ORIGINAL RESEARCH

published: 10 June 2024

doi: 10.3389/jaws.2024.12928

The Madrid Posterior Component

Separation: An Anatomical Approach
for Effective Reconstruction of
Complex Midline Hernias
Marcello De Luca 1,2*, Manuel Medina Pedrique 2,3, Sara Morejon Ruiz 2,3,
Joaquin M. Munoz-Rodriguez 4, Alvaro Robin Valle de Lersundi 2,3, Javier Lopez-Monclus 4,
Luis Alberto Blázquez Hernando 5 and Miguel Angel Garcia-Urena 2,3
1
UOC Chirurgia Generale Oncologica e Mininvasiva, Azienda Ospedaliera Universitaria, University of Naples Federico II, Naples,
Campania, Italy, 2Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario del Henares, Fundación Investigación e
Innovación Biomédica H. Santa Sofía- H del Henares, Madrid, Spain, 3Grupo de Investigación de Pared Abdominal Compleja,
Universidad Francisco de Vitoria, Madrid, Spain, 4Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de
HIerro, Madrid, Spain, 5Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain

Introduction: In recent years, Posterior Component Separation (PCS) with the Madrid
modification (Madrid PCS) has emerged as a surgical technique. This modification is
believed to enhance the dissection of anatomical structures, offering several advantages.
The study aims to present a detailed description of this surgical technique and to analyse
the outcomes in a large cohort of patients.
Materials and Methods: This study included all patients who underwent the repair of
midline incisional hernias, with or without other abdominal wall defects. Data from patients
at three different centres specialising in abdominal wall reconstruction was analysed. All
patients underwent the Madrid PCS, and several variables, such as demographics,
perioperative details, postoperative complications, and recurrences, were assessed.

*Correspondence
Results: Between January 2015 and June 2023, a total of 223 patients underwent the
Marcello De Luca, Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23–40).
cellodeluca@gmail.com According to the EHS classification, 139 patients had a midline incisional hernia, and
84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to
Received: 29 February 2024
Accepted: 17 April 2024 the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade
Published: 10 June 2024 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation
Citation: for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150
De Luca M, Medina Pedrique M,
Morejon Ruiz S, Munoz-Rodriguez JM,
(67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had
Robin Valle de Lersundi A, previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site
Lopez-Monclus J,
occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%)
Blázquez Hernando LA and
Garcia-Urena MA (2024) The Madrid superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four
Posterior Component Separation: An (1.9%) recurrences were assessed by CT scan with an average follow-up of
Anatomical Approach for Effective
Reconstruction of Complex
23.9 months (range 6–74).
Midline Hernias.
J. Abdom. Wall Surg. 3:12928.
Conclusion: The Madrid PCS appears to be safe and effective, yielding excellent long-
doi: 10.3389/jaws.2024.12928 term results despite the complexity of abdominal wall defects. A profound understanding

Journal of Abdominal Wall Surgery | Published by Frontiers 1 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to
facilitating a complete retromuscular preperitoneal repair without incision of the
transversus abdominis. The extensive abdominal wall retromuscular dissection
obtained enables the placement of very large meshes with minimal fixation.
Keywords: Madrid APPROACH, Madrid posterior component separation, Madrid TAR, posterior component
separation, posterior rectus sheath release

INTRODUCTION (IH) [1–3]. The treatment of large IH, especially in complex

abdominal cases, has been and continues to be a significant
All patients undergoing abdominal surgery with a laparotomic challenge for surgeons [4]. Over the past decades, various
incision are exposed to the risk of developing an incisional hernia techniques have been described based on the prosthetic

FIGURE 1 | Image of dissection of the preperitoneal pathway in the epigastric area of a defrosted cadaver. An incomplete Rives was performed with preservation of
the cranial insertion of the PRS. The blue arrow shows the “incomplete” Rives where the medial incision was stopped at the PRS. The dissection was made leaving the
fatty epigastric rhomboid over the peritoneum. The fibres of the TA muscle can be discerned through the fascia transversalis. R, rectus muscle; P, peritoneum; PRS,
posterior rectus sheath; FER, fatty epigastric rhomboid; FT, fascia transversalis; A, ambivium; TA, transversus abdominis.

FIGURE 2 | Image of dissection of the preperitoneal pathway in the epigastric area of a defrosted cadaver. Lateral to the FER, the dissection had to be changed to a
pre-transversalis plane. The image shows where to start to enter pre-transversalis fascia.

Journal of Abdominal Wall Surgery | Published by Frontiers 2 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

FIGURE 3 | Image of dissection of the preperitoneal pathway in the epigastric area of a defrosted cadaver. The fascia transversalis was left on the floor of the
dissection and the TA muscle is shown.

FIGURE 4 | Image of dissection of the preperitoneal pathway in the epigastric area of a defrosted cadaver. The pre-transversalis plane was developed posterior to
the PRS, without incising the TA muscle fibres.

material reinforcement and the anatomical plane used, each [7,8]. While both, anterior and posterior component separation
attempting to provide advantages over previous techniques. are based on the release of one of the lateral abdominal wall
The use of the retro-muscular and preperitoneal planes, muscles, Heniford proposed to enter the preperitoneal space
described by Rives and Stoppa, allows for the reconstruction of without adding any muscular release [9,10]. The goal of all
the abdominal wall using a non-absorbable prosthetic these techniques remained essentially the same. The
material, positioning it without direct contact with the researchers aimed to obtain an extensive dissection in the
intestinal loops and avoiding subcutaneous dissection [5,6]. retro-muscular and preperitoneal planes allowing the
However, this technique cannot be used for larger midline placement of a large mesh as a closure reinforcement.
defects that require dissection beyond the linea semilunaris or Subsequently, after mastering the technique, improving the
for lateral IH. knowledge of prosthetic materials, and conducting anatomical
To overcome this limitation, Carbonell devised the posterior studies on cadavers, we suggested some modifications to the
component separation (PCS) in 2008, and Novitsky modified it in original TAR [11,12]. The combination of permanent and
2012 by introducing the Transversus Abdominis Release (TAR) absorbable prosthetic materials has been defined as the

Journal of Abdominal Wall Surgery | Published by Frontiers 3 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

FIGURE 5 | Picture taken in a defrosted cadaver to show the pathways of the preperitoneal space before performing the Madrid PCS. 1: preperitoneal pathway in
the Bogros space; 2: preperitoneal pathway in the epigastric area in a pre-transversalis layer. The blue arrow shows the “incomplete Rives” where the medial incision was
stopped at the PRS. The dotted line shows the lateral incision at the posterior rectus sheath in the Madrid PCS. FER, fatty epigastric rhomboid; R, rectus muscle; PRS,
posterior rectus sheath; P, peritoneum; A, ambivium; N, terminal branches of intercostal nerves; FT, fascia transversalis; TA, transversus abdominis.

