Introduction: The anatomic restoration of components with mesh and panniculectomy (AROC-MP) is an evolution in the use of the component separation technique for closure of complicated ventral abdominal wounds. Compared to mesh repairs with the risk of mesh related complications or the component separation technique with recurrence rates over 10%, benefits of the AROC-MP include midline closure of both the posterior and anterior rectus sheaths, anatomical restoration of the rectus muscles, and a mesh repair that is protected on both sides by fascia, affording protection from both mesh exposure and contact with bowel. A limited suprafascial dissection preserves lateral cutaneous perforators, and the panniculectomy resection both removes the region of tissue at greatest risk of ischemic necrosis and reorients the incision away from the original scar plane.

Procedure: A plane above the hernia sac is carried 2cm beyond the origin of the anterior rectus sheath. The sheath is divided and the rectus muscles are bluntly freed circumferentially. The lateral confluence of the sheath is inscribed, exposing a plane between the external and internal oblique fascias that is extended laterally until enough mobility is gained to close the continuous layers of fascia both anteriorly and posteriorly. After closure of the posterior layer, Prolene mesh is inset, followed by closure of the anterior sheath. If appropriate, a panniculectomy is planned. The skin is closed in a transverse fashion with a small vertical extension if necessary.

Results: A multifactorial chart review of all AROC-MP's from June 2002-March 2007 was performed. In greater than 50 patients, there was 1 hernia recurrence, a wound dehiscence rate of less than 6%, no patients with mesh complications, and no reports of bowel obstruction or fistula formation. Most cases of wound dehiscence involved slow necrosis of the umbilicus allowing for cosmetically pleasing scarring of the surrounding skin without exposing mesh, given the presence of overlying fascia. Upon questioning, no patient was dissatisfied.

Conclusion: The AROC-MP allows for restoration of the native orientation of the abdominal wall muscle and fascial components, reduces the rate of hernia recurrence, and prevents bowel fistula or adhesion formation and mesh infection or extrusion.