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Page 2 of 20 Siegal et al. Plast Aesthet Res 2019;6:25 I http://dx.doi.org/10.20517/2347-9264.2019.35

the visceral sac from mesh contact. With minor modifications, the Rives-Stoppa repair became widely
[3,4]
utilized due to well-proven outcomes with low overall morbidity . However, despite the great success of
this repair, the retrorectus repair does not easily facilitate myofascial advancement and the limited surface
area in the retrorectus space prevents wide mesh overlap.

[5]
To overcome these limitations, Ramirez et al. performed anatomic studies describing separation of
the components of the abdominal wall to allow for medial mobility (myofascial advancement) to close
large ventral hernias with restoration of the linea alba. This technique involved developing the avascular
plane between the external and internal oblique muscle layers through relaxing incisions lateral to the
rectus sheath, and became known as the anterior component separation (ACS). The authors were able
to demonstrate up to 10-cm myofascial advancement at the umbilicus with this technique. With early
adoption of this technique, subsequent study revealed some notable drawbacks including technical
challenges in patients with enterostomies, difficulty repairing hernias lateral to the rectus muscles or near
bony prominences, and recurrence rates as high as 32%. Most notably, raising large subcutaneous flaps in
order to perform ACS puts patients at risk for skin necrosis or wound complication, with rates as high as
[6]
40% .
[7]
Considering the limitations associated with the Rives-Stoppa and ACS techniques, Novitsky et al.
[8]
developed the posterior component separation (PCS). Two years later, Carbonell et al. described
their technique of dividing the transversus abdominis aponeurosis lateral to the linea semilunaris and
developing a plane between the TA and IO, which allowed medial advancement of the external oblique
(EO) and IO with a large space for mesh placement in a sublay fashion. One major pitfall of this technique
is the division of the neurovascular bundles supplying the rectus laterally, which can lead to muscle
[6]
atrophy, abdominal wall bulges, recurrent hernia, and asymmetry .

To further the novel idea of separating the posterior components, but avoid division of the neurovascular
[9]
bundles, Novitsky et al. described the Transversus Abdominis Release (TAR) in 2012, whereby, after
extending the Rives-Stoppa technique laterally, an incision is made in the posterior rectus sheath to expose
the TA. The muscle of its associated aponeurosis is then divided along its medial edge, separating the TA
from the underlying transversalis fascia and peritoneum.

This modification allows the surgeon to develop the retromuscular space laterally as far as the
retroperitoneum and psoas muscle. Initial study of this technique demonstrated low hernia recurrence and
SSI with improvement in rectus muscle function [9-11] .

PATIENT SELECTION
Patient selection for the appropriate herniorrhaphy is paramount as there is a vast array of techniques,
abdominal wall planes, and patient characteristics. The authors generally reserve laparoscopic repairs for
small to medium sized defects (2-7 cm) in patients without a history of multiple abdominal operations or
previous underlay mesh. Patients with defects greater than 8 cm in diameter are approached with a robotic
or open repair. In some cases, posterior sheath reapproximation at the midline is achievable with a Rives-
Stoppa repair. However, TAR may be required if a classic Rives-Stoppa is unable to achieve midline closure,
when there is insufficient mesh coverage behind the rectus muscle or in the following settings: large
defects, multiply recurrent hernias, non-compliant abdominal walls necessitating myofascial release, and
parastomal hernias. Although it is hard to definitively predict preoperatively which patients will require a
[12]
TAR in addition to a Rives-Stoppa repair, Love et al. hypothesized that Rives-Stoppa repair will achieve
midline closure if the sum of the rectus widths is twice the width of the defect width when measured on
CT scan. The authors recommend that previous subcutaneous or wound related complications should be
approached with TAR rather than open ACS. In patients with tenuous vascularity (diabetics, smokers, and