Hernia (2021) 25:1573–1580 https://doi.org/10.1007/s10029-021-02449-x ORIGINAL ARTICLE Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG) J. A. Pereira‑Rodriguez1,2 · A. Bravo‑Salva1,2 · B. Montcusí‑Ventura1 · P. Hernández‑Granados3 · V. Rodrigues‑Gonçalves4 · M. López‑Cano4,5 on behalf of the EVEREG Registry Members Received: 15 April 2021 / Accepted: 21 June 2021 / Published online: 2 July 2021 © The Author(s) 2021 Abstract Aim To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multi- center cohort of patients. Methods All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed. Results During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m2. ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64–14.65; P = 0.004). Conclusion CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes. Keywords Incisional hernia · Component separation technique (CST) · Hernia registry · Abdominal wall surgery specialization Introduction The component separation technique (CST) has become popular in recent years for incisional hernia (IH) repair * J. A. Pereira‑Rodriguez [1, 2]. Currently, the following two main CSTs are being jpereira@parcdesalutmar.cat used: anterior components separation (ACS) [3] and poste- rior components separation (PCS) [4]. In both techniques, 1 Department of Surgery, Hospital del Mar – Parc de Salut a mesh is added to reinforce abdominal wall closure and to Mar, Passeig Maritim 25‑29, 08003 Barcelona, Spain promote long-term stability [3–5], and both ACS and PCS 2 Department of Experimental and Health Sciences, techniques have proven to be effective [5–7]. Furthermore, in Universitat Pompeu Fabra, Barcelona, Spain some cases they represent the last chance to achieve a good 3 Department of Surgery, Hospital Universitario Fundación quality of life for patients who have to modify their lifestyle Alcorcón, Madrid, Spain due to a hernia [8, 9]. 4 Abdominal Wall Surgery Unit, Hospital Universitari Vall However, most of the evidence regarding the use of both d’Hebron, Barcelona, Spain CSTs is derived from single experiences or high-volume 5 Department of Surgery, Universitat Autònoma de Barcelona, hospitals [6, 10]. There is a lack of data in a multicenter Barcelona, Spain 13 Vol.:(0123456789) 1574 Hernia (2021) 25:1573–1580 cohort of patients. Real-world evidence (i.e., registries) Registered surgery characteristics were as follows: can provide information from different institutions on rou- clinical setting (i.e., elective or emergency), type of CST tine practice of CST in unselected patients and can answer (ACS or PCS), concomitant intra-abdominal procedures questions that are more difficult to analyze with other study (i.e., adhesiolysis, bowel resection, and cholecystectomy), designs (i.e., randomized studies). The registry of incisional panniculectomy, and whether the operation was performed hernia repair (EVEREG) [11] was started in 2012 and was in the Abdominal Wall Unit (AWU). Mesh type, space of promoted by the Abdominal Wall Chapter of the Spanish mesh placement, and type of fixation were chosen accord- Association of Surgeons (AEC), and it represents one of the ing to the cases and preference of each surgeon. few registries of these characteristics present across Europe Perioperative complications, including surgical site and the rest of the globe. occurrences (SSO) (seroma, wound infection, wound The aim of this work is to analyze the outcomes of CST hematoma, and skin necrosis), reoperation, and mortality comparing the results of anterior vs. posterior techniques related to surgery during the first postoperative month, in patients registered in the EVEREG, and to identify the were recorded and classified according the Clavien- factors predicting complications and recurrences of CST. Dindo grade [18]. After hospital discharge, patients were followed-up at 1 month, 6 months, and one and two years after surgery. Recurrence was evaluated by clinical exami- Methods nation; and in case of doubt, an ultrasound or computed tomography was indicated. Patients Exclusion criteria were lack of data for the analysis and absence of follow-up data after surgery. For long-term EVEREG is an online database accessible on the internet complications, a minimum 6-month follow-up was con- (http://​www.​evereg.