Hernia

https://doi.org/10.1007/s10029-021-02535-0

REVIEW

Changes in the abdominal wall after anterior, posterior, and combined

component separation
J. Daes1   · E. Oma2 · L. N. Jorgensen2

Received: 4 July 2021 / Accepted: 1 November 2021

© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2021

Abstract
Key message  Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essen-
tial for understanding the mechanisms of action of the various CS techniques, the changes observed on computed
tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who
have undergone CS.
Abstract 
Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They
allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea
alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding
the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps
most importantly, the anatomic and physiologic changes following CS techniques.
Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify
articles describing abdominal wall changes after CS
Results After excluding non-pertinent articles, 14 articles constituted the basis for this review. 
Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external
oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after
posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both
open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the
muscles’ overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3)
Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior
CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postop-
erative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and
posterior CS are underway.

Keywords  Abdominal wall reconstruction · Bridged repair · Midline closure · Component separation techniques · Ventral
hernia repair · Muscle displacement

Introduction principles, technology, techniques, and materials avail-

Determination of how to optimally manage complex
ventral hernias is an ongoing process. The evolution of
hernia management has varied greatly according to the
* J. Daes
jorgedaez@gmail.com
1
Minimally Invasive Surgery Department, Clínica Porto Azul,
Carrera 58, Número 79‑223 PH B, Barranquilla, Colombia
2
Digestive Disease Center, Bispebjerg Hospital, University
of Copenhagen, 2400 Copenhagen, NV, Denmark
able during different periods and in different locations.
In previous eras, nonsurgical treatment of hernias, pri-
mary closure of defects without meshes and bridging with
meshes were considered standard care. Today, abdominal
wall reconstruction (AWR) is a frequently used term to
describe the repair of ventral hernias wherein the goal
is to recreate the abdominal wall to restore structure and
function. Although there is no universally agreed-upon
definition of an anatomical, functional abdominal wall,
many surgeons now believe that the ultimate goal is the
closure of the linea alba and the hernia defect(s) under

