Anterior Component Separation Technique and Its Modifications for Ventral Hernia Repair

The anterior component separation (ACS) technique was developed as an alternative to remote myocutaneous flaps and free-tissue transfers for the closure of large abdominal wall defects. ACS is generally preferred over the posterior component separation (PCS) in the reconstruction of large, complex abdominal wall defects as it offers greater medialization of the musculofascia to approximate in the midline. This facilitates reinforced rather than bridged repair, which is associated with a markedly lower hernia recurrence rate and overall complication rate. The hallmarks of the original Ramirez ACS are (1) division of the external oblique (EO) aponeurosis, (2) blunt separation of the EO and internal oblique (IO) muscles, (3) division of the medial aspect of the posterior rectus sheath, and (4) elevation of the rectus muscle off the posterior rectus sheath. This original open technique however involves creating wide skin flaps overlying the rectus muscles in order to expose the EO aponeurosis laterally, which disrupts the perforating vessels supplying the overlying skin and subcutaneous tissue. This substantially increases the risk of wound complications following open ACS. Several modifications to the original Ramirez technique have been developed to minimize subcutaneous dead space and improve vascularity to the overlying skin. Our preferred technique, the Modified Minimally Invasive Component Separation (MICS), has been demonstrated to halve the risk of wound-healing complications as compared to the original open technique.