork Sandwich” herniorraphy. J Plast Reconstr Aesth Surg 65:333–341

    Article  Google Scholar 

  22. Sailes FC, Walls J, Guelig D, Mirzabeigi M, Long WD, Crawford A, Moore JH Jr, Copit SE, Tuma GA, Fox J (2010) Synthetic and biological mesh in component separation: a 10-year single institution review. Ann Plast Surg 64:696–698

    CAS  PubMed  Google Scholar 

  23. Rosen MJ, Jin J, McGee MF, Williams C, Marks J, Ponsky JL (2007) Laparoscopic component separation in the single-stage treatment of infected abdominal wall prosthetic removal. Hernia 11:435–440

    Article  CAS  PubMed  Google Scholar 

  24. Butler CE, Campbell KT (2011) Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 128:698–709

    Article  CAS  PubMed  Google Scholar 

  25. Moore M, Bax T, MacFarlane M, McNevin MS (2008) Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese. Am J Surg 195:575–579 discussion 579

    Article  PubMed  Google Scholar 

  26. Nasajpour H, LeBlanc KA, Steele MH (2011) Complex hernia repair using component separation technique paired with intraperitoneal acellular porcine dermis and synthetic mesh overlay. Ann Plast Surg 66:280–284

    Article  CAS  PubMed  Google Scholar 

  27. Agnew SP, Small W Jr, Wang E, Smith LJ, Hadad I, Dumanian GA (2010) Prospective measurements of intra-abdominal volume and pulmonary function after repair of massive ventral hernias with the components separation technique. Ann Surg 251:981–988

    Article  PubMed  Google Scholar 

  28. Yegiyants S, Tam M, Lee DJ, Abbas MA (2012) Outcome of components separation for contaminated complex abdominal wall defects. Hernia 16:41–45

    Article  CAS  PubMed  Google Scholar 

  29. Wind J, van Koperen PJ, Slors JF, Bemelman WA (2009) Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg 197:24–29

    Article  PubMed  Google Scholar 

  30. Broker M, Verdaasdonk E, Karsten T (2011) Components separation technique combined with a double-mesh repair for large midline incisional hernia repair. World J Surg 35:2399–2402

    Article  PubMed Central  PubMed  Google Scholar 

  31. Carbonell AM, Cobb WS, Chen SM (2008) Posterior components separation during retromuscular hernia repair. Hernia 12:359–362

    Article  CAS  PubMed  Google Scholar 

  32. de Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van Nieuwenhoven EJ, van Engeland MI, Bleichrodt RP (2003) “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg 196:32–37

    Article  PubMed  Google Scholar 

  33. de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, Bleichrodt RP (2007) Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a randomized controlled trial. World J Surg 31:756–763

    Article  PubMed  Google Scholar 

  34. Espinosa-de-los-Monteros A, Dominguez I, Zamora-Valdes D, Castillo T, Fernandez-Diaz OF, Luna-Torres HA (2013) Closure of midline contaminated and recurrent incisional hernias with components separation technique reinforced with plication of the rectus muscles. Hernia 17:75–79

    Article  CAS  PubMed  Google Scholar 

  35. Ewart CJ, Lankford AB, Gamboa MG (2003) Successful closure of abdominal wall hernias using the components separation technique. Ann Plast Surg 50:269–273; discussion 273–274

  36. Gonzalez R, Rehnke RD, Ramaswamy A, Smith CD, Clarke JM, Ramshaw BJ (2005) Components separation technique and laparoscopic approach: a review of two evolving strategies for ventral hernia repair. The American surgeon 71:598–605

    PubMed  Google Scholar 

  37. Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, Bee TK (2003) Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 238:349–355 discussion 355–357

    PubMed Central  PubMed  Google Scholar 

  38. Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA (2009) Abdominal wall reconstruction: lessons learned from 200 “components separation” procedures. Arch Surg 144:1047–1055

    Article  PubMed  Google Scholar 

  39. Kolker AR, Brown DJ, Redstone JS, Scarpinato VM, Wallack MK (2005) Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation. Ann Plast Surg 55:36–41 discussion 41–42

