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DOI:
10.4103/ijawhs.ijawhs_55_19
Comparison between transversus
abdominis release and anterior
component separation technique in
complex ventral hernia
Md Yusuf Afaque, Amjad Ali Rizvi
Abstract:
INTRODUCTION: Transversus abdominis release (TAR) is the new revolution in hernia surgery
and hernia surgeons are passionately doing it all over the world. With the increase in the popularity
of TAR technique, there seems a decrease in anterior component separation technique (ACST)
popularity. ACST despite gone modification such as endoscopic and perforator preserving method is
seen as an inferior procedure to TAR. Is TAR better than ACST? What are its theoretical limitations?
We have done a literature review to compare the postoperative outcomes and technicality of open
ACST and open TAR procedure.
METHODS: We performed a search in the database of PubMed, EMBASE, and Cochrane library for
articles that have compared ACST with TAR procedure for postoperative outcomes and technical
superiority. The search was limited to human studies and in the English language with cadaveric
studies included.
RESULTS: We found seven studies that have compared ACST and TAR for various outcomes.
They are three systemic reviews with meta‑analysis, one multicentric prospective randomized
controlled trial, one prospective study, and two cadaveric studies. They have compared the surgical
site infection and surgical site occurrence rates, recurrence rate, quality of life (QOL), and extent of
mobilization of the rectus muscle. Most of the studies found no significant difference between ACST
and TAR; however, the overall quality of the studies may be limited.
CONCLUSION: Open ACST is comparable to open TAR procedure and has equally acceptable
outcomes. In ACST, it seems to be essential to preserve the perforator vessels; however, altogether
further studies are needed to gain more clarity in the daily decision‑making process in the repair of
complex ventral hernias.
Keywords:
Anterior component separation, complex ventral hernia, component separation technique, posterior
component separation, transversus abdominis release

Introduction attempting repair in such hernia was fear of

Department of Surgery, J raising intra‑abdominal pressure enough to

H
N Medical College, AMU,
Aligarh, Uttar Pradesh,
uge ventral hernias were unsolved alter with the diaphragmatic movement and
India issues a couple of years back and the respiration. Recently, we have understood
only option was watchful waiting. These these hernias better and have developed
Address for untreated hernias ultimately become more methods to deal with these. The patients
correspondence:
complex with time, with an increase in the who were earlier told not to get operated
Dr. Yusuf Afaque,
Department of suffering of the patients. The reason for not are now getting operated at hernia centers.
Surgery, J N Medical Now, one can analyze these hernias better
College, AMU, Aligarh, This is an open access journal, and articles are and can predict difficulty respective from
Uttar Pradesh, India. distributed under the terms of the Creative Commons
E‑mail: yusufafaque@ Attribution‑NonCommercial‑ShareAlike 4.0 License, which
gmail.com allows others to remix, tweak, and build upon the work How to cite this article: Afaque MY, Rizvi AA.
non‑commercially, as long as appropriate credit is given and Comparison between transversus abdominis release
Received: 23-12-2019 the new creations are licensed under the identical terms. and anterior component separation technique in
Revised: 18-02-2020 complex ventral hernia. Int J Abdom Wall Hernia Surg
Accepted: 19-04-2020 2020;3:81-6.
Published: 20-08-2020 For reprints contact: reprints@medknow.com