FIGURE 6 | Schematic representation of the anatomy of the Bogros space, under the arcuate line. The preperitoneal plane was developed preperitoneal over the
fatty trident.

“Madrid APPROACH” (Absorbable Posterior Reinforcement of through the release of the posterior rectus sheath (PRS), named
Permanent mesh Of A Complex Hernia) [13], and the the “Madrid modification” [14], has been introduced as an
preservation of the transversus abdominis (TA) muscle fibres effective and safe technique [11].

Journal of Abdominal Wall Surgery | Published by Frontiers 4 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

FIGURE 7 | Schematic representation of the anatomy of the epigastric area and the preperitoneal plane developed pre-transversally.

The aim of this multicentre study is to provide a detailed Postoperative variables, including systemic or local surgical
description of the Madrid posterior component separation complications (SSO, SSI, and SSOPI), were classified according to
(Madrid PCS), including an analysis of the results from a the Clavien-Dindo Classification (CDC) [16]. Intensive care unit
large cohort of patients to update previously stay, length of hospitalisation and readmission were also
published results. analysed. Clinical follow-up was conducted at 6 weeks,
3 months, 6 months, and then annually. A CT scan was
performed when clinical examination raised doubt about a
MATERIALS AND METHODS recurrence. Late complications, such as chronic seroma,
chronic prosthesis infection, chronic pain, bulging, recurrence,
From January 2015 to June 2023, all coecutive patients intestinal obstruction, and mortality, were recorded.
undergoing abdominal wall surgery for midline incisional This study was reported in line with the STROBE statement
hernias were enrolled. The inclusion criterion was the use of [17]. The study was approved by the Research Ethics
the Madrid PCS technique; any other form of abdominal wall Committee of Francisco de Vitoria University (39/2019)
reconstruction for midline IH was excluded. This study involved and the Institutional Review Board (37/2022). The patients
three specialised abdominal wall surgery centres located in provided written informed consent to participate in
Madrid. Patients were prospectively entered into a shared this study.
database on Redcap.
Demographic variables were collected for all patients, Surgical Technique
including age, sex, BMI, comorbidities, CeDAR (Carolinas All patients followed a standardised preoperative optimisation
Equation for Determining Associated Risk), ASA score, type of programme that comprised endocrinological and nutritional
previous surgery and the number of previous attempts at assessments, respiratory physiotherapy, and abstinence from
abdominal wall reconstruction. The characteristics of midline smoking for a minimum of 1 month prior to surgery. While
IH were recorded according to the EHS classification (EHS M1- weight loss was strongly recommended, it was not mandatory.
M5) [15], focusing on size and location. Additionally, all midline Since 2018, preoperative botulinum toxin has been regularly
IH associated with lateral defects (EHS L1-L4) or with inguinal administered for defects greater than 9 cm, and
hernia were also recorded. Finally, variables related to bridging pneumoperitoneum has been employed in cases involving loss
and reinsertion of the TA muscle were documented. of domain.

Journal of Abdominal Wall Surgery | Published by Frontiers 5 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