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Vol.:(0123456789)
 Hernia
physiologic tension, often with reinforcement using mesh
prosthetics [1]. Studies have shown a correlation between
successful midline restoration and a functional abdomen
[2]. Current strategies for complex AWR rely heavily on
myofascial release of the lateral musculature until suit-
able biologic fascia becomes available as a replacement. In
addition, myofascial release of the lateral abdominal wall
components is effective and does not result in overt dys-
function. The abdominal musculature has two distinctive
features that contribute to this phenomenon: the overlap-
ping function of the muscles and their ability to undergo
compensatory trophism. During the last decade, posterior
component separation with transversus abdominis release
(PCS-TAR) has emerged as one of the most commonly
employed approaches to AWR [3, 4]. PCS-TAR owes its
current popularity to several factors:
• It is a natural extension of the Rives−Stoppa technique.
• A mesh is placed in the preferred sublay-retromuscular
position.
• Wide mesh overlap is possible without the need to
develop a lipocutaneous flap.
• The method is associated with low rates of surgical-site
events and hernia recurrence.
Despite the increased popularity of PCS-TAR, several
other myofascial release methods remain in use. Endo-
scopic anterior component separation (ACS) in the selected
patient is a safe, effective alternative for achieving myofas-
cial release during open, laparoscopic, and robot-assisted
AWR [5–9]. Various endoscopic ACS approaches have been
described that permit release of the external oblique (EO)
aponeurosis without the morbidity associated with lipocu-
taneous flap formation or central skin devascularization [9].
Open ACS also continues to be used successfully by many
surgical groups worldwide. The indications for the various
component separation (CS) techniques rely on many factors,
including the size of the defect, the width of the retrorectus
space (Carbonell index), the elasticity of the abdominal wall,
previous repairs, use of meshes, and the body habitus of the
patient.
Adjunct techniques such as the use of Botox and pre-
operative pneumoperitoneum have been used to facilitate
compliance with the modern principles of AWR. Changes in
the abdominal wall after use of Botox have been described,
including elongation of the lateral musculature of the abdo-
men and reduction of the hernia size. An extensive review
of the topic is, however, beyond the scope of this review.
Even with the widespread use of CS techniques for ven-
tral hernia repair, there has been a paucity of information
regarding changes in the lateral abdominal wall muscula-
ture after CS and its combinations. Such information—i.e.,
data on muscle displacement, muscular trophism, changes
13
in the circumference and shape of the abdominal wall, bulg-
ing and semilunar line hernias after CS—would contribute
significantly to the overall knowledge in the discipline.
Understanding these changes could facilitate our compre-
hension of the mechanism of action of the CS techniques,
interpretation of follow-up images, and the correlation of
those changes with patients’ postoperative physiologic and
anatomic alterations.
Literature search strategy
A systematic review of the literature was conducted
using the PubMed database to identify articles describing
abdominal wall changes after ACS, PCS, or combined CS
techniques from January 2000 to September 2021. The
search was performed using the following terms: (compo-
nent separation OR abdominal wall reconstruction) AND
(muscle OR musculature OR lateral abdominal wall) AND
(alterations OR changes OR displacement). We elected all
English-language full-text articles reporting experimen-
tal or clinical original data on changes in the abdominal
wall after CS techniques. In total, 636 record matches
were located in the PubMed database using the literature
search strategy. Sixteen publications were retrieved for a
full review, and 10 of these publications were excluded
from the final analysis because of lack of pertinence to
the main topic under study. Eight more articles pertaining
to the main subject of this review were added from other
sources, including references to already included articles.
Finally, 14 articles constituted the basis for this review.
General changes in the abdominal wall after midline
restoration and defect closure
In a comparative study involving rats, DuBay et al. [10]
found that 35 days postoperatively, rats that underwent
formation of chronic incisional hernias showed more
atrophic changes in the oblique muscles than rats in the
sham laparotomy group. Culbertson et al. [11] used the
same experimental and control groups and showed that
hernia repair resulted in almost complete atrophy reversal
at 5 weeks postoperatively. They attributed this phenom-
enon to the reconstruction of the midline and reloading of
the affected muscles. Many clinical studies have confirmed
these observations and will be discussed in detail.
Surgical restoration of the midline and reversal of the
hernia-induced atrophy may affect the anatomy and func-
tion of the abdominal wall.
Den Hartog et al. [12] evaluated 30 patients after pri-
mary ventral hernia repair or bridged laparoscopic repair
and compared them with 12 healthy control subjects using
a Biodex machine (Biodex Medical Systems Inc., Shirley,
Hernia
NY, USA). Compared with the laparoscopic technique
using bridging mesh, the authors concluded that two-
layered suture repair with reapproximation of the rec-