© 2020 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 81
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Afaque and Rizvi: Comparison between TAR and ACST
the preoperative stage. There are objective as well as
subjective methods to assess them. The objective measure
of how much volume of hernia will have difficulty in the
closure is described as the loss of domain.[1] If the ratio of
hernia sac volume to abdominal cavity volume is more
than 0.25 on computed tomography (CT) volumetry, then
it is considered a significant loss of domain and these
hernia cannot be closed with conventional methods.
Another objective measure of complexity of giant
incisional hernia is described by Carbonells algorithm.[2]
It says that if the width of the hernia defect is equal or
larger than the sum of two recti muscle width, then the
direct defect closure will not be feasible. During surgery
also it can be subjectively assessed whether direct closure
of the hernia defect can be done or not.[3] Defect margins
are brought in the midline and tension is assessed. If
tense closure is expected, then direct closure should not
be done.
To deal with such large hernia, additional maneuver
to expand the abdomen will be required, and now, it
has been done surgically with component separation
techniques. Component separation techniques have
revolutionized the world of ventral hernia repair.
Ramirez et al.[4] in 1990 first described the technique of
open anterior component separation in 10 cadavers.
They divided longitudinally the external oblique
muscle lateral to linea semilunaris and separated this
muscle from the internal oblique muscle. It needed
dissection in the subcutaneous plane with the division
of all perforators and resulted in skin necrosis in 20%
of patients. Perforator preservation in component
separation was described by Lowe et al.[5] in 2000 in a
comparison of open and endoscopic techniques. Open
perforator preserving anterior component separation
technique (ACST) with undermining of the subcutaneous
tissues described by Saulis and Dumanian[6] showed
fewer wound complications compared with traditional
open techniques (2% vs. 20%, P < 0.05). Initially, ACST
was done without mesh and so had high recurrence
rates up to 37.7%, but now, mesh is routinely applied.[7]
Transversus abdominis release (TAR) is an extension
of retrorectus Rives–Stoppa repair[8,9] which involves
incising the posterior rectus sheath following retrorectus
dissection, allowing exposure of the transversus
abdominis (TA) muscle and aponeurosis and division
along the length of the muscle and development
of a sublay space. Its original description was by
Novitsky et al.,[10,11] and an initial comparative study[12]
by them showed that it provides equivalent myofascial
advancement and significantly less wound morbidity
compared to ACST. They also did a cadaveric study[13]
and concluded that TAR provides substantial medial
advancement of both anterior and posterior myofascial
components. Retromuscular dissection deep to the
82 International Journal of Abdominal Wall and Hernia Surgery - Volume 3, Issue 3, July-September 2020
divided TA muscle appeared to be the key step of the
procedure. The TA muscle is the primary stabilizer of
the spine, but TAR does not affect core stability in the
short term and leads to improved back pain and hernia
QOL.[14] TAR achieved good results in various types of
complex hernias like recurrent hernias[15] and in patients
with an open abdomen.[16] It was also successfully done in
hernias after liver transplant[17] and kidney transplant.[18]
Innovations in TAR continued with the start of minimally
invasive approaches, the laparoscopic TAR, and the
robotic TAR popularly called roboTAR.[19,20]
TAR is the new revolution in hernia surgery, and hernia
surgeons are passionately doing it all over the world.
With the increase in the popularity of the TAR technique,
there seems a decrease in ACST popularity. ACST despite
gone modification such as endoscopic and perforator
preserving method is seen as an inferior procedure to
TAR. Is TAR better than ACST? What are its theoretical
limitations? We have done a literature review to compare
the postoperative outcomes (SSI and surgical site
occurrence [SSO] rates, recurrence rate, and QOL) and
extent of medial translation of abdominal musculature
after ACST and TAR procedures.
Methods
We searched the database of PubMed, EMBASE, and
Cochrane library for studies which have compared
ACST with TAR for postoperative outcomes and
technicality. Search terms used were anterior component
separation AND hernia; posterior component separation
AND hernia; “components separation AND hernia;”
“separation of components AND hernia;” external
oblique release AND hernia; transverse abdominis
release AND hernia; abdominal myofascial release AND
hernia. The search was limited to human studies and
in the English language. Studies involving cadavers
were included. The references of the eligible studies
were also screened. If a study is found included in our
selected systemic reviews, then that study was not taken
separately. The author screened all databases on four
separate occasions with the last search on May 25, 2019.
Results
Despite these techniques being recent, we found seven
articles eligible for our review that has compared ACST
and TAR for various outcomes. They are three systemic
reviews, one multicentric prospective randomized
controlled trial, one prospective study, and two cadaveric
studies. They have compared the degree of medial
translation of abdominal musculature, SSI and SSO
rates, QOL, and recurrence rate. Systemic reviews and
meta‑analysis have overlap in studies, and it will be there
as there is limited published literature on this subject.
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Afaque and Rizvi: Comparison between TAR and ACST

