Discussion: Minimally invasive component separation with inlay bioprosthetic mesh (MCSIB) for complex abdominal wall reconstruction.

C abdominal wall reconstruction requires answering two independent and related questions: What is the best way to treat the abdominal wall, and what is the best way to treat the skin? Butler and Campbell present their solutions to these two problems in their article entitled “Minimally Invasive Component Separation with Inlay Bioprosthetic Mesh for Complex Abdominal Wall Reconstruction.” Although I will bring up several technical questions and issues to help think critically about the procedure, I am fundamentally in agreement with its central tenets. Like a fractured bone, a bowel suture line, or a vascular anastomosis, abdominal wall closures best heal in a vascularized soft-tissue envelope. The Achilles heel of the components separation procedure is the wide undermining performed to access the semilunar lines from a midline incision. I remember vividly a 1994 University of Pittsburgh plastic surgery morbidity and mortality conference that illustrated the potential severity of these postoperative wound problems. A patient had a large midline ventral hernia that developed after an open abdominal aortic aneurysm tube graft repair. After standard components separation, the patient suffered complete bilateral abdominal skin necrosis. Our conference discussion theorized that the loss of the iliolumbar vessels of the aorta at the time of the abdominal aortic aneurysm repair in combination with the division of periumbilical perforators at the time of hernia repair caused the severe skin loss. Dr. Jaime Garza sat next to me at that conference. In 1997, Garza presented a method of laparoscopically releasing the external oblique muscles for a components separation repair to avoid skin undermining and to decrease wound complications. The first seven patients treated in this manner were reported in 2000 by Lowe, Garza, and Rohrich.1 In 2002, I demonstrated a statistical reduction in soft-tissue complications from 20 percent to 2 percent in 41 patients using tunnels elevated over the rectus muscles—much like Dr. Butler—with preservation of the periumbilical perforators.2 However, it was Dr. Maas in Europe who beat us all to print with his description of lateral incisions in four patients to reach the semilunar lines in 1999.3 Maintenance of the skin blood flow through narrow 3-cm incisions by Dr. Butler in the current article is a logical extension of these techniques. It avoids the transverse incisions and minimizes skin undermining to achieve the releases. With dependable skin for closure, there will be less skin dehiscence, fewer postoperative open wounds, and fewer infections despite field contamination. At the end of the procedure, discarding redundant skin (and usually the umbilicus in large hernias) serves to remove all scarred skin and the hernia sac, and any bacteria that may have inoculated the soft tissues during the course of a bowel procedure. Use of quilting sutures as performed by the authors to reduce dead space is also an important adjunct to primary wound healing. The well-vascularized soft tissues are especially important when a bridged repair is required. Even when a fascial defect is so large that the medial aspect of the rectus muscles cannot be approximated, performing external oblique releases from far above the rib cage to below the anterior superior iliac spine as described by the authors is the critical first step in complex abdominal wall reconstruction. Chronic hernia formation causes a fibrosis and stiffening of the lateral abdominal wall muscles. Releases of the external oblique will improve abdominal wall compliance, which in turn will achieve a more lasting repair.4 However, simple approximation of the rectus muscles with-