tus abdominis (RA) muscle results in greater isokinetic
strength of this muscle group.
When current AWR principles are not met, bridged
repair is usually required. The type of bridged repair var-
ies according to the surgical approach used and the mesh
location. In the classic laparoscopic ventral hernia repair,
the mesh is placed in an underlay position to bridge the
defect; in PCS, the mesh is placed in an extensive sublay
position to bridge the defect; and in the acute setting of
an open abdomen, the mesh is often placed as an inlay to
bridge the defect. Results of bridged repairs have been
disappointing in many cases, as noted in patients at the
Cleveland Clinic who underwent a TAR-bridged repair.
These patients were retrospectively identified from the
Americas Hernia Society Quality Collaborative database.
The mean hernia width was 26 ± 8 cm. Most hernias (93%)
were incisional hernias, 71% of hernias were recurrent,
and 21% of the patients had each undergone five prior
hernia repairs. At a mean follow-up of 20 ± 10 months, a
composite recurrence rate of 46% was reported [13]. Other
studies have corroborated substandard results after bridged
repairs with high rates of surgical-site events, recurrences,
bulging, and patient dissatisfaction [14, 15]. These results
reinforce the importance of midline restoration and pri-
mary closure of defects.
Changes in abdominal wall musculature after PCS
De Silva et  al. [16] analyzed the computed tomogra-
phy changes between the preoperative period and at least
6 months postoperatively in patients who underwent either
PCS-TAR with midline reconstruction or laparoscopic ven-
tral hernia repair without midline reconstruction. Twenty-
five consecutive patients were analyzed in each group. The
authors reported significant hypertrophy of the EO, internal
oblique (IO), and RA muscles in the TAR group. There were
no significant changes in the muscles in the laparoscopic
repair group [16].
Daes et al. described 17 patients who underwent 30 PCS-
TAR procedures (13 bilateral) for the repair of midline ven-
tral hernias from August 2012 to July 2014. Their 1-year
follow-up CT images revealed that the edge of the transverse
abdominal (TA) muscle relative to the lateral border of the
RA had moved a significant (albeit small) distance laterally
only at the level of the superior mesenteric artery (SMA)
(median lateral movement of 10 mm, P = 0.04). There were
no significant differences at other locations. The authors
stated that the strong attachment among the TA, IO, and
their investing fascia and the rapid integration of meshes
at this location played an important role. There was no
significant change in the TA, EO, and IO heights at 1 year.
Only the thickness (not the width) at the RA at SMA was
significantly different at 1 year (median change of –2.4 mm,
P = 0.02). CT images at the same level before reconstruction
and 2 years after TAR are shown in Fig. 1.
An unpublished Danish study by Oma et al. [18] on dif-
ferent types of CS performed in 105 patients (ACS and
PCS) showed similar results. These patients had a mean
defect width of 12.2 cm. Of the whole series, 5 (5%) and
14 (13%) patients underwent bilateral and unilateral TAR,
respectively, and 16 (15%) underwent unilateral endoscopic
ACS and contralateral TAR. Complete fascial closure was
achieved in 103 (98%) patients. The lateral abdominal wall
muscle thickness and displacement were compared with
preoperative images after bilateral CS and with the undi-
vided side postoperatively after unilateral CS. The TA mus-
cle was significantly displaced laterally by a mean 8.2 mm
(95% confidence interval 0.71–5.7 mm) after TAR. The
combined thickness of the lateral muscles was not signifi-
cantly decreased after TAR [mean decrease of 2.6% (− 4.8
to 9.5%)]. None of the patients developed an iatrogenic
linea semilunaris hernia after TAR. The recurrence rate
for the whole group was 19% after a mean of 1.7- years of
follow-up. The complete study included data on individual
muscle thickness, circumference of the abdomen, and cross-
sectional area of the psoas muscle as a general marker of
physical performance ).
Presuming that the TA is the “corset” of the abdomen,
providing hoop tension throughout the thoracolumbar fas-
cia, the theoretical concern of trunk destabilization after
PCS-TAR has not been demonstrated clinically. Criss et al.
[19] described 13 patients who underwent PCS-TAR for
ventral hernia repair, reporting that restoration of the linea
alba resulted in improved abdominal wall functionality and
patients’ quality of life. Dynamometer analysis of rectus
muscle function showed statistical improvement in the isoki-
netic and isometric measurements.
Changes in abdominal wall musculature after ACS
Hicks et al. [20] were the first to describe the changes in the
abdominal musculature that occurred after open ACS. They
studied 28 patients who underwent repair of large midline
ventral hernias: 15 underwent laparoscopic ACS, 11 under-
went open ACS, and 2 underwent hybrid ACS. The authors
compared CT scans obtained before and at least 6 months
after surgery and found that after ACS, the RA significantly
increased in width and area but decreased in thickness, the
EO significantly decreased in the area but not in thickness,
and the IO and TA significantly increased in area and thick-
ness. The authors did not study the displacement of the
muscles. No information on the recurrence rate, bulging, or
semilunar line hernias was reported. They concluded that
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 Hernia