TABLE 1 | Demographics. space, followed by bilateral caudal and then epigastric

Variable N (%) dissection. Laterally, the entire retromuscular space is dissected
until the merge of the neurovascular bundles, which are
Age, years 63.39 (range 32–87) preserved. This lateral limit has recently been called the
Sex 137 (61.4%) male; 86 (38.6%) female
“ambivium” [20]. Once we have dissected both lateral
BMI, kg/m2 33.25 (range 23–40)
ASA median 2 retromuscular spaces, then inferiorly, beyond the arcuate line
I 17 (7.62%) and taking advantage of the distribution of preperitoneal fat [21],
II 123 (55.16%) dissection continues by dissecting the Retzius space in the
III 78 (34.98%) midline, the Bogros spaces laterally and exposing Cooper’s
IV 5 (2.24%)
CeDAR mean 36.89 (range 2–91)
ligaments. Attention is given to the epigastric vessels, which,
<30% 54 (24.22%) along with the surrounding adipose tissue, are preserved. In the
30%–60% 150 (67.27%) case of an M4 or M5 IH, the spermatic vessels and vas deferens
>60% 19 (8.52%) (or round ligament) are parietalised as shown by Stoppa [6].
Comorbidities Cranially, the medial incision on the PRS stops 7-8 cm from
Any 189 (84.75%)
the xiphoid, preserving the anatomical insertion of the PRS on the
Smocking 48 (21.53%) daily; 60 (26.91%) ex- costal cartilages [Figure 1]. In this epigastric region, the
smocker dissection continues laterally and cranially into the
Anticoagulation 45 (20.18%) preperitoneal space, leaving the lateral fatty tissue of the
Diabetes 54 (24.22%)
epigastric rhomboid fat over the peritoneum and navigating
Immunosuppression 24 (10.76%)
Lung disease 48 (21.53%) just below the “white” PRS. We do both sides first and then,
Hypertension 109 (48.88%) we enter the subxiphoid space. Two centimetres outside the
Neoplasia 72 (32.29%) midline, the preperitoneal plane is changed to a pre-
Previous abdominal wall hernia operation 105 (48.39%) transversalis plane under the fibres of the TA muscle [Figures
Number of previous attempts of IH repair, 2.33 (range 0–13)
2–4]. Cranially, the dissection under the fibres of the TA muscle is
mean
followed by a pre-facia diaphragmatic plane, under the fibres of
Cause of first surgery
the diaphragm. Anatomical findings have shown that, at this
Hepatobiliopancreatic 19 (8.52%) level, the pre-transversalis fascia and pre-diaphragmatic fascia
Digestive tube 114 (51.12%) planes are preferable to the preperitoneal one. The reason is that
Gynaecologic 23 (10.31%)
Abdominal wall 28 (12.56%)
here we lose the protection of the preperitoneal fat distribution,
Urologic 22 (9.87%) with the risk of peritoneal tears. At this phase, the two planes
Cardiac 3 (1.35%) obtained bilaterally converge in the subxiphoid space. Here, a
Post-trauma 9 (4.04%) significant adipose pad is systematically left attached to the
Vascular 2 (0.89%)
xiphoid process and the dissection continues beneath it, over
Orthopaedic 1 (0.45%)
Others 2 (0.89%)
the peritoneum. This fatty pad has previously been referred to as
the fatty triangle [22]. One constant vessel runs on both sides of
this fatty pad, which can be easily controlled. The dissection
continues cranially up to the central tendon of the diaphragm.
The procedure outlined below is the one we are Following the dome shape of the diaphragm is crucial to avoid
currently following. iatrogenic Morgagni hernias. Particular attention must be paid to
The patient is placed in the supine position and covered with a the constant anatomical insertion of the fibres of the diaphragm
skin drape to prevent direct contact of the prosthetic materials on the PRS. When we reach the central tendon, the fascia
with the skin. The previous scar is removed, and unless it is diaphragmatica fuses the tendon and our layer becomes again
particularly extensive, a 15 cm incision is sufficient for optimal the preperitoneal plane and, therefore, is easy to tear. This entire
exposure of the surgical field. Panniculectomy is performed in epigastric preperitoneal dissection entered the plane under the
those cases with very redundant skin and subcutaneous tissue. TA muscle in both upper quadrants.
Subcutaneous dissection does not extend beyond the hernia Therefore, the procedure continues with the PRS release.
defect and the sac is opened as soon as possible longitudinally. The To enter the preperitoneal Bogros space, some fibres of the
two flaps are preserved until the end of the procedure, determining inner fascia transversalis must be torn or broken. Once in the
in advance for each half of the sac which will be left attached to the Bogros space, the arcuate line is identified and with the
PRS to help close the posterior layer, or which will be left attached assistance of a finger, a blunt dissection is performed to
to the anterior rectus sheath to cover the mesh in case of a potential access the lateral preperitoneal space. By pushing the
bridge [18,19]. Extensive adhesiolysis is performed throughout the visceral sac downward and medially, the peritoneal sac can
cavity as far as the anterior axillary line and a coloured cloth is be separated bluntly from the PRS. A down to up PRS release
placed intraabdominally to protect the intestinal bowels. is performed to join the two dissected preperitoneal pathways:
The procedure continues with the execution of what we the epigastric pre-transversalis and the Bogros preperitoneal
consider an “incomplete Rives” technique. Systematically, the one [Figure 5]. Once the first centimetres are cut 0.5–1 cm
dissection begins with lateral dissection of the retromuscular medial to the ambivium, we carefully dissect laterally and

Journal of Abdominal Wall Surgery | Published by Frontiers 6 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

TABLE 2 | Characteristics of IH. TABLE 3 | Operative data.

Variable N(%) Variable N (%)

Midline defect 139 (62.33%) Elective surgery 222 (99.55%)

Midline + lateral defect 84 (37.67%) Emergency surgery 1 (0.45%)

EHS Classification Size of defect of anterior layer

M1 3 (1.35%) Horizontal, cm, mean 12.68 (range 4–30)

M2 7 (3.14%) Vertical, cm, mean 15.56 (range 5–40)
M3 14 (6.28%)
Surgical technique
M4 2 (0.89%)
M5 1 (0.45%) Unilateral Madrid PCS 35 (15.7%)
M1-2 2 (0.89%) Bilateral Madrid PCS 188 (84.31%)
M1-3 32 (14.35%) Bridging of posterior layera 12 (5.38%)
M1-4 19 (8.52%) Bridging of anterior layerb 76 (34.08%)
M1-5 59 (26.46%) Associated surgery to IH repair 179 (80.27%)
M2-3 8 (3.59%) Adhesiolysis 126 (56.5%)
M2-4 29 (13.01%) Omentum resection 2 (0.89%)
M2-5 14 (6.28%) Intestinal resection 9 (4.04%)
M3-4 1 (0.45%) Suture of bowel 13 (5.83%)
M3-5 28 (12.56%) Intestinal transit reconstruction 7 (3.14%)
M4-5 4 (1.79%) Ileostomy closure 1 (0.45%)
L1 SUBCOSTAL 21 (9.42%) Other abdominal operation 21 (9.42%)
L2 FLANK 15 (6.73%) Panniculectomy 47 (21.08%)
L3 ILIAC 38 (17.04%) None 44 (19.73%)
L4 LUMBAR 10 (4.48%) Reimplant of TA 43 (19.29%)

Slater Classification Drains

Minor 12 (5.38%) Over the mesh 149 (66.82%)

Moderate 125 (56.05%) Subcutaneous and over the mesh 72 (32.29%)
Major 86 (38.57%) Subcutaneous 1 (0.45%)
None 1 (0.45%)
VHWG Classification
Mean operative time, min 235 (range 75–540)
Grade 1 33 (14.79%) a
Grade 2 126 (56.5%) Impossibility to completely close peritoneum and/or posterior rectus sheaths.
b
Impossibility to completely close linea alba (borders of anterior rectus sheaths).
Grade 3 51 (22.87%)
Grade 4 13 (5.83%)

