Laparoscopic incisional hernia repair in obese patients.

BACKGROUND AND OBJECTIVES: Laparoscopic incisional hernia repair is coming to the forefront as a preferred method of repair due to the advantages offered by minimally invasive techniques. To evaluate safety and feasibility of this approach in obese patients when performed by a general surgeon trained in basic laparoscopy with no prior experience in this technique, we reviewed our early experience in the first 18 patients. METHODS: All patients with incisional hernias presenting to a single surgeon from 2000 to 2002 were offered laparoscopic repair. Patients were informed about the limited experience of the surgeon in this particular field. Those who consented were repaired laparoscopically using a standard 4-port technique, one 12-mm port and three 5-mm ports. All patients with body mass index > or =30 were included in this review. A retrospective review of the data included demographics, operative time, blood loss, hospital stay, postoperative complications, and patient satisfaction. RESULTS: Nineteen laparoscopic repairs were completed in 18 patients. No conversions to open repair were necessary. All patients were females except for 2. All hernia sacs were left in place, some of which were empty while others required extensive lysis of adhesions to release sac contents. Mean fascial defect was 102.5 cm2. One defect was closed primarily without mesh, while the rest were closed using Composix mesh in 1 and Dual Plus Gore-Tex mesh in the rest. Three patients were discharged from the recovery room. Mean follow-up was 24 months. No wound or mesh infections occurred. Eight patients had no complications. Eight patients had asymptomatic seromas. Two patients had hematomas; none of them required drainage. One patient had nonspecific dizziness. One patient presented with bowel obstruction secondary to early recurrence (within a week). The repair was salvaged laparoscopically. Upon evaluation by telephone calls, all patients indicated extreme satisfaction with the results. CONCLUSIONS: A general surgeon with training in basic laparoscopy can safely perform laparoscopic incisional hernia repair on obese patients with minimal complications. The procedure requires a short leaning curve of no more than 3 cases and few extra materials to be feasible at any hospital in the US. Patient satisfaction with this technique is certainly gratifying.     

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20 th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.     

Emergent laparoscopic repair of incarcerated incisional and ventral hernia

Background The role of laparoscopy in the repair of incarcerated incisional or ventral hernia is not yet established. This presentation reviews the authors experience with patients who underwent laparoscopic surgery in presence of incarceration.Methods Patients who had surgery during the years 1997 to 2001 were included in the study. All patients underwent surgery immediately after their admission. In all cases, Gore-Tex Dual Mesh was used.Results The review included 25 patients (21 women and 4 men). Ten of these patients (40%) had undergone at least one earlier repair, and one patient (4%) underwent conversion to open repair because of small bowel injury. The mean operation time was 63 min (range, 15–20 min). The median postoperative hospital stay was 3.2 days (range, 2–7 days). There were no noteworthy postoperative complications. During the follow-up period, no patient experienced recurrent hernia.Conclusions The authors current has experience demonstrated that laparoscopic repair is feasible and can be attempted for patients presenting with incarcerated incisional or ventral hernia.     

Feasibility and outcome after laparoscopic ventral hernia repair using Proceed mesh

Background  There are many different meshes available for laparoscopic repair of ventral hernias. A relatively new product is the Proceed mesh with a bioresorbable layer against the bowels and a polypropylene layer against the abdominal wall. There are, however, no human data available. The aim of this study was to evaluate the feasibility and outcome after laparoscopic ventral hernia repair using the Proceed mesh in humans. Methods  Patients presenting for laparoscopic ventral hernia repair in our department from September 2004 to October 2006 were included in the study. All patients had a standard laparoscopic ventral hernia repair using the Proceed mesh secured with tackers with a double crown technique. Patients were discharged according to standard discharge criteria, and follow-up was performed with a search in the national patient database and with manual search in the patients’ files. Results  Our study included 49 patients with a median age of 64 years (range 30–89) and body mass index of 27.8 (19.4–50.5). The dimensions of the mesh varied from 4 × 4 cm to 30 × 40 cm (median 15 × 15 cm). One patient developed an uncomplicated wound infection and none of the 49 patients developed mesh infections or postoperative seroma requiring surgical intervention. Thus, there were no mesh-related complications. During the follow-up period of 17 months (3–27), we have not seen any postoperative recurrences. The median length of stay was 1 day (range 0–63), and there was no mortality. Conclusion  Laparoscopic ventral hernia repair in humans using the Proceed mesh is feasible and has a low complication rate even in obese patients or those with pulmonary disease.     