Fig. 1  Computed tomogra-
phy images at the same level.
Top: Bbefore reconstruction.
Bottom: 2 years after trans-
verse abdominis release. The
displacement of the transverse
abdominis muscle is minimal
(< 1 cm) and only significant in
comparison with the undivided
side at the level of the superior
mesenteric artery. The muscle
mass is maintained after trans-
verse abdominis release

lateral retraction of the EO muscle suggests that mechanical
unloading is responsible for the atrophic effects. However,
the potential donor-site morbidity seems to be overcome by
apparent compensatory hypertrophy of the remaining lateral
oblique muscles.
Daes et  al. [21] recently reported on changes in the
lateral musculature in a series of patients who underwent
subcutaneous ACS as an adjunct to AWR. Data were pro-
spectively collected and maintained for each patient who
underwent AWR in which endoscopic ACS was performed
as an adjunct from September 2012 to September 2015.
Fifteen patients met the criteria for study inclusion. Most
patients (n = 13, 86.7%) underwent unilateral endoscopic
ACS. The most common procedure was laparoscopic intra-
peritoneal onlay mesh-plus hernia repair (n = 12, 80.0%).
The remaining patients underwent open repair. On axial
CT images, the lateral abdominal wall thickness was meas-
ured at the level of two fixed retroperitoneal structures:
the origin of the SMA from the aorta and the aortic bifur-
cation. Displacement of the EO muscle was evaluated on
axial views at the level of the SMA. The authors measured
the distance between the linea alba and the lateral divided
border of the EO muscle and between the lateral edge of
the RA muscle and the laterally divided border of the EO
muscle. For patients who underwent unilateral endoscopic
ACS, comparisons were made between the side with the EO
myofascial release and the undivided side. For patients who
underwent bilateral endoscopic ACS, preoperative abdomi-
nal images were used as the control. CT images were also
evaluated for the presence of midline hernia recurrence,
linea semilunaris hernias (iatrogenic hernias), and lateral
eventration (bulging without a hernia). The authors per-
formed a mean of 20 measurements per patient to ensure
the accuracy of the results. The mean hernia defect width
was 8.4 cm (range 6–15 cm). There was no difference in the
thickness of the lateral abdominal musculature between the
endoscopic ACS side and the undivided side. There was a
significant lateral displacement of the EO muscle from the
lateral edge of the RA muscle on the endoscopic ACS side
(mean distance, 3.7 cm; P = 0.0006) (Fig. 2). These results
were similar to those observed by Hicks et al. [20]. Dur-
ing a mean follow-up of 2.6 years (range 0.5–7.4 years), no
patients developed midline hernia recurrence, an iatrogenic
linea semilunaris hernia, or lateral eventration.

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Hernia
The unpublished Danish study by Oma et al. [18] described
the changes in the abdominal musculature that occurred after
endoscopic ACS using an intermuscular approach. Among the
105 patients in that study (including all CS techniques) with a
mean defect width of 12.2 cm, 55 (52%) and 15 (14%) patients
underwent bilateral and unilateral endoscopic ACS, respec-
tively, and 16 (15%) underwent unilateral endoscopic ACS
and contralateral TAR. The EO muscle was significantly dis-
placed laterally by a mean of 2.74 cm (95% confidence interval
2.29–3.19 cm). The combined thickness of the lateral muscles
was slightly decreased after endoscopic ACS [mean decrease,
10.5% (5.8–15.6%)]. One (1%) patient developed an iatrogenic
linea semilunaris hernia after endoscopic ACS. The recur-
rence rate in the total series of 105 patients who underwent
CS patients was 19% after a mean follow-up of 1.7 years. The
final evaluations of these changes and the changes in individual
muscles and the abdominal wall circumference are underway.
Cavalli et al. [22] described 172 patients who underwent
ACS by a novel posterior approach (through the retrorectus
space). The authors observed preservation of the RA muscle
thickness on postoperative CT images at 1 year, preservation
of RA and TA function in the core stability test, and preser-
vation of the lateral abdominal wall integrity.
Lisiecki et al. [23] studied the morphologic changes of the
abdominal architecture in 21 patients who underwent AWR