    Article  CAS  PubMed  Google Scholar 

  40. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ (2012) Posterior and open anterior components separations: a comparative analysis. Am J Surg 203:318–322 discussion 322

    Article  PubMed  Google Scholar 

  41. Celdran-Uriarte A, Fraile M, Garcia-Vasquez C, York E, Manso B, Granizo JJ (2011) A simplified incision of the external oblique aponeurosis during the components separation technique for the repair of large incisional hernias. Am J Surg 202:e31–e33

    Article  PubMed  Google Scholar 

  42. Cox TC, Pearl JP, Ritter EM (2010) Rives-Stoppa incisional hernia repair combined with laparoscopic separation of abdominal wall components: a novel approach to complex abdominal wall closure. Hernia 14:561–567

    Article  CAS  PubMed  Google Scholar 

  43. Morris LM, LeBlanc KA (2013) Components separation technique utilizing an intraperitoneal biologic and an onlay lightweight polypropylene mesh: “a sandwich technique”. Hernia 17:45–51

    Article  CAS  PubMed  Google Scholar 

  44. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 204:709–716

    Article  PubMed  Google Scholar 

  45. van Geffen HJ, Simmermacher RK, van Vroonhoven TJ, van der Werken C (2005) Surgical treatment of large contaminated abdominal wall defects. J Am Coll Surg 201:206–212

    Article  PubMed  Google Scholar 

  46. Shabatian H, Lee DJ, Abbas MA (2008) Components separation: a solution to complex abdominal wall defects. Am Surg 74:912–916

    PubMed  Google Scholar 

  47. Patel KM, Nahabedian MY, Gatti M, Bhanot P (2012) Indications and outcomes following complex abdominal reconstruction with component separation combined with porcine acellular dermal matrix reinforcement. Ann Plast Surg 69:394–398

    Article  CAS  PubMed  Google Scholar 

  48. Baumann DP, Butler CE (2010) Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg 126:1573–1580

    Article  CAS  PubMed  Google Scholar 

  49. Campbell CA, Butler CE (2011) Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 128:447–458

    Article  CAS  PubMed  Google Scholar 

  50. Chang EI, Foster RD, Hansen SL, Jazayeri L, Patti MG (2007) Autologous tissue reconstruction of ventral hernias in morbidly obese patients. Arch Surg 142:746–749 discussion 749–751

    Article  PubMed  Google Scholar 

  51. Girotto JA, Chiaramonte M, Menon NG, Singh N, Silverman R, Tufaro AP, Nahabedian M, Goldberg NH, Manson PN (2003) Recalcitrant abdominal wall hernias: long-term superiority of autologous tissue repair. Plast Reconstr Surg 112:106–114

    Article  PubMed  Google Scholar 

  52. Hadeed JG, Walsh MD, Pappas TN, Pestana IA, Tyler DS, Levinson H, Mantyh C, Jacobs DO, Lagoo-Deenadalayan SA, Erdmann D (2011) Complex abdominal wall hernias: a new classification system and approach to management based on review of 133 consecutive patients. Ann Plast Surg 66:497–503

    Article  CAS  PubMed  Google Scholar 

  53. Kanaan Z, Hicks N, Weller C, Bilchuk N, Galandiuk S, Vahrenhold C, Yuan X, Rai S (2011) Abdominal wall component release is a sensible choice for patients requiring complicated closure of abdominal defects. Langenbeck’s archives of surgery/Deutsche Gesellschaft fur Chirurgie 396:1263–1270

    Article  PubMed  Google Scholar 

  54. Lineaweaver W (2012) Improvement of success rates for abdominal component reconstructions using bovine fetal collagen. Ann Plast Surg 68:438–441

    CAS  PubMed  Google Scholar 

  55. Moazzez A, Mason RJ, Darehzereshki A, Katkhouda N (2013) Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up. Hernia 17:633–638

