Anterior component separation techniques: is it necessary to preserve the perforators? a systematic review and meta-analysis

Background: Anterior component separation (ACS), or Ramirez component separation technique, is an established technique still used by surgeons to repair a ventral hernia. Compared with other ventral hernia repair techniques, recent studies about ACS show more postoperative complications like wound breakdown, wound infection, hematoma, skin necrosis, seroma, and recurrence. Our study aims to compare the ACS technique with the preservation perforator technique and verify if the perforator preservation technique can decrease postoperative complications.

Materials and methods: Cochrane Central, Embase, and PubMed were systematically searched for studies comparing the perforator-sparing ACS ventral hernia repair and the standard technique. Outcomes assessed were wound breakdown, skin necrosis, wound infection, seroma, hematoma, reoperation, and recurrence at least 3 months postoperatively. Statistical analysis was performed with R Studio.

Results: 94 studies were screened, and 11 studies were selected for full-text reading. Seven studies were selected, comprising 761 patients, of which 309 (40.6%) underwent the perforator-sparing ACS technique. We found lower wound breakdown rates for the preservation technique (RR 0.45; 95% CI 0.32; 0.63; p < 0.01). Also, the perforator-sparing technique presented lower reoperation rates (RR 0.59; 95% CI 0.35; 0.72; p < 0.01). No differences were found in skin necrosis (RR 0.22; 95% CI 0.03; 1.63; p = 0.14), wound infection (RR 0.69; 95% CI 0.25; 1.90; p = 0.47), seroma (RR 0.29; 95% CI 0.07; 1.26; p = 0.1), hematoma (RR 0.73; 95% CI 0.11; 5.06; p = 0.75), or recurrence (RR 0.81; 95% CI 0.37; 1.74; p = 0.59) rates.

Conclusion: Our comprehensive systematic review with meta-analysis compared the perforator-sparing ACS with the standard technique and found lower wound breakdown and reoperation rates for the perforator-sparing technique. No differences were found in the other outcomes analyzed.