with open ACS. In a comparison of CT images before and
after surgery, they found a decrease in the total body area
and circumference with a reduction of the distance between
the fascia and skin but, interestingly, with conservation of
the fascial area and fascial circumference. These changes
were probably related to fact that most patients underwent
an adjunct panniculectomy.
Jensen et al. [2] performed a prospective case–control
study of 18 consecutive patients with large incisional hernias
who underwent AWR with linea alba restoration using an
endoscopic ACS technique and a control group of patients
with an intact abdominal wall who underwent colorec-
tal resection. The truncal flexion and extension strength,
handgrip strength, leg extension power, and quality of life
(36-Item Short Form Survey and Carolinas Comfort Scale)
were assessed preoperatively and 1 year postoperatively. The
patients were compared with a control group of 18 patients
with an intact abdominal wall who underwent colorectal
resection. The authors found that 1 year after AWR, both
truncal flexion and trocar extension strength had increased
and that the physical component of overall quality of life
had improved. In the control group, surgery resulted in a
decrease in both truncal flexion and extension strength.
Combining ACS and PCS
Sequential use of PCS-TAR after failed ACS is a viable (and
perhaps the only available) alternative for patients who have
exhausted all other options. Pauli et al. [24] reported a series
of 21 patients who had previously undergone ACS who had
acceptable morbidity and recurrence rates after using this
sequential approach.
Daes et al. [17] discussed the possibility of using con-
comitant ACS and PCS after observing only limited TA
muscle displacement following TAR, thereby allowing a
safe concomitant anterior separation of the lateral compo-
nents. The distance between the two CSs would allow the
preservation of a common wall comprising two layers of
muscle instead of the frequently invoked single layer. To
explore that possibility, the authors performed enhanced-
view total extraperitoneal TAR followed by ipsilateral endo-
scopic ACS-EO in two fresh cadaver models and open PCS-
TAR followed by ipsilateral endoscopic ACS-EO in three
fresh cadaver models [17]. The PCS-TAR was appropriately
performed medial to the semilunar line and the endoscopic
ACS-EO lateral to the semilunar line. The hemi-abdomen
was then cross-sectioned at the level of the umbilicus. The
common wall between the CS spaces was carefully exam-
ined, and the spaces between the two releases were meas-
ured. As shown in Fig. 3, the entire length of the semilunar
line and the lateral abdominal wall remained well reinforced
by two complete layers: the IO and TA muscles and their
investing fasciae. As also shown in Fig. 3, the myofascial
releases occurred within a median of 4 cm of each other
(range 3.8–4.1 cm). Details of the cadaver dissection can be
found at https://​youtu.​be/f-​lLEns​Q0pQ.
Lopez-Monclus et al. [25] described 12 patients with
complex incisional hernias, a mean hernia width of 23.5 cm,
and previous attempts at repair, who underwent  concomitant
open PCS-TAR and ACS. The authors performed a Madrid
modification (incision of the posterior sheath, including the
posterior lamella of the IO muscle, medial to the TA muscle)
in seven of the PCS-TAR procedures. At a mean follow-
up of 27 months, there had been no recurrence, one case of
asymptomatic bulging, and (as expected in these complex
cases) a high rate (66%) of surgical site occurrences. Quality
of life scores showed significant improvement. We reviewed
the preoperative and postoperative CT images of five of
those patients and found that the abdominal wall changes
described individually for the patients who underwent PCS
and ACS were also observed in the patients who underwent
combined PCS/ACS (Fig. 4). Cavalli et al. [22] reported on
29 patients who underwent combined ACS by a posterior
approach and a PCS-TAR technique with at least 1 year of
follow-up by clinical examination and CT imaging. They
found that the thickness of the RA was preserved and that no
diastasis recti or midline or semilunar line hernias occurred.
Normal function of the RA and TA muscles was confirmed
by studies of the abdominal wall kinetics.
Most experts in the field reject the use of combined PCS
and ACS. Their main argument is that the rate of semilunar
13
 Hernia

