Anterior Components Separation Repair of Incisional Ventral Hernia 
Richard Davis 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
This is the repair to use for very large defects. 
It includes division of the external oblique muscle 
and mobilization of the anterior rectus sheath. You 
can get up to 7cm of extra length per side with these 
steps, to bridge midline defects of up to 14cm. If the 
defect is wider than that, closure can still be 
accomplished provided the hernia sac is intact, using 
mesh to bridge the defect and the sac interposed 
between the mesh and the bowels. As described, 
carefully preserve the entire hernia sac and save it in 
case this problem arises. 
For hernias smaller than 8cm, mobilization of 
the anterior rectus sheath is not necessary. The retro-
rectus space can be developed as described in the 
chapter “Retrorectus Mesh Placement Repair of 
Midline Incisional Hernia” If after this maneuver the 
fascial edges do not reach comfortably, you can 
release one or both of the external obliques to make 
the closure tension-free. 
The operation proceeds in the following 
steps:  
● Mobilization and preservation of the hernia sac 
● Lysis of adhesions and return of the bowels to the 
abdominal cavity 
● Mobilization of the anterior and posterior rectus 
sheath  
● Division of the external oblique aponeurosis. 
● Closure of the fascia at the midline and 
placement of the mesh, including resection of the 
hernia sac 
● Coverage of the mesh as much as possible, with 
anterior rectus sheath or rectus muscle 
● Closure of the fascia and skin, maximizing the 
amount of tissue that lies between the mesh and 
the skin.  
 
Steps: 
1. Incise the skin through the previous midline scar 
and carefully dissect down to the hernia sac.  
2. Dissect the hernia sac off the surrounding 
subcutaneous fat. Gentle downward traction on 
the sac and upward traction on the skin will allow 
this plane to reveal itself. Ideally you are not 
cutting through scar tissue, you are dissecting 
unscarred fat immediately adjacent to the sac. 
Follow this plane of dissection down until you 
can palpate the rectus muscle, which is the 
medial edge of the hernia defect. 
 
Dissecting the hernia sac off the surrounding subcutaneous fat. 
Proper traction and counter-traction and careful hemostasis 
allow you to see the plane, dividing the uninflamed fatty tissue 
just adjacent to the hernia sac and pulling it downwards.   
 
3. Extend your dissection anterior to the rectus 
sheath, separating the subcutaneous fat from the 
anterior rectus sheath until you are 2-3cm past the 
lateral border of the rectus muscle. This 
separation should extend from the costal margin 
to the inguinal ligament.  
 
Plane of dissection anterior to the rectus sheath extends to 2-
3cm lateral to the lateral edge of the rectus muscle.  
 
4. Enter the hernia sac at the midline(if you have not 
already done so inadvertently) and lyse any 
bowel adhesions until the intra-abdominal 
viscera can lie freely within the abdominal 
cavity. Preserve the hernia sac as much as 
possible.  
5. Incise the anterior rectus sheath 2cm lateral to its 
medial edge and carry your incision to about 3cm 
Anterior Components Separation Repair of Incisional Ventral Hernia 
Richard Davis 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
past the most cranial and caudal extent of the 
hernia defect. 
6. Dissect the rectus muscle off the fascia, at first 
moving medially towards the medial edge of the 
muscle. Then pass posterior to the muscle, 
moving from medially to laterally, to the most 
posterolateral edge of the rectus muscle. 
 
Incision of the anterior rectus sheath 2cm medial to its medial 
edge, then dissection of the anterior surface extending 
posterolaterally. This complete dissection has the effect of 
mobilizing the fascia adjacent to the red dot 2-3cm towards the 
midline. Remember that below the semilunar line, the posterior 
rectus sheath is not existent, you are dissecting the plane 
between the transversalis fascia and the muscle.  
 
7. With your non-dominant hand, grasp the rectus 
sheath between thumb and index finger, feel the 
lateral edge, and gently pull towards the midline.  
8. Make an incision through the fascia of the 
external oblique muscle, 2 cm lateral to where 
you feel the lateral edge of the rectus muscle. 
This fascia should separate under tension to 
reveal the transverse fibers of the internal oblique 
muscle underneath. Once you have seen this, you 
have confirmed that your incision is in the right 
place. Extend it from the costal margin to the 
inguinal ligament.  
 
Dissection of the subcutaneous fat off the anterior rectus sheath 
has been completed. Grasping the rectus sheath in the non-
dominant hand, the surgeon is able to feel its lateral edge and 
make an incision 2cm beyond this edge. The transversely 
oriented fibers of the internal oblique muscle will appear, 
indicating the incision is in the appropriate location.  
 
9. Under 
direct 
visualization, 
with 
proper 
retraction, 
separate 
the 
external 
oblique 
aponeurosis from the internal oblique muscle. 
There will be several perforators passing through 
this plane, it is important to divide these with 
suture ligation or electrocautery to prevent a 
postoperative hematoma in this space. Proceed 
all the way to approximately the posterior 
axillary line.  
 
