Violation of the Rectus Complex is Not a Contraindication to Component Separation for Abdominal Wall Reconstruction

PURPOSE:  Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects.  Surgeons often avoid CS when the rectus abdominis complex has been violated, believing that it may complicate performance of CS and, thus, negatively impact surgical outcomes.  However, there is no credible evidence to support rectus violation as a contraindication to CS. On the basis of our experience with CS, we hypothesized that patients have similar outcomes whether or not the rectus complex has been violated.

METHODS:  We retrospectively evaluated the surgical outcomes of all consecutive patients who underwent CS for abdominal wall reconstruction over a 12-year period at The University of Texas MD Anderson Cancer Center. Primary outcome measures were wound-healing complications and hernia recurrence in patients with and without rectus violation.  Patients with rectus violation were further classified into four groups (prior/current ostomy, prior/current gastrostomy/jejunostomy tube, surgical transection of rectus complex, and surgical resection of rectus complex) for subanalyses. Univariate and multivariate logistic regression analysis was used to identify potential associations between patient, defect, and reconstructive characteristics and surgical outcomes.  

RESULTS:  One hundred and seventy patients were included in the study: 116 (68%) patients with and 54 (32%) patients without rectus violation.  Mean follow-up was 15.9 ± 14.1 months.  Patient characteristics were similar between the rectus violation and non-violation groups.  Overall complication rates were similar between the violation (n=29, 25%) and the non-violation (n=13, 24%) groups, as were the specific surgical outcomes between the violation and the non-violation groups, respectively:  recurrent hernia (8% vs. 9%, p=0.77), abdominal bulge (4% vs. 6%, p=0.68), skin necrosis (21% vs. 22%, p=0.84), skin dehiscence (7% vs. 4%, p=0.51), cellulitis (9% vs. 9%, p=1.0), and abscess (13% vs. 9%, p=0.61).  Subset analysis showed the ostomy group to have the highest incidence of complications among the violation types (34%), but this was still statistically equivalent to the non-violation group (24%, p=0.42).

CONCLUSIONS:  We found that surgical outcomes were similar for CS whether or not the rectus complex was violated. To our knowledge, this study is the first to directly evaluate the effects of violation of the rectus complex on surgical outcomes in CS patients.  Contrary to what has been previously recommended, CS can be reliably performed in cases of rectus violation without incurring additional morbidity.