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The “open book” component separation: a fifteen-year single-surgeon review
Alexander F. Mericli, M.D.1, Derek E. Bell, M.D.2, Brent R. DeGeorge, M.D., Ph.D.1, David B. Drake, M.D.1.
1University of Virginia, Charlottesville, VA, USA, 2University of Rochester, Rochester, NY, USA.

Purpose: Post traumatic and complex abdominal wall hernias can be challenging for the reconstruction surgeon. The use of autologous tissue is preferable to synthetic mesh when possible. The authors reviewed the15 year experience of the “open book” technique of ventral hernia repair. This repair entails a single fascial incision releasing the external oblique and concurrently incorporates the anterior rectus sheath as a turnover flap for abdominal wall reconstruction. This modification allowed for large defects to be closed with autologous tissue alone and for a two layer fascial repair in a vest over pants fashion. Please see Figure 1 for a brief step-wise illustration of the surgical procedure. We now report our fifteen-year experience using this technique.
Methods: A fifteen-year, single-surgeon retrospective review was conducted of hospital and office charts of 35 consecutive patients who underwent component separation using the open book variation. Comorbidities, hospital course, etiology of initial abdominal wall defect, defect size, use of mesh, date of last drain removal, length of hospital stay, and length of follow-up were recorded. Additionally, complications were recorded including hernia recurrence, reoperation, readmission (major complications); and infection, seroma, hematoma, and dehiscence (minor complications).
Results: 63% of the patients in the study had at least one recognized comorbidity before component separation. Only two patients (2/36; 6%) suffered a hernia recurrence over the course of the fifteen years. The overall post-operative complication rate was 13/35 (40%). The minor complication rate was 13/36 (40%), including infection (7/35; 20%), skin necrosis (7/35; 20%), and hematoma (2/25; 6%). The major complication rate was 5/36 (14%), including two hernia recurrences (6%), four hospital readmissions (11%), and five re-operations (14%). Factors associated with a statistically significant increased rate of overall complications included COPD (80%; p=.03) and hypertension (39%; p=.04). The average length of follow-up was 468 ± 89 days.
Conclusions: Our series suggest that the open-book variation is associated with one of the lowest hernia recurrence rates when compared to the published literature. Additionally, the major complication rate is acceptable given these patients’ many comorbidities and complicated surgical history. The presence of COPD and/or hypertension was found to be statistically associated with an increased complication rate. The open-book variation of the component separation technique is an effective addition to the reconstructive surgeon’s armamentarium.


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