Incision of the external oblique aponeurosis. By grasping the 
rectus muscle and pulling it gently towards the midline, the 
surgeon can feel the muscle’s lateral border. Incise the 
external oblique muscle 2cm lateral to that edge. If the 
incision is properly placed, the transversely oriented fibers of 
the internal oblique muscle can be seen underneath. Extend 
the incision from the costal margin to the inguinal ligament. 
Dissect this space under direct visualization all the way to the 
posterior axillary line, ligating perforating vessels as you go.  
Anterior Components Separation Repair of Incisional Ventral Hernia 
Richard Davis 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Once the surgeon has confirmed that the external oblique 
aponeurosis has been incised (rather than the anterior rectus 
sheath) the incision (red line) is extended from costal margin 
to inguinal ligament (blue lines.) 
 
 
Both maneuvers of the Anterior Components Separation have 
been completed on the patient’s left side. The mobilized 
portions of anterior and posterior rectus sheath (green dot) 
have been separated from the rectus muscle and the non-
mobilized anterior rectus sheath (green arrow.) The divided 
edge of the external oblique aponeurosis (blue arrow) has 
moved medially, away from its lateral edge (blue dot.) The 
space between the blue and green dots represents the amount 
of distance that has been gained by these maneuvers.  
 
10. Once these steps have been repeated on both 
sides, the rectus sheath from each side can 
should now be loose enough to meet at the 
midline. Trim the hernia sac and then 
approximate the rectus sheath with non-
absorbable suture. The posterior rectus sheath 
below the semilunar line will not be fascia.  
11. Alternatively, if you cannot approximate the 
rectus sheath at this point, trim and close the 
hernia sac to cover the intestines. You will 
proceed with the remaining steps of this 
operation including mesh placement, and the 
mesh will “bridge” the defect. 
12. Trim a piece of mesh into an ellipse to fit into 
the space behind the rectus muscles. Secure it in 
place with full thickness interrupted non-
absorbable sutures through the lateral rectus 
muscle and anterior rectus sheath. Do not 
tighten these sutures excessively, this could 
endanger the neurovascular supply of the 
muscle.  
 
Mesh (yellow dot) in place over the approximated rectus 
sheath and behind the rectus muscles. It has been sewn in 
place with interrupted nonabsorbable suture, passed through 
the lateral rectus sheath (blue dots) which are tied loosely to 
avoid neurovascular injury. The rectus muscles and anterior 
sheath are unable to meet in this patient, so the strength of the 
repair will come from the posterior rectus sheath above the 
semilunar line, and the mesh itself. Note that the mesh is 
sutured on both sides at the apex, in this photo these sutures 
Anterior Components Separation Repair of Incisional Ventral Hernia 
Richard Davis 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
are obscured by skin but their position is shown by blue dots 
as well.  
 
13. Most likely it will not be possible to 
approximate the anterior rectus sheath. The 
rectus muscles themselves should be loosely 
approximated to cover the mesh, if possible. 
The goal is to have as much tissue as possible 
between the mesh and the skin.  
14. Verify hemostasis in the space between the 
external and internal oblique muscles. Place 
drains in this space. If conditions are clean and 
nursing care is excellent on your ward you can 
place a drain over the mesh as well, but this can 
potentially expose the mesh to infection if the 
drain is not properly cared for.  
15. Reapproximate the subcutaneous fat in several 
layers to provide more “distance” between the 
skin and the mesh. Then close the skin.  
 
Pitfalls 
● Visceral injury and spillage during lysis of 
adhesions. Do not place a mesh under these 
conditions. Perform the other steps as above 
without placing mesh.   
● Damage to the neurovascular supply of the 
midline structures: Avoid deep sutures 
between the internal oblique and transversus 
abdominis muscles at the posterolateral edge 
of the rectus.  
● Inability to approximate the fascia despite 
complete release: confirm that all steps have 
been done completely, specifically that the 
external oblique release is complete, from 
costal margin to inguinal ligament, all the 
way to the posterior axillary line.  
● Postoperative wound infection: if this is 
superficial, drain it completely and give 
antibiotics. If this becomes a sinus tract 
when it heals, the mesh has become 
infected. Removal of the mesh will be 
necessary. In case of a recent operation this 
can be deferred as long as the patient is not 
toxic.  
● Postoperative fluid collection around the 
mesh: the patient will present with fullness 
in the area. Ultrasound will confirm the 
presence of fluid collection, and allow you 
to distinguish whether it is an abscess or a 
seroma. If it is a large seroma, drain it 
percutaneously under ultrasound guidance. 
Be meticulous about sterility when doing 
this, to avoid transforming it into an abscess.  
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
