Modified Components Separation Technique Research Articles

OC-012 THE COMBINATION OF THE THREE MODIFICATIONS OF THE COMPONENT SEPARATION TECHNIQUE IN THE MANAGEMENT OF COMPLEX SUBCOSTAL WALL DEFECT

Abstract Aim To present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall defect. Material and Methods Between January 2010 and January 2022, seven patients with complex subcostal hernia defects compromised by infection, radiation, or chemotherapy underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the “method of wide myofascial release” at the side of the hernia defect; (b) “openbook variation” of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position. Results The median (range) length and width of the complex subcostal hernias were 15 cm (10–19) and 15 cm (8–24), respectively. The overall morbidity rate was 57.1% (wound infection, seroma and skin necrosis). There was no hernia recurrence during the median follow-up time of 19 (range 3–84) months. Conclusion The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall defect.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia.

The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia. Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position. The median length and width of the complex subcostal hernias were 15cm (10-19) and 15cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19months. The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

Treatment of patients with large and complex incisional hernia with modified component separation technique and long-term follow-up

Treatment of patients with large and complex incisional hernia with modified component separation technique and long-term follow-up

Simultaneous Complex Incisional Hernia Repair and Bariatric Surgery for Obese Patients: a Case Series of a Single-Center Early Experience.

Obesity is associated with recurrence of complex incisional hernia repair (CIHR). Bariatric procedure during CIHR can improve recurrence rates without increasing morbidity. This study aimed to describe our results after CIHR in patients with obesity, in which a simultaneous bariatric procedure was performed. We performed a retrospective observational study including patients who underwent surgery between January 2014 and December 2018, with a complex incisional hernia (CIH) according to the Slater classification and body mass index (BMI) ≥35. CIHR was the main indication for surgery. We collected demographic data, comorbidities, CIH classification according to the European Hernia Society, type of bariatric procedure, postoperative morbidity using the Dindo-Clavien classification, and short-term results. Computed tomography (CT) is performed preoperatively. Ten patients were included in the study (7 women). The mean BMI was 43.63±4.91 kg/m2. The size of the abdominal wall defect on CT was 8.86±3.93 cm. According to the European Hernia Society classification, all CIHs were W2 or higher. Prosthetic repair of the CIH was selected. Onlay, sublay, preperitoneal, and inlay mesh placement were performed twice each, as well as one modified component separation technique and one transversus abdominis release. Gastric leak after sleeve gastrectomy was the only major complication. Short-term outcomes included one recurrence, and % total weight loss was 24.04±8.03 after 1-year follow-up. The association of bariatric procedures during CIHR seems to be feasible, safe, and could be an option for surgical treatment in selected patients.

Long term outcomes of abdominal wall reconstruction using open component separation and biologic mesh in the liver, kidney, and small bowel transplant population.

The aim of this study is to critically examine the multidisciplinary approach to abdominal wall reconstruction (AWR) in the solid organ transplant (SOT) population at our institution, MedStar Georgetown University Hospital, using a modified component separation technique (CST). A retrospective review of AWR utilizing modified open CST with biologic mesh in SOT patients was performed from January 2010 to June 2018. Patient demographics, comorbidities, operative details, complications, and outcomes were recorded. Descriptive statistics, logistic and linear regression analyses were performed to appraise outcomes. Thirty-five patients were included; mean age was 53years. Patient demographics and comorbidities were: 82.9% male, 45.7% history of tobacco use, and 28.6% diabetes. Fifty-one percent had undergone prior hernia repair. Transplant types were: kidney (9), liver (16), liver/kidney (1), small bowel (7), multivisceral (2). All were on an immunosuppressive regimen at time of surgery; 22.9% included steroids. Average defect size was 361cm2. Additional soft tissue procedures were performed in 65.7% (n = 23) of patients. Median time to healing was 29.0days. Complication rate was 31.4% (n = 11); six patients required reoperation within 90days. Recurrence rate was 5.7% (n = 2) at mean of follow up of 3.0years. Additional soft tissue procedures were statistically significant for healing time (p = 0.037). Steroid use was statistically significant for reoperation within 90days (OR = 12.500; 95% CI 1.694-92.250); however, steroid use was not significant after correction for confounders. Modified open CST with biologic mesh is a safe, efficacious approach to complex AWR in the SOT population with recurrence rates comparable to the general population.