​es/). The register of patients is anony- sidered for the analysis. mous, and there are 178 participating centers across the The development of the study was performed follow- country (38% of 467 National Health System Hospitals). ing the international guidelines of clinical investigation EVEREG is permanently open to all centers that want to (Ethics Code and Helsinki Declaration) and according participate, and all types of hospitals are included. The reg- to the legal regulations for confidentiality and personal istry data structure, committee’s approval process, and data data according to Spanish law. The local ethics committee collection system have already been described previously approved the study protocol (2012/4908/I). [11]. Briefly, it is a prospective database maintained by the surgeons in charge of each center, in which the parameters of the patients, the type of hernia, operations, and complica- Statistical analysis tions are collected for each CST performed. The follow-up is performed through clinical control with an appointment one The statistical analysis was performed using the IBM sta- month, 6 months, 1 year, and 2 years after surgery. Patients tistical package for the Social Sciences (SPSS) program undergoing a CST technique (anterior or posterior) and reg- (IBM Inc., Rochester, MN, USA) version 25 for Win- istered in the EVEREG from July 2012 to December 2019 dows. Quantitative variables were expressed as mean and were included and analyzed. standard deviation (SD) and qualitative variables as pro- portions. To analyze the association between qualitative Variables variables, we used the Chi-squared test (χ 2) or Fisher’s exact test when necessary, as well as Student’s t test or Demographic variables, including patient’s age, gender, and the Mann–Whitney U test for quantitative variables. The body mass index (BMI), obesity, and overweight follow- normality of the distribution of the quantitative variables ing WHO classification [14] were collected. Comorbidi- was verified using the Kolmogorov–Smirnov test. Statis- ties selected were hypertension, diabetes mellitus, chronic tical significance was established at P < 0.05. The odds obstructive pulmonary disease, chronic renal failure, onco- ratio (OR) of IH recurrence was calculated with its 95% logic history, abdominal aortic aneurysm, and American confidence intervals (CI). In the multivariate analysis for Society of Anesthesiologists’ (ASA) physical status score complications, the predictive capacity of each variable [12]. and its independence from the other predictor variables IHs were classified according to their location and size were analyzed using a binomial logistic regression model according to the EHS classification [15] and complexity by sequentially introducing the variables with an input F [16]. Previous repair and prior use of mesh were identified. of 0.5. A Cox proportional hazards regression model was Pre-operative optimization with progressive pneumoperito- used to analyze the risk factors related to recurrence. neum (PPP) or botulinum toxin (BT) was also recorded [17]. 13 Hernia (2021) 25:1573–1580 1575 Results Table 1 shows the characteristics of the patients and the comparison between both techniques. Males represented From July 2012 to December 2019, a total of 11,612 IHs 54.5% of the cohort. Median age at time of surgery was were registered in the EVEREG. A total of 1536 (13.3%) 64 years (IQR 55.0–71.0 years), with 31.3% being older than patients underwent CST and were available for analysis. A 70 years. Median BMI was 29.7 kg/m2 (IQR 26.5–33.5), total of 1193 (77.6%) patients were treated with an ACS with a 48.7% rate of obesity (BMI > 30 kg/m2). One-third technique and 343 (22.4%) with a PCS technique. All opera- of the cohort (N = 502, 32.7%) had an ASA score III–IV tions were performed by an open approach. with a higher percentage in ACS patients (34%; P = 0.05), Table 1  Pre-operative demographics of patients and hernia characteristics N = 1536 ACS N = 1193 PCS N = 343 P Demographics and comorbidities Age, years, median (IQR) 64.0 (55.0–71.0) 64.0 (54.0–72.0) 64.0 (55.0–70.0) 0.972 Age > 70 years, N (%) 480 (31.3) 383 (32.1) 97 (28.3) 0.178 Sex female, N (%) 699 (45.5) 552 (46.3) 147 (43.0) 0.282 BMI, kg/m2 median (IQR) 29.7 (26.5–33.5) 29.7 (26.6–33.5) 29.4 (26.3–33.3) 0.399 BMI > 30 kg/m2 (obesity), N (%) 747 (48.7) 586 (49.2) 161 (46.9) 0.452 BMI > 35 kg/m2 (severe obesity), N (%) 293 (19.1) 229 (19.2) 64 (18.7) 0.808 Alcohol abuse, N (%) 204 (13.3) 159 (13.3) 45 (13.1) 0.920 Smoking N (%) 403 (26.2) 324 (27.2) 79 (23.0) 0.126 AHT, N (%) 791(51.5) 633 (53.3) 158 (46.1) 0.022 Diabetes mellitus, N (%) 336 (21.9) 268 (22.5) 68 (19.8) 0.297 COPD, N (%) 277 (18.0) 227 (19.8) 50 (14.6) 0.059 CRF, N = 657 (%) 65 (9.9) 30 (8.9) 35 (11.0) 0.368 Immunosuppression N = 524 (%) 79 (15.1) 69 (15.8) 10 (11.4) 0.286 Oncologic history, N (%) 411 (26.8) 324 (27.2) 87 (25.4) 0.508 AAA, N = 524 (%) 8 (1.5) 6 (1.4) 2 (2.3) 0.532 ASA