Wound Classification
it is pre-transversalis fascia and pre-diaphragmatic fascia
Clean 157 (70.4%)
Clean-Contaminated 44 (19.73%)
[Figure 7]. A horizontal line of fascia transversalis can
Contaminated 13 (5.83%) always be observed between the upper third pre-
Dirty 9 (4.04%) transversalis and the two lower thirds preperitoneal.
VHSS Classification Finally, the abdominal wall reconstruction is carried out. The
PRS, along with the peritoneum and the preserved hemi-sac, is
Stage 1 50 (22.42%)
Stage 2 119 (53.36%) used to close the posterior wall in the midline with a continuous
Stage 3 54 (24.22%) slowly-absorbable 00 or 000 monofilament suture. If the posterior
wall cannot be closed, a bridge repair using a piece of absorbable
mesh is made. All openings larger than 0.5 cm are closed.
cranially with gentle manoeuvres on the preperitoneal space Subsequently, a 20 × 30 cm bioabsorbable mesh (GORE® BIO-
under the TA muscle to release the tension on the peritoneum. A® Tissue Reinforcement, WL Gore & Associates, Inc. Flagstaff,
The down to up PRS release advanced cranially parallel to the AZ, United States) is positioned without fixation as a
ambivium up to the umbilical area, always combining the reinforcement of the posterior layer. This mesh is tailored to fit
incision with the previous lateral preperitoneal dissection. the shape of the inguinal region. Above it, in the same
Subsequently, the direction becomes oblique to the midline to retromuscular-preperitoneal space, an extensive 50 × 50 cm
meet with the point where we stopped the medial incision on macroporous polypropylene mesh (Bulevb®, Dipro Medical
the PRS in the epigastric area. After complete PRS release, the Devices SRL, Torino, Italy) is placed and fixed only to Cooper’s
preperitoneal dissection continues laterally until the ligaments with long-term absorbable sutures. The mesh is placed in
identification of the tip of the twelfth rib cranially, the a diamond shape for larger patients. In M4-M5 defects, or in the
psoas muscles, and the posterior iliac crest caudally. At this presence of inguinal hernias, this mesh is given the Stoppa
level, it is common to coagulate the constant deep circumflex configuration to protect the myopectineal areas [6].
vessels arising from the iliopsoas muscle. The dissection plane Subsequently, anaesthesia of the muscle plane is performed by
in the lower two-thirds of the abdomen is preperitoneal infiltrating levobupivacaine between the internal oblique and TA
[Figure 6], while in the upper third, as mentioned earlier, muscles. In younger patients or those who are physically active,

Journal of Abdominal Wall Surgery | Published by Frontiers 7 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

TABLE 4 | Postoperative complications.

Variable N (%) Clavien-Dindo >1

Any complication 84 (37.67%)

Seroma 38 (17.04%)
- requiring procedural intervention 30 (13.45%) 30 IIIa
Hematoma 12 (5.38%)
- requiring procedural intervention 3 (1.35%) 2 IIIa; 1 IIIb
SSI 36 (16.14%) 7 II; 28 IIIa; 1 IIIb
- superficial 23 (10.31%) 7 II; 16 IIIa
- organ/space 6 (2.69%) 6 IIIa
- deep 7 (3.14%) 6 IIIa; 1 IIIb
Wound dehiscence 7 (3.14%)
Abdominal complications
Ileus 22 (9.87%)
Intestinal obstruction 2 (0.89%)
Fistula 10 (4.48%) 7 IIa; 2 IIIa; 1 IIIb
Intra-abdominal hypertension (IAP) > 11 mmHg 9 (4.04%) 9 IVa
IAP >20 mmHg + organ failure 1 (0.45%) 1 IVa
Systemic complications
Urinary infection 10 (4.48%) 1 II
Venous line infection 6 (2.69%) 4 II; 2 IIIa
Respiratory failure 16 (7.18%) 5 II; 3 IVa; 4 IVb
Pneumonia 9 (4.04%) 5 II; 1 IIIa; 2 IVb
Cardiac complication 13 (5.83%) 8 II; 3 IVb
Intensive Care Unit stay 89 (39.91%)
Lenght of hospital stay, day, mean 10.92 (range 1–98)
Readmission 19 (8.52%)
Follow-up 199 (89.24%)
Lost to follow-up 10 (4.48%)
Deceased due to unrelated causes 14 (6.28%)
Duration of follow-up, day, mean 718 (range 180–2,216)
Late SSI
- superficial 0
- deep wound infection 2 (0.94%) 2 IIIa
- mesh infection 5 (2.35%) 5 IIIb
Chronic seroma 6 (2.69%) 5 IIIa; 1 IIIb
Chronic pain
- occasionally need for pain treatment 7 (3.29%)
- daily pain treatment 2 (0.94%)
- discomfort 6 (2.82%)
Bulging
- symptomatic 2 (0.94%)
- asymptomatic 14 (6.57%)
Foreign body reaction 2 (0.89%)
Recurrence 4 (1.88%) 2 IIIb

we usually reinsert the lateral border of the PRS cut to the mesh RESULTS
with running sutures of slowly-absorbable material. If closure
of the anterior layer is not possible, the borders of the bridge A total of 223 patients underwent surgery, including 137 men
are sutured with running sutures and covered with a peritoneal (61.4%) and 86 women (38.6%). The mean age was 63.4 years
flap. In bridges larger than 4 cm in width, we suture an (range 32–87). A total of 100 patients had a BMI >30 kg/m2 with a
additional sheet of mesh to the bridged area as an inlay. At mean of 33.3 (range 23–40). In total, 84.8% of patients (n = 189)
least one suction drainage is always placed in the had at least one comorbidity, with the most common being
retromuscular-periprosthetic space. arterial hypertension (48.9%), a history of oncological
pathology (32.3%), and diabetes (24.2%). A 21.5% of patients
Statistics were active smokers, while 26.9% had quit smoking less than
The description of variables and statistical analysis were 12 months before. The mean CeDAR was 36.9%, with
conducted using Microsoft® Excel® for Microsoft 365 MSO 150 patients (67.3%) falling between 30% and 60%. The
(Version 2,312 Build 16.0.17126.20132) 64-bit. Quantitative median ASA score was 2, with the majority of patients being
variables were expressed as mean and range, while categorical ASA2 and ASA3, 123 (55.2%) and 78 (35%), respectively. Table 1
variables were presented as absolute frequencies and percentages. shows the origin of IH. Of the total enrolled patients, 105 (48.4%)