Fig. 2  Abdominal wall measurements on axial computed tomography There is significant lateral displacement of the external oblique mus-
images after anterior component separation (ACS) on the left side. cle from the lateral edge of the rectus abdominis muscle on the endo-
There is no difference in the thickness of the lateral abdominal mus- scopic ACS side (left side, 5.3 cm) in comparison with the undivided
culature between the endoscopic ACS side and the undivided side. side (right side, 2.6 cm). Both numbers are encircled in red ovals

Fig. 3  Top: completed
combined anterior compo-
nent separation and posterior
component separation with two
complete layers—the transverse
abdominis and internal oblique
muscles and their fasciae—
which form a common wall
between the two-component
separations (top). Bottom:
distance (arrow) between the
transverse abdominis division
site and the corresponding
external oblique aponeurosis
division site

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Hernia

line disruptions observed after a single CS is already high. Interpretation of abdominal wall changes
Hence, this complex combined approach might lead to
higher morbidity associated with an already complex pro- The differences in the reported changes in the abdominal
cedure. Zolin et al. presented an unpublished study from wall musculature among studies, although small, may be
the Cleveland Clinic at the 2020 Americas Hernia Society due to differences in the study populations, techniques
annual meeting on 33 patients who had undergone a redo used, measurement strategies, time period of the evalua-
TAR for AWR (Table 1). The results showed that 36% of the tions, nutritional status, and interpretation of the findings.
patients developed linea semilunaris disruption after their Variability of abdominal core training during the postop-
index operation. Thus, caution should be exercised because erative period may have also contributed to the different
the risks of combining PCS-TAR and ACS-EO, especially outcomes.
by novice surgeons, could outweigh the potential benefits. In Measuring the muscle area may be an accurate way to
such cases, a small bridge mesh may be preferable. evaluate trophism. Measuring the thickness of the muscu-
lature at many points in the same axial or coronal CT image
and at different levels also allows for the accurate assess-
Table 1  Etiology of recurrence in a series of 33 patients who under- ment of muscular trophism. Some studies have included
went redo TAR​ recurrent cases in the measurement, which can affect the
Etiology of recurrence after open index TAR​ Patients results because of the incomplete restoration of the linea
(n = 33) alba. The lack of histologic evaluation of our patients pre-
vents us from drawing clear conclusions regarding the myo-
Linea semilunaris injury 12 (36.4)
pathic changes that might occur following CS. Because all
Mesh fracture 7 (21.2)
measured activities executed during functional tests require
Posterior sheath breakdown 5 (15.2)
primary and accessory muscles for their performance, it is
Mesh displacement/coverage 5 (15.2)
difficult to pinpoint the precise muscle affected. Abdomi-
Parastomal reherniation 4 (12.2)
nal wall changes after CS suggest that the compensa-
Mesh infection 3 (9.1)
tory changes and overlapping function of the abdominal
In total, 36% of the patients developed linea semilunaris disruption wall muscles play a role in improving function after CS
after the index operation (posterior component separation with TAR). techniques.
Courtesy of Zolin et al
Hicks et  al. [20] attributed the lateral displacement
Data are presented as n (%)
and changes in the area of the EO muscle to mechanical
TAR​transversus abdominis release

Fig. 4  Changes in the lateral

musculature after concomitant
open anterior component sepa-
ration and posterior component
separation from preoperatively
(left) to 4 years postoperatively
(right). Inset: detailed displace-
ments of the external oblique
and transverse abdominis
muscles

13
 Table 2  Changes in the abdominal wall after anterior, posterior, and combined components separation
Posterior component separa- Muscle trophism Muscle displacement Muscle function Abdominal wall shape Recurrence/bulging
tion

13
De Silva et al. [16] Hypertrophy of RA, EO, and N.I N.I N.I N.I
26 patients IO
Open technique Atrophy of TA
Follow–up of at least
6 months
Daes et al. [17] No changes in RA, EO, IO, TA displaced laterally only N.I N.I No recurrence
17 patients or TA at the level of the SMA
Open technique (10 mm). No displacement at
Follow–up at 1 year other levels
Oma et al. [18] No changes in thickness of TA displaced laterally 8.2 mm N.I N.I No semilunar line hernias
35 patients lateral muscles Total recurrence rate (including
Open and laparoscopic all CS techniques) of 19%
technique
Follow–up of 1.7 years
Criss et al. [19] N.I N.I Dynamometer analysis N.I N.I
13 patients showed statistical improve-
Open technique ment in RA muscle
6 months of follow–up isokinetic and isometric
measurements
Anterior component separa- Muscle trophism Muscle displacement Muscle function Abdominal wall shape Recurrence/bulging
tion

Hicks et al. [20] Hypertrophy of RA, IO, and N.I N.I N.I N.I
28 patients (15 laparoscopic, TA muscles. EO showed
11 open, 2 hybrid) increased width and reduced
Follow–up of at least thickness
6 months
Daes et al. [21] No changes in RA, EO, IO, Significant lateral displace- N.I N.I No recurrence or bulging
15 patients or TA ment of EO (3.8 cm)
Endoscopic
Follow–up of up to 7 years
Oma et al. [18] Minimal changes in thickness Significant lateral displace- N.I N.I One semilunar hernia 19% gen-
86 patients of lateral wall ment of EO (2.74 cm) eral recurrence rate (includ-
Endoscopic ing all CS techniques)
Mean follow–up of 1.7 years
Cavalli et al. [22] RA thickness preserved N.I Normal RA and TA function N.I No recurrence or bulging
172 patients in core stability and vacuum
Open technique tests
Follow–up of at least 1 year
Lisiecki et al. [23] N.I N.I N.I Increase in total body circum- N.I
21 patients ference and area. Fascial
Open technique circumference remained the
Hernia