The first systemic review by Cornette et al.[21] included
36 observational cohort studies with 2544 patients for
data‑analysis and divided them into four groups: open
anterior approach (OAA), Transversus Abdominis
Release (TAR), laparoscopic anterior approach (LAA),
and perforator preserving approach (PPA). SSO was
found to be 21.4% in the OAA, 23.7% in transversus
abdominis release, 20.3% in LAA, and 16.0% in PPA,
respectively. Recurrence rate was 11.9% (OAA),
5.25% (TAR), 7.02% (LAA), and 6.47% (PPA). Adding
the period of follow‑up as relative weight, where longer
follow‑up is regarded as more important than short
follow‑up, the calculated incidence rate showed the
highest recurrence in the LAA group (7.6%) and the
lowest in the PPA group (3.4%). Hence, comparing PPA
with TAR, the PPA has lower SSO as well as the yearly
incidence of recurrence [Table 1].
The meta‑analysis by Hodgkinson et al.[22] identified
seven studies describing 281 cases of TAR for midline
incisional hernia using a retromuscular mesh placement
and six comparable studies describing 285 cases of
OAA with retromuscular mesh placement. Studies
which described endoscopic anterior component
separation and/or non‑retromuscular mesh placement
(onlay mesh placement) were not included. Pooled
analysis showed a hernia recurrence rate of 5.7% (3.0–8.5)
for TAR and 9.5% (4.0–14.9) for open anterior component
separation and it was not significant (P = 0.23). There was
also no significant difference in wound complication rates
between TAR and open ACST, “superficial” 10.9 versus
21.6% (P = 0.15); and “deep” 9.5 versus 12.7% (P = 0.53).
A systematic review of five retrospective cohort studies
with 646 patients by Wegdam et al. [23] found that
the TAR has a wound morbidity rate comparable to
the ACSTs (15% vs. 20%) but a much lower recurrence
rate (4% vs. 13%). The authors commented that the low
recurrence rate in TAR group may be largely because
one tertiary expert center accounted for 66% of the
646 patients,[24] the number of studies was threefold
lower in this TAR review than in the ACST meta‑analysis,
and mesh was used in all TAR patients but 61%–73% of
ACST patients.
The first prospective multicentric randomized trial has
evaluated clinical outcomes in 120 patients comparing
both mesh type (biological meshes, human acellular
dermal matrix vs. porcine acellular dermal matrix) and
also the surgical technique (ACST/overlay vs. TAR/
underlay).[25] They found no statistically significant
difference in recurrence rates at 1 year between the two
techniques (ACST = 9.8%, TAR = 11.9%) and the ACST
group has advantages including lower surgical site
infection rate (1.6% vs. 11.9% P = 0.03) and improved
physical functioning over 1 year. However, ACST group
had a higher seroma rate.
Comparative study[26] between ACST and TAR on ten
cadavers was done, and the tension and advancement
of each technique using a tensiometer were measured.
The extent of advancement of the anterior rectus sheath
was measured for both the techniques. It was found
that ACST gives a greater degree of abdominal wall
advancement compared to the TAR technique. An
average advancement percentage of the total width
for TAR versus ACST was 3.1% versus 4.1% in the
epigastric, 8.4% versus 12% in the umbilical and 6.0%
versus 9.6% in the suprapubic regions. This was the
first study to quantify the degree of abdominal wall
advancement in both ACST and TAR techniques.
Moores et al. [27] cadaveric study on five cadavers
compared the effect of ACST on the anterior layer with
TAR on the posterior layer. They found a statistically
significant difference in average fascial translation
in the favor of TAR in the mid‑abdomen (3.62 cm
ACS vs. 4.94 cm TAR, P = 0.008) and in the lower
abdomen (3.50 cm ACS vs. 4.38 cm TAR, P = 0.026).
However, in the upper abdomen, there was no
statistically significant difference (3.02 cm ACS vs.
3.62 cm TAR P = 0.209). These cadaveric studies did
not compare translation in the anterior layer and the
posterior layer separately.
The QOL before and after the various types of open
CST was studied prospectively by Blair et al.[28] using
the Carolinas Comfort Scale (CCS) in 292 patients. They
performed TAR or only posterior rectus sheath release
in relatively smaller hernias and ACST along with
posterior rectus sheath release in larger hernias. At the
end of 1, 6, and 12 months, there was no difference in
CCS pain scores, movement limitation, or mesh sensation
among the groups (P < 0.05). It was found that QOL
was not impacted by the type of component separation
on short‑ or long‑term follow‑up. The overall QOL
improved significantly after repair when compared to
preoperative QOL for all three component separation
techniques studied.

Table 1: Systemic Review by Cornette et al.[21]

Number of Prevalence of Recurrence The yearly incidence
included studies SSO (%) rate (%) of recurrence (%)
TAR 8 180/761 (23.7) 40/761 (5.3) 3.8
Perforator preserving ACST 5 39/242 (16.0) 13/201 (6.5) 3.4
TAR: Transversus abdominis muscle release, ACST: Anterior component separation technique

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Afaque and Rizvi: Comparison between TAR and ACST

