The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias



Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR).


A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case–control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale.


The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16–4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL.


The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST’s generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.

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

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA


  1. 1.

    Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–583 discussion 583-575

  2. 2.

    Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, Beck W, Holzman MD (2012) Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 16:179–183

  3. 3.

    Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: 9 years’ experience with 850 consecutive hernias. Ann Surg 238:391–399

  4. 4.

    Heniford BT, Ross SW, Wormer BA, Walters AL, Lincourt AE, Colavita PD, Kercher KW, Augenstein VA (2018) Preperitoneal ventral hernia repair: a decade long prospective observational study with analysis of 1023 patient outcomes. Ann Surg.

  5. 5.

    Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJ JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J (2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343:392–398

  6. 6.

    Millikan KW (2003) Incisional hernia repair. Surg Clin North Am 83:1223–1234

  7. 7.

    Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, Liu J, Butler CE (2013) Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 217:999–1009

  8. 8.

    Holihan JL, Askenasy EP, Greenberg JA, Keith JN, Martindale RG, Roth JS, Mo J, Ko TC, Kao LS, Liang MK, Ventral Hernia Outcome Collaboration Writing G (2016) Component separation versus bridged repair for large ventral hernias: a multi-institutional risk-adjusted comparison, systematic review, and meta-analysis. Surg Infect (Larchmt) 17:17–26

  9. 9.

    Nguyen DH, Nguyen MT, Askenasy EP, Kao LS, Liang MK (2014) Primary fascial closure with laparoscopic ventral hernia repair: systematic review. World J Surg 38:3097–3104

  10. 10.

    Young D (1961) Repair of epigastric incisional hernia. Br J Surg 48:514–516

  11. 11.

    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

  12. 12.

    Cobb WS, Warren JA, Ewing JA, Burnikel A, Merchant M, Carbonell AM (2015) Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence. J Am Coll Surg 220:606–613

  13. 13.

    Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC (2011) Predictors of mesh explantation after incisional hernia repair. Am J Surg 202:28–33

  14. 14.

    Maloney SR, Schlosser KA, Prasad T, Kasten K, Kercher KW, Gersin KS, Colavita PD, Heniford BT (2019) 12 years of component separation technique (CST) in abdominal wall reconstruction (AWR). Surgery (in press)

  15. 15.

    Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ (2013) Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg 217:991–998

  16. 16.

    Berger RL, Li LT, Hicks SC, Davila JA, Kao LS, Liang MK (2013) Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. J Am Coll Surg 217:974–982

  17. 17.

    Cobb WS, Carbonell AM, Kalbaugh CL, Jones Y, Lokey JS (2009) Infection risk of open placement of intraperitoneal composite mesh. Am Surg 75:762–767

  18. 18.

    Rosen MJ, Bauer JJ, Harmaty M, Carbonell AM, Cobb WS, Matthews B, Goldblatt MI, Selzer DJ, Poulose BK, Hansson BM (2017) Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the COBRA study. Ann Surg 265:205

  19. 19.

    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

  20. 20.

    Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Heniford BT, Augenstein VA (2016) Predictive modeling for chronic pain after ventral hernia repair. Am J Surg 212:501–510

  21. 21.

    Heniford BT, Walters AL, Lincourt AE, Novitsky YW, Hope WW, Kercher KW (2008) Comparison of generic versus specific quality-of-life scales for mesh hernia repairs. J Am Coll Surg 206:638–644

  22. 22.

    Heniford BT, Lincourt AE, Walters AL, Colavita PD, Belyansky I, Kercher KW, Sing RF, Augenstein VA (2018) Carolinas comfort scale as a measure of hernia repair quality of life: a reappraisal utilizing 3788 international patients. Ann Surg 267:171–176

  23. 23.

    Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing RF, Heniford BT (2012) Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair. Ann Surg 256:714–723

  24. 24.

    Holihan JL, Askenasy EP, Greenberg JA, Keith JN, Martindale RG, Roth JS, Mo J, Ko TC, Kao LS, Liang MK (2016) Component separation versus bridged repair for large ventral hernias: a multi-institutional risk-adjusted comparison, systematic review, and meta-analysis. Surg Infect 17:17–26

  25. 25.

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

  26. 26.

    Kumar S, Edmunds RW, Dowdy C, Chang YW, King R, Roth JS (2018) Anterior versus posterior component separation: which is better? Plast Reconstr Surg 142:47S–53S

  27. 27.

    Loh CYY, Nizamoglu M, Shanmugakrishnan RR, Tan A, Brassett C, Lovett B, Tare M, El-Muttardi N (2018) Comparing transversus abdominus release and anterior component separation techniques in reconstructing midline hernias: a cadaveric study. J Plast Reconstr Aesthet Surg 71:1507–1517

  28. 28.

    Criss CN, Petro CC, Krpata DM, Seafler CM, Lai N, Fiutem J, Novitsky YW, Rosen MJ (2014) Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery 156:176–182

  29. 29.

    Archer S, Pinto A, Vuik S, Bicknell C, Faiz O, Byrne B, Johnston M, Skapinakis P, Athanasiou T, Vincent C (2018) Surgery, complications, and quality of life: a longitudinal cohort study exploring the role of psychosocial factors. Ann Surg.

  30. 30.

    Blair LJ, Cox TC, Huntington CR, Groene SA, Prasad T, Lincourt AE, Kercher KW, Heniford BT, Augenstein VA (2017) The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR). Surg Endosc 31:3539–3546

  31. 31.

    Helbach MV, Koedam TW, Knol JJ, Velthuis S, Bonjer HJ, Tuynman JB, Sietses C (2019) Quality of life after rectal cancer surgery: differences between laparoscopic and transanal total mesorectal excision. Surg Endosc 33:79–87

  32. 32.

    Klima DA, Tsirline VB, Belyansky I, Dacey KT, Lincourt AE, Kercher KW, Heniford BT (2014) Quality of life following component separation versus standard open ventral hernia repair for large hernias. Surg Innov 21:147–154

  33. 33.

    De Silva GS, Krpata DM, Hicks CW, Criss CN, Gao Y, Rosen MJ, Novitsky YW (2014) Comparative radiographic analysis of changes in the abdominal wall musculature morphology after open posterior component separation or bridging laparoscopic ventral hernia repair. J Am Coll Surg 218:353–357

  34. 34.

    Cornette B, De Bacquer D, Berrevoet F (2018) Component separation technique for giant incisional hernia: a systematic review. Am J Surg 215:719–726

Download references

Author information

Correspondence to B. Todd Heniford.

Ethics declarations


Dr. Kercher is on the speakers’ bureau at Bard, Ethicon, and W.L. Gore. Dr. Colavita is on the speakers’ bureau at Allergan. Dr. Augenstein is on the speakers’ bureau at Allergan, Intuitive, Acelity, and W.L. Gore. Dr. Heniford is on the speakers’ bureau at Allergen and W.L. Gore and has received grants from Allergen and W.L. Gore. Drs. Maloney and Schlosser and Ms. Prasad have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Maloney, S.R., Schlosser, K.A., Prasad, T. et al. The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias. Surg Endosc 34, 981–987 (2020) doi:10.1007/s00464-019-06892-x

Download citation


  • Hernia repair
  • Component separation
  • Abdominal wall reconstruction
  • Propensity score match
  • Wound complications