A modification of the “components separation” technique for closure of abdominal wall defects in the presence of an enterostomy

The repair of contaminated abdominal-wall defects is still a challenge for surgeons treating patients with abdominal sepsis. The use of prosthetic material to repair these defects is contraindicated because it gives disappointing results. Reconstructions with autologous material, such as free fascial or musculofascial flaps, are not satisfactory either. The operations of free fascial transplant harvesting are time-consuming and are frequently followed by functional deficits at the donor site. Functional results of those reconstructions are disappointing because of bulging of the denervated muscles, and high reherniation rates of up to 20%. In 1990 Ramirez and associates introduced the “Components Separation Technique” for closure of large abdominal-wall defects without the use of prosthetic material. Their technique is based on translation of the muscular layers of the abdominal wall, thereby enlarging the surface of the abdominal wall (Fig. 1). A compound flap is created which can be advanced more than 10cm at the waistline, at each side. The technique has 3 disadvantages. First, the skin and subcutaneous tissue must be mobilized laterally over a large distance in order to reach the aponeurosis of the external oblique muscle, which is retracted laterally into the flank. This creates a large wound surface that covers the whole ventral abdominal wall, from costal margin to pubic bone. Second, mobilization of the skin endangers its blood supply, which may lead to skin necrosis in the midline if circulation through the intercostal arteries is interrupted. Third, the technique is difficult to use in patients with an enterostomy or if a new enterostomy must be made. We describe a modification of the technique of Ramirez and colleagues, designed to preserve the blood supply of the skin and subcutaneous tissue, and to overcome the problem of stoma reconstruction in these patients.