Ramirez 1990 - PRS - Components separation

Summary

This paper presents an anatomic and clinical study on a "components separation" method for closure of large abdominal wall defects. The authors performed cadaver dissections to understand the anatomy of the abdominal wall muscles and fascia. They found the external oblique can be separated from the internal oblique in an avascular plane, while the internal oblique and transversus abdominis are adherent. The rectus abdominis can be separated from its posterior sheath. This allows greater mobilization and medial advancement of the muscle components compared to mobilizing the abdominal wall en bloc.

Clinically, the technique was used in 11 patients with abdominal wall defects ranging from 4x4cm to 18x35cm. The external oblique was separated from the internal oblique, and the rectus muscle was separated from its posterior sheath. This allowed approximation of the rectus and internal oblique/transversus layers in the midline for closure, with additional advancement of the external oblique and overlying skin. All flaps survived and patients had good abdominal wall strength on follow-up. Four patients with preoperative back pain had resolution of pain postoperatively.

In summary, this anatomic study shows the abdominal wall muscles and fascia can be separated into components with maintained vascularity. Clinically, separating the components allows greater medial advancement and closure of large defects compared to standard techniques. The functional reconstruction maintains abdominal wall strength and dynamics. Advantages include avoiding use of synthetic mesh, which has high complication rates, and avoiding remote muscle flaps which require additional donor sites. This components separation method provides an alternative for autologous reconstruction of complex abdominal wall defects with good functional and aesthetic outcomes. Further study on larger numbers of patients is warranted to fully evaluate outcomes. Overall, this represents an innovative approach for reconstructive surgeons to consider when facing challenges of closing large ventral hernias or abdominal wall defects resulting from trauma, tumor resection, infections, or previous operative complications.