Surgical treatment strategies for giant inguinoscrotal hernia \u2013 a case report with review of the literature

BackgroundAn inguinoscrotal hernia is defined as “giant” if descending below the midpoint of the inner thigh of a patient in upright position. In developed countries this is a rare entity. In the literature different surgical techniques have been reported so far to achieve a successful treatment.Case presentationWe present the case of a 63 year-old man suffering from a giant inguinoscrotal hernia, whom we treated using a combined open transabdominal and inguinal approach following an unsuccessful laparoscopic attempt. Meshes were placed in a premuscular position (Lichtenstein’s procedure) and in a preperitoneal position. In addition, a reconstruction of the abdominal wall by modified components separation technique was performed. During the early postoperative period no complications were registered. Intensive care treatment was not necessary. The patient was discharged on postoperative day 8 in an excellent condition. Six months after surgery a scrotal hematocele was diagnosed and operatively removed. After a follow-up of 1.5 years neither hernia recurrence, nor chronic groin pain were recorded. The patient reported to be sexually active. His quality of life improved notably.Additionally, a Medline and PubMed database research was performed to create an overall picture of the existing surgical treatment strategies. Included were patients with diagnosis of primary giant inguinoscrotal hernia according to the given definition. Emergency interventions and cases without details of the surgical approach were excluded.ConclusionsFirstly, this report describes a novel, successful surgical treatment of a giant inguinoscrotal hernia without administering preoperative progressive pneumoperitoneum therapy or visceral resection. Secondly, we summarize cases previously reported as a practical guide for possible surgical therapy approaches.

Modified components separation technique: experience treating large, complex ventral hernias at a University Hospital.

An increasing number of patients have large or complex abdominal wall defects. Component separation technique (CST) is a very effective method for reconstructing complex midline abdominal wall defects in a manner that restores innervated muscle function without excessive tension. Our goal is to show our results by a modified CST for treating large ventral hernias. A total of 351 patients with complex ventral hernias have been treated over a 10-year period. Pre- and postoperative CT scans were performed in all patients. All ventral hernias were W3, according to the EHS classification 1. We analyzed demographic variables, co-morbidities, hernia characteristics, operative, and postoperative variables. One hundred and seventy patients (48.4%) were men; the average age of the study population was 51.6±23.2years with an average BMI of 32.3±1.3. The hernia was located in the midline in 321 cases (91.5%) versus the flank in 30 (8.5%). In 45 patients, preoperative botulinum toxin (BT) and progressive pneumoperitoneum (PPP) were needed due to giant hernia defects when the VIH/VAC ratio was>20%. Postoperative complications related to the surgical site were seroma (35.1%), hematoma (9.1%), infection (7.2%), and wound necrosis (8.8%). Complications related to the repair were evisceration in 3 patients (1.1%), small bowel fistula in 4 patients (1.5%), 11 cases of mesh infection (2.9%), and abdominal compartment syndrome (ACS) in 2 patients. There were 29 hernia recurrences (8.2%) with a mean follow-up of 31.6±8.1months. The modified CST is an effective strategy for managing complex ventral hernias that enables primary fascial closure with low rates of morbidity and hernia recurrence.

Staged abdominal closure with intramuscular tissue expanders and modified components separation technique of a giant incisional hernia after repair of a ruptured omphalocele

In patients with omphalocele, several different techniques are performed for repair of the abdominal wall defect. We present the case of a staged abdominal closure of a giant incisional hernia after repair of a ruptured omphalocele. At birth, skin flap coverage associated with silo formation occurred, but the abdominal wall defect remained, resulting in a giant abdominal hernia. To expand the layers of the abdominal wall, tissue expanders were placed between the bilateral internal oblique and transverses abdominis muscles. Postoperatively, a modified components separation technique was performed. The abdominal wall was closed in the midline. Upon closure of the skin in the midline, bilateral relaxing incisions were performed, covering the remaining defect with artificial dermis. At the age of one year and 7 months, the patient had no recurrent incisional hernia nor any wound complications.

