Ramirez component separation technique

Mark the landmarks with a skin marker before incising the skin. The landmarks include:

• Costal arch
• Symphysis pubis
• Hernial orifice
• Possible course of the skin incision

After marking the landmarks and settling on the mesh size to be used, incise the skin from the xyphoid process to the symphysis pubis, taking down all scar tissue and excess skin.

Carefully dissect the skin to be excised, including any subcutaneous tissue present, off the deeper tissue. This may be effected with dissecting scissors or by electrocautery. Special care must be taken not to injure any adherent intestinal loops.

To free any adherent intestinal loops from the abdominal wall, perform lateral adhesiolysis either in parallel with the skin excision or after the latter has been completed. Here, too, the intestinal loops must be spared because otherwise the surgical field will be contaminated, thereby exposing the mesh implant to the risk of infection.

After extensive adhesiolysis free the posterior lamina off the medial margin of the rectus sheath. This dissection runs from the costal arch or far (here 7 cm) along the posterior aspect of the xyphoid process to the retropubic space and should reach the lateral margins of the rectus sheath.

Note: Opening up the retroxyphoidal space requires sharp dissection of the posterior lamina of the rectus sheath off the xyphoid process.
On both sides of the white line, the posterior lamina of the rectus sheath must then be transected transversely for 5 cm. This opens up the preperitoneal space. The preperitoneal fatty tissue appears in the “fatty triangle”. Also, see the article of incisional hernia repair with subfascial mesh augmentation