Robot-assisted laparoscopic repair of ventral hernia with intracorporeal suturing

Background: This study presents a novel technique for laparoscopic ventral hernia repair using the da Vinci Robot and intracorporeal suturing. Thus, it offers an alternative to transabdominal sutures and tackers. Methods: A ventral hernia model was created in six pigs. The mesh was fixed to the circumference of the fascia using interrupted sutures. The outer border of the mesh was then fixed to the posterior fascia using running sutures. Results: There were no complications. The depth and location of the interrupted and running sutures were confirmed postmortem. Conclusions: The transabdominal sutures and tackers used in laparoscopic ventral hernia repair can be the focus for postoperative pain and adhesions. As an alternative, the da Vinci Robot can be used to facilitate intracorporeal suturing of the mesh directly to the fascial edge and to secure the circumference of the mesh to the posterior fascia. The preliminary results are promising and represent a safe method that can be implemented in humans.     

Single incision laparoscopic ventral hernia repair

Background and Objectives:

Laparoscopic ventral hernia repair (LVH) requires several skin incisions for trocar placement. We have developed a single incision approach to LVH repair. The technique was introduced in clinical practice to any consenting patients who were candidates for a standard multi-port laparoscopic hernia repair. A consecutive series of patients was then followed to evaluate feasibility.

Methods:

Over an 8-month period, 14 patients (9 females, 5 males) underwent LVH repair by an academic surgeon. One of 2 access methods was used in each patient through a single 1.5-cm to 2-cm skin incision. One technique utilized two 5-mm ports with a temporarily placed 11-mm port for mesh insertion. The second technique utilized the SILS port (Covidien, Norwalk, CT). Standard or roticulating laparoscopic instruments were used with both techniques.

Results:

Range (mean) BMI: 23 to 59 (38), Age: 26 to 73 years (53), Duration: 37 to 87 minutes (57), Defect size: 1cm to 8cm (2), 3 with Swiss-cheese defect hernias. The procedure was successfully performed in all patients. No conversions to a multiple-port approach or to an open procedure were necessary. There were no mortalities, major complications, or recurrences during the mean follow-up period of 4 weeks.

Conclusion:

Single incision ventral hernia repair is technically feasible, effective, and reproducible. The technique is easy to master, and safe for any patient who is a candidate for laparoscopic ventral hernia repair. Further data collection with long-term follow-up will be needed to ensure equivalent outcomes. There will be demand for this approach by patients for cosmetic reasons, and it may serve as a bridge to natural orifice techniques.     

Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m<Superscript>2</Superscript>

Background Laparoscopic ventral hernia repair (LVHR) for morbidly obese patients with a body mass index (BMI) exceeding 35 kg/m² has not been well investigated. Methods Hernia recurrence was evaluated by surveillance computed tomography. A p value less than 0.05 was considered significant. Results Between 2003 and 2006, LVHR was attempted for 27 patients with a BMI exceeding 35 kg/m². There was one conversion to open surgery (3.7%). The 27 patients included 8 men (29.6%) and 19 women (70.4%) with a mean age of 48 years (range, 33–73 years). The mean BMI was 46.9 kg/m² (range, 35–70 kg/m²). Nine patients (33%) were superobese (BMI > 50 kg/m²), and five patients (22.7%) underwent emergency LVHR because of small bowel obstruction. Concomitant LVHR with laparoscopic gastric bypass (LGB) was performed for 13 patients (48%). Primary, incisional, or recurrent incisional ventral hernia was present in 7 (26%), 15 (55%), and 5 (19%) patients, respectively. A large hernia (>50 cm²) was found in 20 patients (74%). The mesh used was porcine submucosal small intestine extracellular matrix for 15 patients (57%), Gore-Tex for 9 patients (35%), and Composix for 2 patients (8%). The mean hernia size was 158 cm² (range, 12–806 cm²), and the mean mesh size was 374 cm² (range, 117–2,400 cm²). The mean operative time was 190 min (range, 80–480 min), and the mean hospital length of stay (LOS) was 3.6 days (range, 1–11 days). Minor or major complications occurred in seven patients (25.9%), and five patients (18.5%) experienced recurrence during a mean follow-up period of 14.9 months (range, 3–32 months). Emergency setting, BMI, concomitant LGB, hernia type, hernia size, and mesh type had no statistically significant effect on operative time, LOS, morbidity, or recurrence rates. Conclusions For morbidly obese patients, LVHR is safe and effective, but it is associated with higher likelihood of recurrence, and patients should be appropriately informed. Presented at the 10th World Congress of Endoscopic Surgery Meeting, Berlin, Germany, September 2006     