Extragenital malignant mixed Mullerian tumor in the incisional hernia - primary carcinosarcoma in the abdominal wall: Case report

This report presents a primary Mullerian carcinosarcoma localized in the incisional hernia i.e. anterior abdominal wall.There is no data in the literature about this localization of extragenital Mullerian carcinosarcoma. The patient had previous medical history of right-sided ovarian cystadenocarcinoma managed by hysterectomy, bilateral ovariectomy and chemotherapy. An incisional hernia occurred 1 year after the operation and Mullerian carcinosarcoma at the right border of the incisional hernia 16 years later. There was no tumor spreading into the abdominal cavity and pelvis. Full thickness of the abdominal wall resection and coexisting incisional hernia resulted in a large 25x20 cm abdominal wall defect managed by the modified components separation technique and implanting meshes. Major abdominal wall resection and abdominal wall reconstruction using the modified components separation technique reinforced with meshes could be one of possible solutions in the surgical treatment of primary malignant mixed Mullerian tumor localized in the abdominal wall.

Multilayer Myofascial-Mesh Repair for Giant Midline Incisional Hernias: A Novel Advantageous Combination of Old and New Techniques

BackgroundThe components separation technique has been proposed as the best solution when facing large abdominal wall defects. In counterpart, this sometimes comes at the price of high rates of wound complications and recurrence. Moreover, the components separation method alone seems insufficient for huge defects, in which it is impossible to reapproximate the rectus muscles without tension. For these cases, we illustrate a novel operation using a modified components separation technique. MethodsTwenty-eight patients with giant midline incisional hernias were treated with a combination of the components separation (bilateral sliding rectus abdominis advancement flaps), an autologous multilayer repair, and a retromuscular mesh reinforcement. ResultsTwenty-four (85 %) patients have been analyzed. Transverse defect size ranged from 15 to 25 cm (average, 18.8 cm). Wound complications occurred in nine (37 %) cases; three of them required drainage of a subcutaneous abscess. After a mean follow-up of 22 (range, 12–48) months, one (4 %) recurrence was identified. ConclusionsMultilayer myofascial-mesh repair was associated with a low recurrence rate, and wound complications were managed without issues. This approach is a reliable technique for most surgeons and may constitute a new part of the armamentarium for the repair of challenging defects.

Modified components separation technique for TRAM flap donor site closure

Sir, Components separation is a method of abdominal closure for complex abdominal wall defects first described by Ramirez et al. in 1990 [1]. Since then several modifications have been described [2–4], and these methods achieve local fascial approximation whilst maintaining dynamic abdominal wall function. The most common method involves transection of the external oblique aponeurosis just lateral to the linea semilunaris, with separation of the external oblique from the internal oblique muscle laterally (Fig. 1). This plane is relatively aneurovascular, preserving vascularity and innervation to the anterior abdominal wall. When required, further gain can be achieved by additional separation of the posterior rectus sheath from the rectus abdominal muscle or by releasing the external oblique muscle laterally. The defect created is then usually reinforced with prosthetic mesh repair. Following transverse rectus abdominis musculocutaneous (TRAM) flap harvest, direct fascial approximation is desirable as it results in a low risk of abdominal bulge and hernia formation [5], however where this is not possible, techniques such as inlay of prosthetic mesh or acellular dermal matrix are required to achieve abdominal closure. We have found a novel technique of limited components separation to have great utility following free muscle-sparing TRAM flap harvest without any bulges or hernias occurring to date. The linea semilunaris is first incised along the lateral border of the defect and the external oblique aponeurosis mobilized (Fig. 2a, b). The extent of the undermining is sufficient to allow advancement to gain direct fascial closure without tension (Fig. 3a). The external oblique aponeurosis is then reapproximated with the anterior lamina of the internal oblique aponeurosis at the linea semilunaris with horizontal mattress nonabsorbable sutures to restore normal anatomy and to ensure that fascial closure is tensionless (Fig. 3b). The fascial defect is then closed using horizontal mattress nonabsorbable sutures. A prosthetic mesh inlay may be utilized in addition to further reinforce the closure, assessed on an individual case basis, which is fully covered with vascularized tissue, which we consider desirable and may help to reduce the potential for infection. This simple modification of the components separation technique extends the range over which direct fascial approximation at the donor site may be achieved whilst simultaneously reducing tension at the site of primary fascial repair. In addition we advocate reconstruction of M. Schaverien (*) Department of Plastic Surgery, Ninewells Hospital, Dundee DD1 9SY, UK e-mail: markschaverien@fastmail.fm

Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience

Although damage control strategies and the open abdomen have improved survival, they present their own unique set of challenges in caring for the multiply injured trauma patient. We previously reported the technique of staged abdominal wall closure for the management of the open abdomen. The purpose of this study was to evaluate the efficacy of various techniques of abdominal wall reconstruction (final stage of management) on long-term outcomes after planned ventral hernia, and to better define risk factors for recurrence. Patients undergoing abdominal wall reconstruction over a 15-year period were identified and stratified by gender, age, severity of shock, injury severity, and method of repair: secondary fascial closure +/- prosthetic, standard components separation (SCS) +/- prosthetic and modified components separation (MCS) +/- prosthetic. Long-term outcomes (recurrence) were determined using hospital records, telephone interview, and physical examination. Multivariable logistic regression analysis was performed to determine independent predictors of recurrence. One hundred fifty-two patients were identified. Fourteen (9%) patients underwent secondary fascial closure +/- prosthetic, 47 (31%) underwent SCS +/- prosthetic, and 91 (60%) underwent MCS +/- prosthetic. Long-term follow-up (up to 14.6 years, mean 5.3 years) was obtained in 114 (75%) patients. Sixteen patients (14%) had a recurrence. Prosthetic use increased recurrence 4-fold. There were 2 known recurrences (5%) in patients with MCS without prosthetic. Logistic regression identified both female gender and body mass index as independent predictors of recurrence. The MCS technique is the procedure of choice for repair of giant abdominal wall defects. This approach can avoid the need for prosthetics. In fact, MCS without prosthetic resulted in an acceptably low hernia recurrence rate (5%).

Component Separation Technique for Abdominal Wall Reconstruction in Burn Patients With Decompressive Laparotomies

Component separation technique has been used successfully in ventral hernia repair occurring after damage control surgery. Abdominal compartment syndrome, seen in severely injured burn patients, frequently requires decompressive laparotomy. The patient is at risk during this time not only for burn injury complications but also for those from an open abdomen. This report presents the successful application of the component separation technique for early closure of decompressive laparotomies in patients with >75% total body surface area burn, which included the abdominal wall. Skin flaps (necrotic/burned skin) overlying the abdominal wall fascia were raised bilaterally at the costal margin, from the anterior superior iliac spine inferiorly to the ribs superiorly. An incision was made just lateral to the rectus sheath through the aponeurosis of the external oblique muscle. With this, the fascia was mobilized to the middle with no tension. With no elevation of the patient's intrathoracic pressure on closure of the abdomen, multiple no. 2 Ethibond fascial figure of eight sutures closed the abdomen. Skin flaps were excised, so that grafting of the abdominal wall could occur. Burn patients, who required decompressive laparotomies for abdominal compartment syndrome in response to massive fluid resuscitation, tolerated early closure by the modified component separation technique. This markedly improved the care of these critically burned individuals, allowing for less third space fluid loss, less difficulty in management of the open abdominal wound, along with decreased risk of potential enterocutaneous fistula and intraabdominal abscess formation.

Modified extraperitoneal endoscopic separation of parts for abdominal compartment syndrome

Standard therapy for abdominal compartment syndrome (ACS) is laparotomy and temporary abdominal wall closure with significant morbidity. The component separation technique allows for difficult abdominal closure. We studied a modified extraperitoneal endoscopic separation of parts technique on an animal model of ACS. Twelve anesthetized pigs were instrumented for measurement of central venous pressure, arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, and intraabdominal pressure (IAP). ACS to 25 mmHg was created by infusing saline into an intraabdominally placed bag. Animals were divided in two equal groups. Pigs in group A underwent minimally invasive resection of the nerves supplying the rectus muscles bilaterally. Pigs in group B underwent minimally invasive modified component separation technique bilaterally. Change in IAP and other physiological parameters were recorded. (Group A) IAP increased significantly from 7.3 mmHg +/- 3.8 to 25.2 mmHg +/- 1.5 with infusion of saline. Following nerve transection on the right side there was a nonsignificant decrease in IAP from 25.2 mmHg +/- 1.5 to 22.3 mmHg +/- 1.4 and following nerve transection on the left side there was a further decrease in IAP to 20.3 mmHg +/- 1.9. (Group B) IAP increased significantly from 3.8 mmHg +/- 0.4 to 24.7 mmHg +/- 0.5 with infusion of saline. Following separation of parts on the right side there was a significant decrease in IAP from 24.7 mmHg +/- 0.5 to 15.0 mmHg +/- 1.7 and there was a further decrease in IAP to 11.3 mmHg +/- 1.4 following separation of parts on the left side. The only significant change in the physiological parameters measured was observed in CVP in both groups. We present a porcine model of extraperitoneal endoscopic release of abdominal wall components as a treatment option for ACS.