Journal of Abdominal Wall Surgery | Published by Frontiers 8 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

included 35 (15.7%) unilateral Madrid PCS and 188 (84.3%)

bilateral Madrid PCS procedures. Operative variables are detailed
in Table 3, indicating that closure of the posterior layer was
consistently achieved, except in 12 patients (5.4%). Bridging of
the anterior layer was performed in 76 patients (34.1%), and
reinsertion of the transversus abdominis (TA) muscle was
conducted in 43 patients (19.3%). The mean operative time
was 235.3 min (range 75–540 min).
A total of 139 patients (62.3%) did not experience any
postoperative complications [Table 4]. Of the complications
reported in 38 patients (17%), postoperative seroma
development was noted in 30 patients (13.5%), requiring
procedural intervention. Additionally, 12 patients (5.4%) had a
postoperative hematoma, with 3 cases (1.4%) necessitating
operative management. Surgical site infections (SSI) occurred
in 36 patients (16.1%), with 23 (10.3%) superficial, 7 (3.1%) deep,
and 6 (2.7%) organ/space infections. Of these, only 1 patient
(0.5%) required removal of the infected mesh. The mean length of
hospital stay was 10.9 days (range 1–98 days).
A total of 199 patients (89.24%) completed at least a 6-month
FIGURE 8 | Schematic of the retromuscular and preperitoneal space clinical follow-up [Table 4]. In 4 cases (1.8%), clinical follow-up
dissected according to the Madrid PCS. PRS, Posterior rectus sheath.
was not feasible, necessitating a telephone interview. The mean
follow-up duration was 718 days (range 180–2,216 days). During
follow-up, 14 patients (6.3%) died due to causes unrelated to
surgery, while an additional 10 patients (4.5%) did not attend
regular check-ups. Late complications included 7 patients (3.3%)
experiencing deep wound or prosthesis infections, requiring
surgery in 5 cases (2.4%). Chronic seroma developed in
6 patients (2.7%), and a foreign body reaction was observed in
only 2 patients (0.9%). Chronic pain was reported by 15 patients
(7%), with 2 subjects (0.9%) requiring daily pain treatment.
Patients with uncertain clinical signs of recurrence underwent a
follow-up CT scan, which revealed a total of 4 recurrences (1.9%).

DISCUSSION
The PCS with TAR is a technique described to repair large midline
hernias where the Rives-Stoppa technique is insufficient for
abdominal wall reconstruction. This technique, as outlined by
Novitsky et al, allows for the successful treatment of large IH,
requiring extensive dissection, while maintaining the advantage of
using a permanent prosthesis in the sublay position [7]. The results
reported in their case series are very favourable, despite the fact that
FIGURE 9 | Figure of an internal view of the abdominal wall to represent
approximately 90% of the patients had a grade 2-3 IH based on the
the differences between the Madrid PCS and TAR. * Shows the preservation
of the cranial insertion of the PRS. modified hernia grading scale and a median hernia width of 15 cm. In
a subsequent study, this group reported a low number of recurrences
(3.7%) with a complete closure rate of the anterior layer of the
abdominal wall of 97% [23]. Zolin et al. reported a 92% success rate in
had already undergone abdominal wall repair, with a mean of closing the anterior layer, with a composite hernia recurrence rate of
2.3 attempts (range 0–13) [Table 1]. 26% in a case series of 1,203 patients, 57% of whom had recurrences
Of the 223 patients, 139 (62.3%) had a pure midline defect, and a median hernia width of 15 cm [24]. The effectiveness of this
while 84 (37.7%) also presented with an associated lateral defect, technique in terms of recurrence was also reported by Winder et al. In
as illustrated in Table 2. The midline defects were always W3, their study, although with a smaller group of patients, the authors
whereas the cases in which a lateral defect was associated with the reported a 2.7% recurrence rate [25]. Heniford et al. confirmed these
midline ones were W1 in 21 cases (24.7%), W2 in 60 cases results in their study of 1,023 patients in whom PCS with TAR was
(71.8%), and W3 in 3 cases (3.6%). The surgical approach performed in case of dissection difficulties with the pure preperitoneal

Journal of Abdominal Wall Surgery | Published by Frontiers 9 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

FIGURE 10 | Picture taken of a defrosted cadaver in which an incomplete Rives was dissected. It shows the medial arise of the medial merge of the nerves in the
epigastric area. R, rectus muscle; PRS, posterior rectus sheath; FER, fatty epigastric rhomboid; A, ambivium; N, terminal branches of intercostal nerves.

