Posterior components separation during retromuscular hernia repair

Abstract

Retromuscular ventral hernia repair with mesh is a durable technique. In this paper, we describe a novel technique which allows for significant mesh overlap via the retromuscular space in cases of massive ventral hernia. The retromuscular space is developed laterally, to the edge of the rectus sheath. The posterior rectus sheath is incised, dividing the posterior aponeurosis of the internal oblique. The dissection is carried out laterally between the internal oblique and the transversus abdominis muscle, creating space for a large mesh underlay. We have performed this technique successfully in 20 patients with a mean defect area of 223 cm² and a mean mesh area of 698 cm². Three patients developed wound complications and none complained of long-term pain or abdominal wall deformity. There has been one recurrence due to technical error after a mean 12-month follow-up. This technique of dissection between the internal oblique and transversus abdominis muscles allows for the closure of large hernia defects. The mechanism is two-fold: (1) mobility for closure of the posterior rectus sheath, dorsal to the prosthetic; and (2) increased mobility of the rectus, internal, and external obliques, allowing reconstruction of the linea alba.