One–year follow–up same

 Table 2  (continued)
Anterior component separa-
tion
Jensen et al. [2]
18 patients
Open technique
One–year follow–up
Combined simultaneous
component separation
Daes et al. [17]
Cadaver dissection
Lopez–Monclus et al. [25]
12 patients
Open ACS and open PCS
Follow–up of 27 months
Cavalli et al. [22]
29 patients
Open ACS and open PCS
Follow–up of at least 1 year
RA rectus abdominis; EO external oblique; IO internal oblique; TA transversus abdominis; SMA superior mesenteric artery; N.I. no information; N.A. not applicable; CS component separation;
ACS anterior component separation; PCS posterior component separation; CT computed tomography
13
Muscle trophism Muscle displacement
N.I N.I
Muscle trophism Muscle displacement
N.A Distance between ACS and
PCS: 3.5 to 4.0 cm
A preserved, two–layered
common wall
N.I Minimal lateral displace-
ment of TA and significant
displacement of EO in five
CT scans studied
RA thickness preserved N.I
Muscle function
Increase in truncal flexion
and extension strength and
improved quality of life
Muscle function
N.A
N.I
Normal RA and TA function N.I
in core stability and vacuum
tests
Hernia
Abdominal wall shape Recurrence/bulging
N.I N.I
Abdominal wall shape Recurrence/bulging
N.A N.A
N.I No hernia recurrence
One case of bulging
No diastasis, recurrence, or
semilunar line disruption
 Hernia
unloading of the muscle. Although the number of patients
was limited, Daes et al. [21] observed a correlation between
the degree of EO displacement and the size of the hernia
defect. The authors reported that the lateral displacement
of the EO is proportional to the displacement of the autolo-
gous flap (composed of the RA, IO, and TA as it crosses the
abdomen to facilitate hernia closure) and is therefore also
proportional to the hernia size. In a few cases in which we
closed the defect transversely after performing a unilateral
endoscopic ACS (no actual use of CS), the EO was mini-
mally displaced.
Based on the different changes observed in the abdom-
inal wall after ACS and PCS, we concluded that another
mechanism of action must be responsible. The degree of
EO displacement suggests that the ACS technique works by
creating an autologous flap that moves across the abdomen
to repair a central or contralateral defect. Minimal lateral
displacement of the TA and lateral muscles suggests another
mechanism of action in the PCS-TAR technique. It has been
theorized that releasing the hoop tension provided by the
TA muscle over the entire thoracoabdominal fascia allows
closure of the anterior and posterior layers of the abdomen
under physiologic tension. The changes in the circumfer-
ence of the abdominal wall, currently under evaluation by
the Danish group, may provide further clues. Table 2 sum-
marizes the changes in the abdominal wall after anterior,
posterior and combined components separation described
in the reviewed articles.
Conclusion
After reviewing the literature on post-CS abdominal wall
changes, we concluded the following. (1) The EO muscle
significantly displaces laterally after ACS, the TA muscle
shifts very little after PCS, and muscle trophism is gener-
ally maintained after both techniques. These findings are
consistent for both open and minimally invasive CS. (2) The
anatomy and physiology of the abdominal wall muscles are
preserved mainly by the muscles’ overlapping function and
their ability to undergo compensatory trophism after midline
restoration (reloading). (3) Well-performed CS techniques
are associated with a low risk of bulging and semilunar line
hernias. (4) ACS and PCS probably have different mecha-
nisms of action. (5) Current studies on how the patients’
nutritional status and postoperative conditioning can alter
abdominal wall changes after CS and the mechanisms of the
actions involved in ACS and PCS are underway.                      atrophy and fibrosis. Ann Surg 245:140–146
Acknowledgements  We thank Nancy Schatken, BS, MT(ASCP) and
Angela Morben, DVM, ELS, from Edanz (https://w
​ ww.e​ danz.c​ om/a​ c),
for editing a draft of this manuscript.
13
Author contributions  Study concept and design JD, Acquisition of
data JD, EO, LNJ, Analysis and interpretation JD, EO, LNJ, Study
supervision LNJ, JD.
Declarations 
Conflicts of interest the author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/or publication of
this article.
Ethical approval  IRB approval was waived due to the nature of the
study.
Human and animal rights  The research did not involve human partici-
pants. Animals did not participate in the study.Only non-identifiable
material was used in the present study.
Informed consent  Informed consent was waived due to the nature of
the study.
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