technique, reporting a 5% recurrence rate [10]. Finally, Sagnelli et al, between the PRS, the diaphragm, and the TA muscle. We have
in their recent study, reported excellent results regarding the observed that the fibres of the diaphragm invariably insert at the PRS.
effectiveness of the technique. In their case series of 117 patients Therefore, maintaining the integrity of the PRS avoids injury to these
with complex IH, PCS with TAR was performed, and the abdominal diaphragmatic fibres. Consequently, it seems convenient to change to
wall was reconstructed with a double prosthesis, following the Madrid a preperitoneal plane in the subxiphoid area. When we started
APPROACH, with a reported recurrence rate of less than 1% [13]. In learning the TAR technique, we became aware that the terminal
this current case series, where the Madrid PCS was performed, we branches of the T7, T8, and T9 intercostal nerves arise more medially
report a recurrence rate of 1.9%, lower than most studies in the than previously reported and they are difficult to preserve unless the
literature, confirming that this technique is a valid alternative to the TAR is performed very medially [Figure 10]. It is not so uncommon
original one. to see muscle atrophy of the rectus muscle in CT controls and patients
One of the key points of the Madrid PCS is the reconstruction complaining of a bulge. We then decided to perform the lateral
using very large meshes, applying Stoppa´s concept of “giant release of the PRS in the upper third, following the myofascial limit of
reinforcement of the visceral sac” to the midline IH [6]. The space the TA muscle. Since this medial release is more difficult to perform
for this mesh is obtained by a wide dissection over the parietal than a TAR, we have standardised the technique with our
peritoneum and under the overlying abdominal wall muscles: from recommendation to follow the pathways of the preperitoneal
Cooper’s ligament to the central tendon, and from the tip of the plane before starting the lateral release. Therefore, before any
twelfth rib and the psoas muscles to the contralateral ones. Anatomical release is made, we recommend entering the preperitoneal plane
findings have shown that this vast retromuscular and preperitoneal starting at the Bogros space and pre-transversalis fascia in the
space includes the PRS, the preperitoneal trident, the parietal subxiphoid area. As explained previously [21], the preperitoneal
peritoneum, the fascia transversalis, and the fascia diaphragmatica fat distribution allows entering the plane under the TA muscle
[Figure 8]. This thin layer is referred to as“the posterior layer” in PCS without any lateral release at the PRS. Finally, the Madrid PCS is
techniques. Its use provides sufficient extension and overlap to a technique halfway between Novitsky´s TAR and Heniford´s
effectively repair large defects in the midline and the combination preperitoneal repair [7,9,10]. Furthermore, preserving the TA
of midline and lateral ones [26]. The difference with complete muscle cranially may contribute to the stabilisation and
preperitoneal dissection [10,27] is that with the Madrid PCS, the mobilisation of the trunk.
medial and lateral release facilitates the midline closure of large defects. Another point of discussion is the difference in midline
Although the Madrid PCS was initially considered a modification approximation obtained comparing the Madrid PCS and TAR.
of the TAR [11, 12, 14, 28], the significant anatomical differences We certainly think that, from an anatomical point of view, we are
probably suggest that it should be categorised as a PRS release rather also performing a release at the insertion of the TA muscle, and
than a TAR. These differences are: first, the preservation of the PRS the difference must only be in the cranial preservation of the PRS.
insertion, and second, the lateral release of the PRS without cutting Anatomical studies in the cadaver laboratory may reveal if there is
the TA muscle [Figure 9]. The first aspect involves the cranial a substantial difference, although we agree that these cadaver
preservation of the PRS at its physiological attachment to the studies may have significant limitations [29].
chondrocostal cartilage. Anatomical dissections in the cadaver Despite good results in terms of recurrence rate, any complex
laboratory and experience in performing PCS have shown us that abdominal wall repair is not free from complications. Novitsky et al,
there is a close anatomical and, therefore, functional relationship in their study, reported an SSE rate of 18% and an SSI rate of 9% with

Journal of Abdominal Wall Surgery | Published by Frontiers 10 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

a mean length of hospital stay of 6 days [23]. Heniford et al. reported CONCLUSION
a 27% SSE rate and a 15% SSI rate with a mean length of hospital stay
of 5 days [10]. However, in a subsequent study, the same authors The Madrid PCS stands out as a technique that facilitates the
demonstrated how experience can significantly improve the reconstruction of large IHs with remarkable efficacy in preventing
complication rate (from 26% to 13%) and the recurrence rate recurrence. This approach introduces a technical variation rooted
(from 7% to 2%) [27]. Sagnelli et al. also showed complications in the anatomical study of the abdominal wall and the
that were in line with those reported in the Literature. They reported a arrangement of its preperitoneal fat. These modifications not
seroma rate of 26%, a hematoma rate of 17%, and only a 3.4% SSI rate only improve the intuitive execution of the technique but also
[13]. Slightly better results were obtained by Zolin et al, who reported foster a more respectful approach to the musculofascial and
only 8% of SSOPI in patients with more than 1 year of follow-up [24]. nervous components of the anterior abdominal wall.
Finally, a recent meta-analysis, including 5 studies from 2016 to 2017, Furthermore, the Madrid PCS allows for the placement of
reported similar results, with an average SSO rate of 15% and an SSI large prostheses in the retromuscular-preperitoneal space,
rate of 7% [30]. aligning with the fundamental principle of the giant prosthetic
In our case series, 38% of patients experienced a complication, reinforcement of the visceral sac. This adherence contributes to a
either systemic or related to the surgical site. The reported rates of low incidence of long-term recurrences, contributing to the
seroma and SSI were 17% and 16%, respectively. Of these, only one favourable outcomes associated with the technique.
patient, who also underwent simultaneous intestinal transit
reconstruction, required reoperation to completely remove the
infected mesh. With regard to late infections, 7 (3%) patients were DATA AVAILABILITY STATEMENT
readmitted for treatment. Of these, 5 patients had a mesh infection,
and in all cases, the prosthesis was removed. Compared to other The datasets presented in this article are not readily available
studies, our results regarding postoperative complications were higher, because the authors confirm that the data supporting the findings
which could be influenced by the patient´s non-ideal preoperative of this study are available within the article (and/or) its
conditions and the careful collection of prospective data. supplementary materials. Requests to access the datasets
Approximately 85% of our patients had at least one comorbidity, should be directed to cellodeluca@gmail.com.
and 67% had a CeDAR score of developing a surgical site complication
between 30% and 60%. Furthermore, 53% and 24% of the patients
were classified as grade 2 and 3 according to the Ventral Hernia ETHICS STATEMENT
Staging System (VHSS) classification [31].
There are several notable limitations. There is no comparison The study was approved by the Research Ethics Committee of
group. This design choice limits the ability to assess the relative Francisco de Vitoria University (39/2019) and the Institutional
effectiveness and safety of the Madrid PCS compared to Review Board (37/2022). The patients provided written informed
alternative surgical approaches. However, we do consider this consent to participate in this study.
approach to be the most anatomically respectful. The
population treated at three specialised centres also limits its
applicability to other centres not dedicated to the abdominal AUTHOR CONTRIBUTIONS
wall. The study may be subject to selection bias since patients
were recruited from specialised centres, and those with more All authors participated in the design and interpretation of the study.
complex cases or comorbidities may be overrepresented. This MD, MM, SM, and JM analyzed the datas. MD and MG-U wrote the
could impact the external validity of the findings. On the other manuscript, AR, JL, and LB reviewed of the manuscript. All authors
hand, the selection criteria for enrolling patients avoid selection contributed to the article and approved the submitted version.
bias and the application of the same protocol prevents the bias of
misclassification. Finally, we recognise an inherent publication
bias due to the tendency to publish positive results, potentially FUNDING
leading to an overestimation of the effectiveness of the Madrid
PCS. technique. Nonetheless, this study offers a large sample The author(s) declare that no financial support was received for
reporting favourable long-term outcomes demonstrating the the research, authorship, and/or publication of this article.
durability and sustained effectiveness of the Madrid PCS in
addressing midline incisional hernias. Additionally, the main
aim of this study was to provide a comprehensive description of CONFLICT OF INTEREST
the surgical technique based on anatomical findings. This
knowledge is considered crucial for surgeons, suggesting that The authors declare that the research was conducted in the
a thorough anatomical approach contributes to the success of absence of any commercial or financial relationships that
this technique. could be construed as a potential conflict of interest.

