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Siegal et al. Plast Aesthet Res 2019;6:25 I http://dx.doi.org/10.20517/2347-9264.2019.35 Page 3 of 20

patients with vasculopathies), we avoid open ACS and recommend a TAR approach, although a minimally
invasive component separation (compared to open ACS) may be an appropriate option as this approach has
[13]
demonstrated superior outcomes to open ACS .
There are few relative contraindications to performing a TAR. TAR can be exceptionally challenging in
patients with previously placed pre-peritoneal or retromuscular mesh. In patients who have undergone
resection of the posterior abdominal wall components (such as occurs during radical cystectomy or
procedures to excise peritoneal cancer implants), the loss of tissue planes may make the creation or
continuation of a retromuscular plane impossible. Similarly, TAR should be used with caution in patients
who have undergone previous ACS as this could lead to lateral hernia formation, although favorable results
[14]
have been reported by Pauli et al. in short-term follow up.

PREOPERATIVE PREPARATION
The authors strongly recommend preoperative CT imaging of the abdomen and pelvis as it well elucidates
the abdominal wall musculature, hernia defect, contents, and dimensions. CT scans can also show signs
of active infection, previous mesh, and any evidence of underlying visceral abnormalities. Routine use of
contrast is unnecessary, although IV contrast is recommended with concerns for intra-abdominal infection
and oral contrast should be used to evaluate gastrointestinal pathologies such as obstructions or fistulas.
Imaging is also advantageous in obese patients where physical exam is limited to evaluate the hernia.

Of upmost importance is preoperative patient optimization. There are increased complications after
hernia repair in patients who are actively smoking, poorly controlled diabetics, obese, or with poor
[15]
nutrition. Cigarette smoking adversely affects wound healing . After 4 weeks of smoking cessation, the
[16]
inflammatory aspect of wound healing normalizes . Thus, a minimum of one month of smoking cessation
is recommended before elective repair. Similar to smoking, poor glucose control (HbA1c > 7%) increases
[17]
the rate of surgical site infections (SSI) . Studies have shown a 30% increase in SSIs with every increase
[18]
of 40 mg/dL of glucose over 110 mg/dL . We recommend HbA1c < 7% before offering elective component
separation hernia repair.

Obesity greatly effects the formation of hernias, hernia recurrence, and hernia repair morbidity. There is
also an association between nosocomial infection, readmissions, and requirement for transfusions among
obese patients. Wound morbidity increases sharply with body mass index (BMI), where a BMI > 40 incurs
[19]
a 1.66 odds of surgical site occurrence (SSO) . We routinely encourage overweight patients to pursue an
active weight loss program with a goal of achieving a BMI < 40. Given the often-elective nature of hernia
repair, we routinely follow patients for three months. Patients are supported by our institutional weight loss
program; however, if reasonable weight loss is not achieved despite best efforts, we often refer patients to
our bariatric surgery program.

Lastly, we ensure our patients are nutritionally optimized. A large, multi-center study of nearly 90,000
veterans demonstrated that the single most valuable predictor of surgical morbidity was a serum albumin
< 3.0 g/dL, which emphasizes the need to evaluate and address the nutritional status of patients prior
[20]
[21]
to operation . Validated nutritional risk assessment tools are readily available . There are many data
in support of nutritional supplementation preoperatively. One common regimen is arginine/omega-3
supplementation (Impact Advanced Recovery; Nestle Healthcare Nutrition Inc., Florham Park, NJ) given 3
[22]
times a day for the 5 days prior to surgery .

RELEVANT ANATOMY FOR TRANSVERSUS ABDOMINIS RELEASE
With the above-mentioned evolution from a Carbonell PCS technique to Novitsky’s TAR, understanding
of the TA anatomy is vital. The TA is the deepest of the lateral muscles, and fibers run in a horizontal