Open transversus abdominis release in incisional hernia repair: technical limits and solutions

Introduction: Incisional hernias with a defect width of more than10 cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. Methods: A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. Results: The standard PCSTAR can generally be used for a defect width of up to 15–17 cm. For defects greater than 17 cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0–97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. Summary: For a defect width greater than 17 cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.