Component separation technique to repair large midline hernias

In patients with omphalocele, several different techniques are performed for repair of the abdominal wall defect. We present the case of a staged abdominal closure of a giant incisional hernia after repair of a ruptured omphalocele. At birth, skin flap coverage associated with silo formation occurred, but the abdominal wall defect remained, resulting in a giant abdominal hernia. To expand the layers of the abdominal wall, tissue expanders were placed between the bilateral internal oblique and transverses abdominis muscles. Postoperatively, a modified components separation technique was performed. The abdominal wall was closed in the midline. Upon closure of the skin in the midline, bilateral relaxing incisions were performed, covering the remaining defect with artificial dermis. At the age of one year and 7 months, the patient had no recurrent incisional hernia nor any wound complications.

Versorgung ventraler Riesenhernien unter Verwendung einer modifizierten Komponenten-Separationstechnik

Closure of Ventral Giant Hernias through Modified Component Separation Technique Incisional hernias are a fairly common complication of median laparotomies. They appear in about 10% of all cases. Repair techniques without net inlay are associated with a recurrence rate up to 50%. Therefore, procedures using surgical meshes in sublay technique became the method of choice. Very large abdominal wall defects, commonly due to laparostoma techniques, including laterality of the rectus muscle require an extended operative procedure. During the last 2 years, 8 patients between 24 and 74 years of age underwent repair of a ventral giant hernia at our department. The vertical and horizontal diameters of these hernias ranged from 10 to 24 cm. In 4 cases a mesh-grafted intestinal prolaps occurred after previous laparostoma procedure. Our operative technique includes the classical steps of component separation with incision of the external oblique muscle origin combined with implantation of a surgical mesh behind the rectus muscle (sublay technique). Mesh grafts over the intestines are de-epithelialized using a CO₂ laser in order to save operating time and to prevent unnecessary blood loss. The dermal remnants are then placed underneath the dorsal rectus sheath. Postoperative complications included delayed wound healing and temporary seroma formation in 1 patient. In a second case a slowly progressive and hardly symptomatic hernia superior to the right iliac crest occurred 11 months postoperatively. There was no recurrence of a surgically treated ventral hernia during a mean follow-up of 11 months. Tension-free closure of large midline defects is managed through component separation technique. Thus, the anatomy of the abdominal wall and its dynamic competence are restored. Laser vaporization of mesh-grafted areas decreases the operating time, the blood loss, and the risk of intestinal lesions. In addition, risk of hernia recurrence is supposed to substantially be reduced using the additional net sublay technique.

Staged Management of Giant Abdominal Wall Defects

Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects. Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates. Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%). The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.

Planned Ventral Hernia Staged Management for Acute Abdominal Wall Defects

Analysis of a staged management scheme for initial and definitive management of acute abdominal wall defects is provided. A four-staged scheme for managing acute abdominal wall defects consists of the following stages: stage I--prosthetic insertion; stage II--2 to 3 weeks after prosthetic insertion and wound granulation, the prosthesis is removed; stage III--2 to 3 days later, planned ventral hernia (split thickness skin graft [STSG] or full-thickness skin and subcutaneous fat); stage IV--6 to 12 months later, definitive reconstruction. Cases were evaluated retrospectively for benefits and risks of the techniques employed. Eighty-eight cases (39 visceral edema, 27 abdominal sepsis, 22 abdominal wall resection) were managed during 8.5 years. Prostheses included polypropylene mesh in 45 cases, polyglactin 910 mesh in 27, polytetrafluorethylene in 10, and plastic in 6. Twenty-four patients died from their initial disease. The fistula rates associated with prosthetic management was 9%; no wound-related mortality occurred. Most wounds had split thickness skin graft applied after prosthetic removal. Definitive reconstruction was undertaken in 21 patients in the authors' institution (prosthetic mesh in 12 and modified components separation in 9). Recurrent hernias developed in 33% of mesh reconstructions and 11% of the components separation technique. The authors concluded that 1) this staged approach was associated with low morbidity and no technique-related mortality; 2) prostheses placed for edema were removed with fascial approximation accomplished in half of those cases; 3) absorbable mesh provided the advantages of reasonable durability, ease of removal, and relatively low cost--it has become the prosthesis of choice; and 4) the modified components separation technique of reconstruction provided good results in patients with moderate sized defects.