Discussion
There has been remarkable progress in understanding
the complex ventral hernia and their management. Even
anatomy of abdominal musculature has been studied
in a different perspective by hernia surgeons, and now,
we understand them better. The classical anatomy
texts describe the TA muscle to end medially at linea
semilunaris, and after that, it continues as aponeurosis
up to the midline. The abdominal CT of 100 healthy
young individuals was analyzed by Punekar et al.[29] to
find the presence of TA muscle below the posterior rectus
sheath in different parts of the abdomen. They found the
presence of TA muscle within the rectus sheath at the
costal margin plane in 100% of cases. However, it was
present in 36% at the umbilicus and in only 2% slightly
above the posterior superior iliac spine. In TAR we start
the division of TA muscle in the upper abdomen where
this muscle is present in all the individuals medial to
linea semilunaris. Actually what we divide in the lower
abdomen is TA aponeurosis and not the muscle. The
credits go to hernia surgeons for finding and dividing TA
muscle below the posterior rectus sheath where it was not
supposed to be there and innovating a novel technique.[10]
In our review, five of the studies have shown that ACST
has outcomes comparable or better than TAR. Two
studies showed a more favorable outcome with TAR.
The systemic review by Wegdam et al.[23] suggested that
the TAR has a wound morbidity rate comparable to the
ACSTs but a much lower recurrence rate. However,
they also suggested that the low recurrence rate with
TAR is mainly due to one tertiary expert center that
accounts for 66% of the 646 patients, much less patients
enrolled in TAR group, and mesh was not used in all
ACST patients. The cadaveric study by Moores et al.[27]
found a statistically significant difference in average
fascial mobilization in the mid‑abdomen and the lower
abdomen with TAR giving more mobility. In the upper
abdomen, there was no difference. They compared the
effect of ACST on the anterior layer with TAR on the
posterior layer and not their effect on the same layer.
Summary of studies comparing ACST and TAR is shown
in Table 2.
Sometimes in giant hernia, even TAR ends up in bridging
repair. In bridging repair, all the abdominal muscles
are unable to approximate in the midline. Although it
achieves some form of abdominal closure, the advantage
of approximated muscles will be missing. It is similar
to IPOM patients, in whom the defect is not closed
by suturing and the mesh is below the skin and sac.
Although IPOM has not been found inferior to IPOM
plus (defect closure) for small incisional hernias,[30,31] it
is not reasonable to accept bridging repair in component
separation technique. In our opinion, most of the
patients taken for IPOM have a small hernia located
within a largely normal abdomen wall presenting
with well‑approximated muscles. In contrast, complex
hernias, in which a component separation technique
is indicated, are characterized by large defects and
reduced muscle structure of the ventral abdominal wall.
Therefore, in these patients, a re‑approximation of the
muscles seems to be essential.
TAR is a very useful repair technique for complex
ventral hernia with the advantage of a huge space for

Table 2: Selected Studies for Review

Authors Year Type of study Number of studies/patients studied Conclusion
Cornette 2018 Systemic 36 observational cohort studies ACST has lower SSO as well as the yearly
et al.[21] review incidence of recurrence
Hodgkinson 2018 Meta‑analysis Seven studies describing 281 cases No significant difference in recurrence and wound
et al.[22] of TAR and six comparable studies complication rates between TAR and open ACST
describing 285 cases of open ACST
Wegdam 2019 Systemic Five retrospective cohort studies with TAR has a wound morbidity rate comparable to the
et al.[23] review 646 patients anterior component separation techniques but a
much lower recurrence rate
Bochicchio 2019 Prospective 120 patients No significant difference in recurrence rates
et al.[25] multi‑centric at 1 year and the overlay group (ACST) have
randomized trial advantages including lower surgical site infection
rates and improved physical functioning over 1 year
Loh et al.[26] 2018 Comparative Ten cadavers ACST gives a greater degree of abdominal wall
cadaveric study advancement compared to the TAR technique
Moores 2018 Comparative Five cadavers Statistically significant difference in average fascial
et al.[27] cadaveric study translation in the mid abdomen and in the lower
abdomen with TAR giving more translation. In the
upper abdomen, there was no difference
Blair et al.[28] 2017 Prospective 292 patients Quality of life on Carolinas Comfort Scale is not
comparative impacted by the type of component separation
study technique on short‑ or long‑term follow‑up
TAR: Transversus abdominis muscle release, ACST: Anterior component separation technique

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Afaque and Rizvi: Comparison between TAR and ACST
mesh placement, neurovascular bundle preservation,
and the possibility that lateral hernias can be dealt with
simultaneously. Overall, ACST is comparable to TAR.
ACST with preservation of the perforating vessels has
a low recurrence, SSI, and skin necrosis rates. It also
achieves a good amount of anterior abdominal wall
medialisation.
The limitations of our study are that the selected studies
have compared different outcomes. Four studies
have compared postoperative events, two studies
postprocedure abdominal musculature translation, and
one study QOL. The selected studies are nonrandomized
except one, and the selected systemic reviews with
meta‑analysis are also of nonrandomized studies. Both
the cadaveric studies have low sample size, and the
findings on the cadaveric tissues also vary from the
living tissues.
Conclusion
Open ACST is comparable to open TAR procedure and
has equally acceptable outcomes. In ACST, it seems to
be essential to preserve the perforator vessels; however,
altogether further studies are needed to gain more clarity
in the daily decision‑making process in the repair of
complex ventral hernias.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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