Mortality following laparoscopic ventral hernia repair: lessons from 90 consecutive cases and bibliographical analysis

The popularity of laparoscopic repair of ventral hernias is increasing due to the apparent advantages of the procedure, but this approach is still a controversial technique. The aim of our study was to evaluate the mortality rate of laparoscopic ventral hernia repair and analyse the literature. The authors performed a prospective study in 90 patients with ventral hernia who were treated by laparoscopic repair. Clinical parameters and intra- and postoperative complications were evaluated. A case of mortality was reported due to a nonrecognised bowel injury. The mean follow-up (100%) was 42 months (range: 1–5 years). A bibliographical analysis was carried out (MEDLINE). Four bowel injuries were presented (4.4%): three recognised, which required conversion (two treated with minilaparotomy and completed afterwards by laparoscopy, and one by laparotomy); and one nonrecognised, which was re-operated on but evolved to sepsis and multiorgan failure and resulted in death in 48 h (1.1%). Four further mortality rates have been documented in the literature (0.6%, 1.1%, 3.1%, and 3.4% of their series). Bowel injury and mortality show a statistically significant tendency to decrease with the number of operations (P<0.05). In conclusion, in our study the risk of mortality with laparoscopic ventral hernia repair has been higher than 1%, which must be made known. It is a risk that depends on the surgeons experience but which does not seem to be predictable.     

Pregnancy and ventral hernia repair

Summary Reluctance to repair anterior abdominal wall hernias in women of childbearing age is probably unjustified. A unique series is described of 27 women who gave birth to 41 full-term babies following repair of an anterior abdominal wall hernia with no recurrence of the hernia. Nineteen had primary and recurrent umbilical hernias and an incisional hernia in a low transverse incision repaired by the onlay darn technique and have produced 29 babies. Eight had umbilical hernias, gross diastasis of the recti and post-cesarean section vertical incisional hernias repaired by the Shoelace technique followed by 12 full-term pregnancies. Little is written about the fate of the abdominal wall subjected to pregnancies following repair of ventral hernias, since the majority of women having these hernias repaired are past the child-bearing age or are warned off further pregnancies by their doctors or undergo tubal ligation with the hernia repair. The Shoelace repair is described, stressing its advantages over mesh hernioplasties in women who wish to have further pregnancies. There is apparently no reason to refuse to repair these hernias. There are even positive indications in view of serious complications associated with pregnancy in the presence of an anterior wall hernia. Prosthetic mesh tends to contract and harden and may seriously interfere with abdominal expansion in pregnancies so these hernias are probably best repaired by the Shoelace technique.     

Ventral hernia surgery in morbidly obese patients,immediate or after bariatric surgery preparation: Results of a case-matched study

Background

Obesity is a risk factor for the development of ventral hernia and increases the risk of recurrence and surgical site infection after hernia repair (HR).

Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients

OBJECTIVE: The aim of this study was to evaluate our experience with LVHR in morbidly obese patients (BMI > 40) and to compare their outcomes to those of patients with lower BMI. METHODS: Data on adult (>18 years old) patients who underwent LVHR with mesh over the last 13 years performed by four experienced surgeons were collected retrospectively and from a previously collected database. Of the 1,071 patients, 901 had completed LVHR and were available for follow-up. One hundred and thirty-four patients (group A) met BMI criteria for morbid obesity (>/=40, mean 46), 767 patients had BMI < 40, mean 30 (group B). The follow-up time ranged from 1 to 91 months. The Wilcoxon rank sum test was used for nonparametric data analysis. Outcomes were stratified on the follow up time and analyzed using Cochran-Mantel-Haenszel methodology. RESULTS: The groups did not differ in terms of ASA score, previous surgery and conversion rate (p = 0.22, 0.32 and 0.23). Morbidly obese patients were younger (48.3 vs. 54; p < 0.01) and were more often female (p = 0.02), but this did not correlate with outcome. Group A also had longer operative time (154 vs. 119 min, p < 0.01) and hospital stay (3.6 vs. 2.4 days, p = 0.03). Mesh size was significantly larger in group A (449 vs. 349 cm(2), p = 002). During mean follow-up time of 19 months hernia recurrence was 8.3% in group A and 2.9% in group B (p = 0.003), with an odds ratio of 4.3 (95% CI 1.9-9.9). However, there was no significant difference in the rate of complications (19.7 vs. 15.3%; p = 0.46). CONCLUSIONS: LVHR in the morbidly obese population is both safe and feasible, although there is a higher, but still acceptable recurrence rate. Despite the increased risk for recurrence, LVHR in morbidly obese patients minimizes the potential wound and mesh complications that frequently occur for open mesh repair in this group of patients.     

Burst strength of laparoscopic and open hernia repair

Background: There are few reports of overall strength of laparoscopic and open incisional hernia repair. Methods: After anesthesia, a 2-inch circular defect was made in the abdominal wall of 28 female swine. Gore-Tex DualMesh Biomaterial (W. L. Gore & Associates, Flagstaff, AZ) was used for all repairs. Sixteen animals underwent open repair and 12 underwent laparoscopic repair. Burst strength was detected within 2 weeks and at 6 weeks by euthanizing the animals and insufflating the abdominal cavity with water while measuring the intraabdominal pressure until it could no longer be pressurized. Results: Three events occurred after insufflation: rupture around patch (R), dissection from insufflation or pressure monitoring sites (D), or rectal prolapse (P). Failure after open early repair occurred at 289 (range 219–388) mmHg with 7-R, 1-P and late 289 (196–343) mmHg with 1-R, 6-P. Failure after laparoscopic early repair occurred at 259 (191–388) mmHg with 4-R, 1-P, 1-D and late 291 (140–330) mmHg with 2-R, 1-P, 3-D. Late groups were less likely to rupture. Conclusion: Both hernia repairs are durable at early and late periods. Tissue ingrowth adds to repair strength. We could not show that one repair was stronger than the other. Nonetheless, laparoscopic repair tended to degrade by dissection, which was our highest pressure event.     

Laparoscopic ventral and incisional hernia repair: An 11-year experience

Incisional hernias develop in 2%–20% of laparotomy incisions, necessitating approximately 90,000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%–52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3–5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27–100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14–405 min), and estimated average blood loss was 25 mL (range 10–200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1–141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.     

A comparative study of adhesion formation and abdominal wall ingrowth after laparoscopic ventral hernia repair in a porcine model using multiple types of mesh

Background The ideal mesh for laparoscopic ventral hernia repair is not yet identified.Methods We laparoscopically placed polypropylene (PPM), expanded polytetrafluoroethylene (ePTFE), and polyester with antiadhesive collagen layer (PCO) in eight pigs using sutures and tacks for fixation. After 28-day survival, we compared adhesion formation, fibrous ingrowth, and shrinkage among the types of mesh.Results Mean area of adhesions to PCO (8.25%) was less than that to ePTFE (57.14%, p < 0.001) or PPM (79.38%, p < 0.001). Adhesions peel strength was less for PCO (2.3 N) than for PPM (16.1 N, p < 0.001) or ePTFE (8.8 N, p = 0.02). Peel strength of mesh from the abdominal wall was less for ePTFE (1.3 N/cm of mesh width) than for PCO (2.8 N/cm, p = 0.001) or PPM (2.1 N/cm, p = 0.05). ePTFE area (94.4 cm²) was less than that for PCO (118.6 cm², p < 0.001) or PPM (140.7 cm², p < 0.02).Conclusion PCO had fewer and less severe adhesions than ePTFE or PPM while facilitating excellent ingrowth of the adjacent parietal tissue.     

