Repair of large abdominal wall hernias remains a challenge.
Due to the persistently high recurrence rate, surgeons have not rested trying to improve the various techniques. At present, the preferred repair in primary and recurrent incisional hernias of the abdominal wall relies on synthetic sublay meshes.
The anatomical and clinical trial published 1990 by Oscar M. Ramirez (1) described the repair of large abdominal wall defects with widely displaced fascia and muscle margins by a plastic procedure carrying his name, the so-called component separation technique (CST) for tension-free construction of the abdominal wall. This involves separating myofascial [MM1] components of the abdominal wall (external/internal oblique), and possibly parts of the rectus muscle, from their posterior sheaths.
As one eminent example of the last three decades in American plastic and reconstructive surgery, the Ramirez CST primarily does not rely on additional material covering the defect. On the contrary, the defect is covered by skilled transfer of muscular components of the abdominal wall. “This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components…”. In his days, the focus of Ramirez’ trial was less on omitting alloplastic material and more on the myocutaneous sliding flaps and free transplants usually employed then.
While in the years following Ramirez’ initial publication the treatment of giant abdominal wall hernias increasingly turned to the implantation of additional (now mostly alloplastic) material, these newer technique aiming to lower the recurrence rates have to measure up to the original goal of Ramirez: Obtaining the material for covering the defect solely by separating the components of the abdominal wall.
The literature search did not find any papers comparing the original technique by Ramirez, solely separating components of the abdominal wall, with procedures employing additional mesh augmentation.
There are very few valid published data which might help to decide which technique would be appropriate in the next patient. The randomized trial by De Vries Reilingh from Nijmwegen (3) on 19 patients with CST and 18 patients with prosthetic repair (PR) using synthetic mesh implants (here: ePTFE patch) demonstrated the following results after 5 months: “Reherniation occurred in 10 patients after CST and in 4 patients after PR.” The Kaplan-Meier estimate after 36 months yielded almost no difference between both techniques.
For a mean follow-up of 24 months, the literature for the Ramirez procedure has reported recurrence rates between 0% and about 30%, depending on the underlying disorder of the patients and the complexity of the hernia.
A retrospective study (2) published by the Bonn University Medical Center in June of 2012 on the course of abdominal wall reconstruction by component separation in 40 patients reported a recurrence rate of no less than 28% and a 22.5% rate of postoperative infection. However, for these results it should be noted that the giant abdominal wall defects were primarily seen in patients with colostomy and following Hartmann procedure.
In the 2007 trial discussed above, de Vries Reilingh divided his comparably sized group of patients into 19 cases solely with CST and 18 case with patch repair. Secondary wound healing was seen in 10(CST) and 13 (PT) patients respectively, and the recurrence rate noted above demonstrates the still pressing challenge to look for reliable repair techniques.