Journal of Abdominal Wall Surgery | Published by Frontiers 11 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

PUBLISHER’S NOTE organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article,
All claims expressed in this article are solely those of the authors or claim that may be made by its manufacturer, is not guaranteed
and do not necessarily represent those of their affiliated or endorsed by the publisher.

6336 Patients and Results of a Survey. Ann Surg (2004) 240(2):205–13.

REFERENCES doi:10.1097/01.sla.0000133083.54934.ae
17. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP,
1. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, et al. The Strengthening the Reporting of Observational Studies in
Heisterkamp J, et al. Small Bites Versus Large Bites for Closure of Epidemiology (STROBE) Statement: Guidelines for Reporting
Abdominal Midline Incisions (STITCH): A Double-Blind, Multicentre, Observational Studies. Int J Surg (2014) 12:1495–9. doi:10.1016/j.ijsu.2014.
Randomised Controlled Trial. Lancet (2015) 386(10000):1254–60. doi:10. 07.013
1016/s0140-6736(15)60459-7 18. Malik A, Macdonald AD, de Beaux AC, Tulloh BR. The Peritoneal Flap
2. Cobb WS, Warren JA, Ewing JA, Burnikel A, Merchant M, Carbonell AM. Hernioplasty for Repair of Large Ventral and Incisional Hernias. Hernia
Open Retromuscular Mesh Repair of Complex Incisional Hernia: Predictors of (2014) 18(1):39–45. Epub 2013 Apr 9. PMID: 23568492. doi:10.1007/
Wound Events and Recurrence. J Am Coll Surg (2015) 220(4):606–13. doi:10. s10029-013-1086-7
1016/j.jamcollsurg.2014.12.055 19. Nielsen MF, de Beaux A, Tulloh B. Peritoneal Flap Hernioplasty for
3. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo Reconstruction of Large Ventral Hernias: Long-Term Outcome in
D, et al. European Hernia Society Guidelines on the Closure of 251 Patients. World J Surg (2019) 43(9):2157–63. PMID: 31065774. doi:10.
Abdominal Wall Incisions. Hernia (2015) 19:1–24. doi:10.1007/ 1007/s00268-019-05011-0
s10029-014-1342-5 20. Vierstraete M, Pereira Rodriguez JA, Renard Y, Muysoms F. EIT Ambivium,
4. Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Linea Semilunaris, and Fulcrum Abdominalis. J Abdom Wall Surg (2023) 2:
et al. Criteria for Definition of a Complex Abdominal Wall Hernia. Hernia 12217. PMID: 38312427; PMCID: PMC10831682. doi:10.3389/jaws.2023.
(2014) 18(1):7–17. doi:10.1007/s10029-013-1168-6 12217
5. Rives J, Pire JC, Flament JB, Polot JP. Major Incisional Hernias. In: Chevrel JP, 21. Garcia-Urena MÁ, Lopez-Monclus J, de Robin Valle de Lersundi A,
editor. Surgery of the Abdominal wall. New York: Springer-Verlag (1987). Blazquez Hernando LA, Medina Pedrique M, Rial Justo X, et al.
p. 116–44. Pathways of the Preperitoneal Plane: From the "Fatty Triangle" in
6. Stoppa RE. The Treatment of Complicated Groin and Incisional Hernias. Rives to the "Fatty Trident" in Extended Retromuscular Abdominal
World JSurg (1989) 13(5):545–54. doi:10.1007/BF01658869 Wall Reconstruction. A Tribute to Prof. Schumpelick. Hernia (2023)
7. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus Abdominis 27(2):395–407. doi:10.1007/s10029-022-02602-0
Muscle Release: A Novel Approach to Posterior Component Separation 22. Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V. Pitfalls in
During Complex Abdominal Wall Reconstruction. Am J Surg (2012) Retromuscular Mesh Repair for Incisional Hernia: The Importance of the
204(5):709–16. doi:10.1016/j.amjsurg.2012.02.008 "Fatty Triangle. Hernia (2004) 8(3):255–9. Epub 2004 Jun 5. PMID: 15185126.
8. Carbonell AM, Cobb WS, Chen SM. Posterior Components Separation During doi:10.1007/s10029-004-0235-4
Retromuscular Hernia Repair. Hernia (2008) 12(4):359–62. doi:10.1007/ 23. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein
s10029-008-0356-2 SB. Outcomes of Posterior Component Separation With Transversus
9. Novitsky YW, Porter JR, Rucho ZC, Getz SB, Pratt BL, Kercher KW, et al. Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement. Ann
Open Preperitoneal Retrofascial Mesh Repair for Multiply Recurrent Ventral Surg (2016) 264:226–32. PMID: 26910200. doi:10.1097/SLA.
Incisional Hernias. J Am Coll Surg (2006) 203(3):283–9. Epub 2006 Jul 13. 0000000000001673
PMID: 16931299. doi:10.1016/j.jamcollsurg.2006.05.297 24. Zolin SJ, Krpata DM, Petro CC, Prabhu AS, Rosenblatt S, Rosen S, et al. Long-
10. Heniford BT, Ross SW, Wormer BA, Walters AL, Lincourt AE, Colavita Term Clinical and Patient-Reported Outcomes After Transversus Abdominis