    Article  CAS  PubMed  Google Scholar 

  56. Shestak KC, Edington HJ, Johnson RR (2000) The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plastic and reconstructive surgery 105:731–738 quiz 739

    Article  CAS  PubMed  Google Scholar 

  57. Varkarakis G, Daniels J, Coker K, Oswald T, Schleich A, Muskett A, Akdemir O, Lineaweaver W (2010) Effects of comorbidities and implant reinforcement on outcomes after component reconstruction of the abdominal wall. Ann Plast Surg 64:595–597

    CAS  PubMed  Google Scholar 

  58. Szczerba SR, Dumanian GA (2003) Definitive surgical treatment of infected or exposed ventral hernia mesh. Ann Surg 237:437–441

    PubMed Central  PubMed  Google Scholar 

  59. Mericli AF, Bell D, DeGeorge BR Jr, Drake DB (2013) The single fascial incision modification of the “open-book” component separation repair: a 15-year experience. Ann Plast Surg 71:203–208

    Article  CAS  PubMed  Google Scholar 

  60. Saulis AS, Dumanian GA (2002) Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg 109:2275–2280 discussion 2281–2282

    Article  PubMed  Google Scholar 

  61. Picazo-Yeste J, Morandeira-Rivas A, Moreno-Sanz C (2013) Multilayer myofascial-mesh repair for giant midline incisional hernias: a novel advantageous combination of old and new techniques. J Gastrointest Surg 17:1665–1672

    Article  PubMed  Google Scholar 

  62. Borud LJ, Grunwaldt L, Janz B, Mun E, Slavin SA (2007) Components separation combined with abdominal wall plication for repair of large abdominal wall hernias following bariatric surgery. Plast Reconstr Surg 119:1792–1798

    Article  CAS  PubMed  Google Scholar 

  63. Ennis LS, Young JS, Gampper TJ, Drake DB (2003) The “open-book” variation of component separation for repair of massive midline abdominal wall hernia. Am Surg 69:733–742 discussion 742–743

    PubMed  Google Scholar 

  64. DiBello JN Jr, Moore JH Jr (1996) Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias. Plast Reconstr Surg 98:464–469

    Article  PubMed  Google Scholar 

  65. Gordillo GM, Sen CK (2003) Revisiting the essential role of oxygen in wound healing. Am J Surg 186:259–263

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosures

Noah J. Switzer: Nothing to disclose; Mark A. Dykstra: Nothing to disclose; Richdeep S. Gill: Nothing to disclose; Stephanie Lim: Nothing to disclose; Erica Lester: Nothing to disclose; Christopher de Gara: Nothing to disclose; Xinzhe Shi: Nothing to disclose; Daniel W. Birch: consultant for ethicon and covidien; Shahzeer Karmali: consultant for ethicon and covidien

Author information

Authors and Affiliations

  1. Department of Surgery, University of Alberta, 2D2.08 WMC, University of Alberta Hospital, 84410-112 Street, Edmonton, AB, T6G 2B7, Canada

    Noah J. Switzer, Mark A. Dykstra, Richdeep S. Gill, Erica Lester, Christopher de Gara, Daniel W. Birch & Shahzeer Karmali

  2. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

    Stephanie Lim

  3. Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, AB, Canada

    Christopher de Gara, Xinzhe Shi, Daniel W. Birch & Shahzeer Karmali

Authors
  1. Noah J. Switzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark A. Dykstra
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richdeep S. Gill
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stephanie Lim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Erica Lester
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Christopher de Gara
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Xinzhe Shi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Daniel W. Birch
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Shahzeer Karmali
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Noah J. Switzer.

Additional information

Presented at the SAGES 2014 Annual Meeting, April 2–5, 2014, Salt Lake City, Utah.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Switzer, N.J., Dykstra, M.A., Gill, R.S. et al. Endoscopic versus open component separation: systematic review and meta-analysis. Surg Endosc 29, 787–795 (2015). https://doi.org/10.1007/s00464-014-3741-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-014-3741-1

Keywords

Search

Navigation