Endoscopic Component Separation

Anterior endoscopic component separation (ECS) creates a compound flap from the rectus abdominis, internal oblique, and transversus abdominis muscles that can be advanced across the abdominal wall to close defects with minimal tension. ECS contributes to the structural, functional, and cosmetic reconstruction of the abdominal wall while greatly diminishing the morbidity associated with classic anterior open component separation.

Two different anterior ECS techniques are described: the subfascial approach and the subcutaneous approach.

ECS is not a stand-alone procedure but part of an overall operative plan, and preoperative considerations depend on the particulars of that operative plan. Abdominal wall reconstruction (AWR) techniques are found in other chapters.

ECS can be indicated in the following scenarios:

• As part of a totally laparoscopic AWR together with an endoscopic or transfascial closure of defects and the placement of a barrier underlay mesh. This has been the main indication for subcutaneous ECS in our group.

• To assist an open AWR, especially for central defects not amenable to closure with a tension-free primary repair. In the Stoppa technique, a retrorectus space must be available to place a mesh. When wider mesh coverage is needed, a posterior component separation (PCS) with a transversus abdominis release (TAR) is appropriate.

• To assist in defect closure in patients with previous harvesting of the rectal muscle for breast reconstruction.

• When planning a tension-free primary closure of ventral hernias during colostomy reversal, during colon resection, or in another contaminated or infected field, often without the use of mesh.

• In the presence of a stoma without parastomal hernias. In this case, ECS is performed lateral to the stoma without the need to relocate the stoma.

• To assist in the management of abdominal compartment syndrome.

ECS is not indicated in the following scenarios:

• When extensive skin resection or the creation of skin flaps is necessary.

• When defects can be closed primarily without tension.

• When defects are disproportionally wider than longer.

• In patients with multiple recurrent hernias and fixed, noncompliant abdominal walls. In these cases, PCS with or without TAR or an onlay approach may be appropriate.

• When PCS/TAR has previously been performed. However, PCS/TAR could be performed on one side (for stoma reversal) and ECS on the other.

ECS can be performed on one or both sides. Bilateral component separation is preferred by some surgeons to provide symmetrical distribution of tension on the closure. We have performed unilateral component separation without observing cosmetic or functional consequences in most cases with up to 2 years of follow-up.