Reply to comment to article: Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Bruce Tulloh, Andrew Charles de Beaux, DOI 10.1007/s10029-015-1391-4.

Abstract

Thank you for these comments. To clarify, in this manuscript, we do not promote anterior component separation (ACS) as the preferred method of closure for large abdominal wall defects for several of the reasons you have outlined; a high wound infection and seroma rate, a high recurrence rate, concerns for skin flap necrosis, as well as inapplicability to non-midline defects [1, 2]. For the management of large defects, we prefer posterior component separation with transversus abdominis release (PCS/TAR) due to a low recurrence rate, and applicability to hernias in every location in the abdominal wall [2–4]. But, having said that, there is little doubt that the popularization of ACS has made it a heavily utilized technique for definitive abdominal wall reconstruction [2]. While component separation methods are presumed to be destructive to the abdominal wall, there is excellent data that division of the external oblique aponeurosis in ACS and the division of the transversus abdominis muscle in PCS/TAR do not result in abdominal wall instability. Rather, the reapproximation of the linea alba afforded with these techniques results in improved abdominal wall function and quality of life [5]. The procedure you have described in 21 patients is a bridged repair covered with hernia sac, with no recreation of the linea alba [6]. While this procedure is an acceptable procedure for patients with no need for a functional abdominal wall (the elderly, those with limited life expectancy) it would not be the procedure of choice for definitive, functional reconstruction of the abdominal wall. Patients with bridged repairs of any type typically complain of persistent midline bulging where the mesh is unsupported and are at higher risk of hernia recurrences and central mesh fracture (depending on the type of mesh used) [7, 8]. We respectfully disagree with your assertion that PCS/ TAR is a salvage procedure. We believe that it is a reconstructive (not destructive) operation that should be considered the first-line procedure for the definitive closure of large abdominal wall defects as it permits wide defect overlap, with the mesh in the preferred sublay position and permits primary fascial closure in 95 % of cases [2, 4]. Bridged repair clearly has a role, but should be reserved for only the largest of hernias with massive loss of domain (in whom primary fascial closure is not feasible) or in patients who are not candidates for a definitive closure due to underlining comorbid conditions.