Comparison of open and laparoscopic prosthetic repair of large ventral hernias.

BACKGROUND AND OBJECTIVES: Open ventral hernia repair is associated with significant morbidity and high recurrence rates. Recently, the laparoscopic approach has evolved as an attractive alternative. Our objective was to compare open with laparoscopic ventral hernia repairs. METHODS: Fifty laparoscopic and 22 open ventral hernia repairs were included in the study. All patients underwent a tension-free repair with retromuscular placement of the prosthesis. No significant difference between the 2 groups was noted regarding patient demographics and hernia characteristics except that the population in the open group was relatively older (59.4 vs 47.82, P < 0.003). RESULTS: We found no significant difference in the operative time between the 2 groups (laparoscopic 132.7 min vs open 152.7 min). Laparoscopic repair was associated with a significant reduction in the postoperative narcotic requirements (27 vs 58.95 mg i.v. morphine, P < 0.002) and the lengths of nothing by mouth (NPO) status (10 vs 55.3 hrs. P < 0.001), and hospital stay (1.88 vs 5.38 days, P < 0.001). The incidence of major complications (1 vs 4, P < 0.028), the hernia recurrence (1 vs 4, P < 0.028), and the time required for return to work (25.95 vs 47.8, P < 0.036) were significantly reduced in the laparoscopic group. CONCLUSIONS: Laparoscopic ventral hernioplasty offers significant advantages and should be considered for repair of primary and incisional ventral hernias.     

Safety of laparoscopic ventral hernia repair in older adults

The published recurrence rate after laparoscopic ventral hernia repair is much less than the rate of recurrence via the open approach. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population. A retrospecitve chart review of all patients undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to September 2004 was performed. Data extracted from charts included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up. Ninety-seven patients underwent laparoscopic ventral hernia repair (50 men and 47 women). The mean age was 68.5 years (37–85 years) with 78% of patients over the age of 60. Patients had undergone a mean of 2.1 prior abdominal operations. Thirty-five (36%) patients had undergone a mean of 1.8 previous open hernia repairs; 54% with mesh. The mean length of stay was 3.4 days (0–31 days). Thirty-three minor complications occurred in 27 patients. Six major complications occurred in five patients. Three patients required reoperation. Thirty-one percent of patients complained of pain at a transabdominal suture site 6 weeks after surgery. Nine percent of patients had seromas lasting longer than 6 weeks. Two recurrences occurred during follow-up and two patients required mesh removal. There were no deaths. Laparoscopic ventral hernia repair can be performed safely in patients regardless of age. Length of stay and overall complications are not affected by age. Long-term follow-up is necessary to evaluate the effectiveness of LVHR in this patient population. This paper was presented at The American Hernia Society, San Diego, CA, USA, 2 December 2005     

Apronectomy with repair of large ventral hernia in a morbidly obese patient

A 42 year old female with a body mass index of 47 presented to the general surgical outpatient clinic with a large apron of skin hanging from the anterior abdominal wall. This adversely affected her mobility and was prone to intertrigo. It was also complicated by the presence of a large ventral hernia with propensity for recurrent incarceration. Apronectomy with repair of ventral hernia was performed A novel technique to anchor the heavy apron was employed. The apron was anchored to an overhead steel bar by means of large orthopaedic Steinman’s pins and stirrups. A total of 18.5 kg of skin and soft tissue were removed. The patient had difficulty in weaning off the ventilator and spent 3 weeks in the intensive care unit. There were no other complications. There was marked improvement in her mobility and overall quality of life after the operation. Apronectomy can be safely performed in conjunction with ventral hernia repair. This method of anchoring the apron greatly facilitates an otherwise difficult operation. The number of operators as well as the operating time is reduced.     

Simple technique for mesh placement during laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair has many advantages over the open approach. Mesh placement and orientation to overlap the hernia defect is a crucial step. The current techniques for mesh placement are time-consuming. A simple technique for mesh placement during laparoscopic ventral hernia repair is described.     

Polyester composite versus PTFE in laparoscopic ventral hernia repair

Introduction:

Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair.

Methods:

A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit.

Results:

Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P=NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS).

Conclusion:

Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.     

Laparoscopically assisted components separation technique for ventral incisional hernia repair

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.