Posterior Component Separation Techniques
Posterior component separation (PCS) with transversus abdominis release (TAR) is the primary technique for posterior component separation, involving three sequential steps: retrorectus dissection, division of the posterior lamella of the internal oblique aponeurosis, and transversus abdominis muscle release. 1
Core Surgical Technique
The PCS-TAR technique follows a systematic approach:
Step 1: Retrorectus Dissection
- The posterior rectus sheath is incised and the retrorectus plane is developed
- This step provides 82.56% of the total reduction in anterior fascial tension 2
- Critical for anterior fascial advancement when midline closure is needed
Step 2: Division of Posterior Lamella of Internal Oblique
- The posterior lamella of the internal oblique aponeurosis is divided
- Contributes 58.78% of the total reduction in posterior fascial tension 2
- Essential for posterior fascial advancement
Step 3: Transversus Abdominis Release (TAR)
- The transversus abdominis muscle is released medial to the linea semilunaris
- Provides 38.17% of additional posterior fascial tension reduction 2
- Exposes a broad retromuscular plane extending from the diaphragm's central tendon superiorly to the space of Retzius inferiorly, and laterally to the retroperitoneum 3
- Preserves neurovascular bundles innervating the medial abdominal wall 3
Step 4: Mesh Placement
- Mesh is placed in a sublay fashion above the posterior layer 3
- The retromuscular plane provides wide mesh reinforcement
- In the overwhelming majority of patients, linea alba reconstruction is achieved 3
Technical Advantages
PCS-TAR provides superior myofascial advancement compared to anterior component separation, particularly in the upper and mid-abdomen 4:
- Complete PCS achieves 10.2 cm of anterior rectus fascia advancement versus 8.8 cm with anterior component separation (p = 0.046)
- Upper abdomen: 8.1 cm vs 6.7 cm (p = 0.01)
- Mid-abdomen: 11.4 cm vs 9.6 cm (p = 0.01)
- Lower abdomen shows similar advancement between techniques
Clinical Applications
The technique is versatile and applicable to 3, 5:
- Midline hernias
- Parastomal hernias
- Flank hernias
- Subcostal hernias
- Recurrent hernias after prior component separations
- Complex hernias with loss of domain
- Subxiphoid defects
- Post-trauma and sepsis cases initially treated with open abdomen
Outcomes
The technique demonstrates excellent durability with a 5% recurrence rate at 2 years 3, and recent data shows 1.9% recurrence at 28 months mean follow-up 5. Posterior fascial closure is achievable in virtually all cases, while anterior fascial closure is achieved in approximately 56% of cases 5.
Complication Profile
- Wound complications occur with similar frequency to other techniques but tend to be less severe 3
- Rarely require operative débridement
- Seroma occurs in 23% of cases 5
- Surgical site infection: 3.8% with no deep wound infections 5
- Minor complications (Clavien-Dindo I-II): 27% 5
- Major complications (Clavien-Dindo III): 1.9% 5
Important Technical Considerations
If anterior fascial advancement is needed, retrorectus dissection alone should be performed first, as TAR does not reduce anterior fascial tension 2. Conversely, both division of the posterior lamella and TAR are necessary for posterior fascial advancement 2.
The technique can be performed via open or robotic-assisted approaches 6, with the robotic technique requiring well-established landmarks for reproducibility and safety.
Guideline Context
Component separation technique is recommended as a useful and low-cost option for repair of large midline abdominal wall hernias (grade 1B recommendation) 1. While the original 1990 Ramirez technique described anterior component separation without prosthetic material, most contemporary series incorporate mesh reinforcement 1.
Caution: High recurrence rates up to 38.7% have been reported with component separation techniques 1, emphasizing the importance of proper patient selection and meticulous technique. Tobacco use, obesity, and comorbidities should not be considered absolute contraindications but require careful perioperative management 5.