PD, et al. Preperitoneal Ventral Hernia Repair: A Decade Long Release With Permanent Synthetic Mesh: A Single Center Analysis of
Prospective Observational Study With Analysis of 1023 Patient 1203 Patients. Ann Surg (2023) 277(4):e900–e906. doi:10.1097/SLA.
Outcomes. Ann Surg (2020) 271(2):364–74. doi:10.1097/SLA. 0000000000005443
0000000000002966 25. Winder JS, Behar BJ, Juza RM, Potochny J, Pauli EM. Transversus Abdominis
11. Robin A, Blazquez Hernando L, Lopez-Monclus J, Cruz Cidoncha A, San Release for Abdominal Wall Reconstruction: Early Experience With a Novel
Miguel Méndez C, Jimenez Cubedo E, et al. How We Do it: Down to up Technique. J Am Coll Surgeons (2016) 223(2):271–8. doi:10.1016/j.jamcollsurg.
Posterior Components Separation. Langenbecks Arch Surg (2018) 403(4): 2016.04.012
539–46. Epub 2018 Mar 3. PMID: 29502282. doi:10.1007/s00423-018-1655-4 26. Munoz-Rodriguez JM, Lopez-Monclus J, San Miguel Mendez C, Perez-Flecha
12. García-Ureña MÁ, López-Monclús J, Cuccurullo D, Blázquez Hernando LA, Gonzalez M, Robin-Valle de Lersundi A, Blázquez Hernando LA, et al.
García-Pastor P, Reggio S, et al. Abdominal Wall Reconstruction Utilizing the Outcomes of Abdominal Wall Reconstruction in Patients With the
Combination of Absorbable and Permanent Mesh in a Retromuscular Combination of Complex Midline and Lateral Incisional Hernias. Surgery
Position: A Multicenter Prospective Study. World J Surg (2019) 43(1): (2020) 168(3):532–42. Epub 2020 May 12. PMID: 32527646. doi:10.1016/j.
149–58. PMID: 30132226. doi:10.1007/s00268-018-4765-9 surg.2020.04.045
13. Sagnelli C, Tartaglia E, Guerriero L, Montanaro ML, D’Alterio G, Cuccurullo 27. Katzen MM, Kercher KW, Sacco JM, Ku D, Scarola GT, Davis BR, et al. Open
D, et al. Long-Term Outcomes of Madrid Approach After TAR for Complex Preperitoneal Ventral Hernia Repair: Prospective Observational Study of
Abdominal Wall Hernias: A Single-Center Cohort Study. Hernia (2023) 25: Quality Improvement Outcomes Over 18 Years and 1,842 Patients. Surgery
1355–61. Epub ahead of print. doi:10.1007/s10029-020-02273-9 (2023) 173(3):739–47. doi:10.1016/j.surg.2022.07.042
14. Reinpold W. Transversus Abdominis Muscle Release: Technique, Indication, 28. Urena MÁG, López-Monclús J, Hernando LAB, Munoz-Rodriguez J, García de
and Results. Int J Abdom Wall Hernia Surg (2018) 1(3):79–86. doi:10.4103/ León LR, Avilés Oliveros A, et al. Narbenhernien: Offene Operationsverfahren
ijawhs.ijawhs_27_18 und Ergebnisse Einer Kohortenstudie mit 343 Patienten [Incisional Hernia:
15. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala Open Abdominal Wall Reconstruction. Current State of the Technique and
E, et al. Classification of Primary and Incisional Abdominal Wall Hernias. Results]. Chirurgie (Heidelb) (2024) 95(1):10–9. doi:10.1007/s00104-023-
Hernia (2009) 13(4):407–14. doi:10.1007/s10029-009-0518-x 02005-6
16. Dindo D, Demartines N, Clavien PA. Classification of Surgical 29. Köhler G. Letter to the Editor: Anterior and Posterior Component
Complications: A New Proposal With Evaluation in a Cohort of Separation; Limitations of Cadaver Studies. Am J Surg (2020) 219(4):

Journal of Abdominal Wall Surgery | Published by Frontiers 12 June 2024 | Volume 3 | Article 12928
De Luca et al. The Madrid Posterior Component Separation

728–9. Epub 2019 May 25. PMID: 31153583. doi:10.1016/j.amjsurg.2019. Copyright © 2024 De Luca, Medina Pedrique, Morejon Ruiz, Munoz-Rodriguez,
05.010 Robin Valle de Lersundi, Lopez-Monclus, Blázquez Hernando and Garcia-Urena.
30. Wegdam JA, Thoolen JMM, Nienhuijs SW, de Bouvy N, de Vries Reilingh TS. This is an open-access article distributed under the terms of the Creative Commons
Systematic Review of Transversus Abdominis Release in Complex Abdominal Attribution License (CC BY). The use, distribution or reproduction in other forums is
Wall Reconstruction. Hernia (2019) 23(1):5–15. doi:10.1007/s10029-018-1870-5 permitted, provided the original author(s) and the copyright owner(s) are credited
31. Petro CC, O’Rourke CP, Posielski NM, Criss CN, Raigani S, Prabhu AS, et al. and that the original publication in this journal is cited, in accordance with accepted
Designing a Ventral Hernia Staging System. Hernia (2016) 20(1):111–7. academic practice. No use, distribution or reproduction is permitted which does not
doi:10.1007/s10029-015-1418-x comply with these terms.

Journal of Abdominal Wall Surgery | Published by Frontiers 13 June 2024 | Volume 3 | Article 12928