III–IV, N (%) 502 (32.7) 405 (34.0) 97 (28.4) 0.050 Hernia characteristics Location Midline, N (%) 1349 (87.8) 1071 (89.8) 278 (81.0) < 0.0001 Trocar, N (%) 55 (3.6) 29 (2.4) 26 (7.6) < 0.0001 Ostomy, N (%) 65 (4.2) 39 (3.3) 26 (7.6) < 0.0001 Other, N (%) 71 (4.6) 67 (5.6) 4 (1.2) 0.001 Defect size* Area, ­cm2 (SD) 176,9 (140.7) 187.7 (140.2) 148.7 (138.1) < 0.0001 Transverse > 10 cm, (W3) N (%) 822 (65.9) 642 (71.0) 180 (52.5) < 0.0001 Longitudinal > 10 cm, N (%) 965 (77.4) 748 (82.7) 217 (63.3) < 0.0001 Previous repair, N (%) 486 (31.6) 357 (29.9) 214 (37.6) 0.007 Previous mesh, N (%) 452 (93.0) 326 (91.3) 126 (97.7) 0.015 Classification of complexity** Minor, N (%) 233 (15.2) 175 (14.7) 58 (16.9) Moderate, N (%) 577 (37.6) 447 (37.5) 130 (37.9) Major, N (%) 726 (47.2) 571 (47.9) 155 (45.2) Pre-operative treatment Pneumoperitoneum, N (%) 73 (4.8) 60 (5.0) 13 (3.8) 0.342 Botulinum toxin, N (%) 78 (5.1) 34 (2.8) 44 (12.8) < 0.0001 BMI body mass index, AHT arterial hypertension, COPD chronic obstructive pulmonary disease, CRF chronic renal failure, AAA​abdominal aor- tic aneurysm, ASA American Society of Anaesthesiologists physical status classification *EHS classification; **Slater NJ et al. [16] 13 1576 Hernia (2021) 25:1573–1580 and arterial hypertension was most frequent in ACS patients frequent was bowel resection (12%). ACS was the most (53.5%; P = 0.022). common technique (77.6%), and 78.8% of the operations The most frequent type of hernia originated in a previ- were performed at an AWU (Table 2). ous midline laparotomy (87.8%), with 65.9% of W3 class Types, position, and fixation of prostheses are shown according to the EHS classification [16]. A total of 31% of in Table 2. Only eight patients did not receive a mesh, patients had a previous repair, with mesh in 93.0% of cases, and 24.3% of cases were repaired using two meshes, more and 47.2% of patients were classified as having major com- frequently in posterior repair (P < 0.0001). When only a plexity [16]. PPP was used as prior therapy in 73 patients mesh was used, the preferred type was reticular polypro- (4.8%) and BT in 78 patients (5.1%). Hernias treated with pylene (90.1%), which was less frequently used in PCS ACS were larger, most frequently in the midline, and more (67.3%). Laminar biosynthetic and biological materials frequently received PPP. PCS hernias more frequently were anecdotally used (0.9%). In ACS, the preferred posi- underwent a previous repair with mesh and a pre-operative tion was onlay (51.2%); and in PCS, the preferred position therapy with botulinum toxin. was sublay (93.6%). Mesh fixation with a suture was the IH characteristics and comparisons are also displayed in more frequently used method (77.1%), and staplers and Table 1. glue were more frequently used in the ACS technique than Most of the operations were elective (96.9%), with a in the PCS technique. high frequency of a concurrent procedure, and the most Table 2  Characteristics of the operations and technique of repair N = 1536 ACS N = 1193 PCS N = 343 P Type of procedure Elective, N (%) 1489 (96.9) 1150 (96.4) 339 (98.8) 0.021 Urgent, N (%) 47 (3.1) 43 (2.8) 4 (0.3) Operative time, min, median (IQR) 150.0 (90.0–210.0) 135.0 (90.0–200.0) 170.0 (120.0–240.0) 0.032 Length of stay, days, median (IQR) 6.00 (4.00–8.00) 6.00 (4.00–8.00) 6.00 (4.00–8.00) 0.123 AWU*, N = 821 (%) 647 (78.8) 363 (74.4) 284 (85.3) < 0.0001 Associated procedures Bowel resection, N (%) 176 (11.5) 145 (12.2) 31 (9.0) 0.110 Panniculectomy, N (%) 122 (7.9) 90 (7.5) 32 (9.3) 0.281 Adhesiolysis, N (%) 53 (3.5) 46 (3.9) 7 (2.0) 0.105 Cholecystectomy, N (%) 39 (2.5) 33 (2.8) 6 (1.7) 0.291 Mesh removal, N (%) 40 (2.6) 30 (2.5) 10 (2.9) 0.681 Technical details Mesh type No mesh N (%) 8 (0.5) 7 (0.6) 1 (0.3) 0.503 Double mesh N (%) 372 (24.3) 226 (19.1) 146 (42.7) < 0.0001 Reticular N (%) 1041 (90.1) 909 (94.7) 132 (67.3) < 0.0001 Composite N (%) 104 (9.0) 45 (4.7) 59 (30.1) < 0.0001 Biosynthetic N (%) 5 (0.4) 1 (0.1) 4 (2.0) 0.027 Biologic N (%) 6 (0.5) 5 (0.5) 1 (0.5) 0.985 Mesh area, ­cm2 (SD) 763.4 (653.2) 785.9 (673.3) 556.3 (350.5) 0.001 Mesh position Inlay N (%) 30 (2.0) 27 (2.3) 3 (0.9) 0.100 Onlay N (%) 615 (40.2) 610 (51.4) 5 (1.5) < 0.0001 Retromuscular and preperitoneal N (%) 779 (51.0) 459 (38.7) 320 (93.6) < 0.0001 Intraperitoneal N (%) 94 (6.2) 81 (6.8) 13 (3.8) 0.40 Mesh fixation Staples N (%) 250 (17.1) 243 (21.7) 7 (2.0) < 0.0001 Suture N (%) 1137 (77.1) 856 (75.6) 281 (81.9) 0.015 Glue N (%) 367 (24.2) 312 (26.5) 55 (16.1) < 0.0001 *AWU​abdominal wall unit 13 Hernia (2021) 25:1573–1580 1577 Complications, including mortality (1.2%), were frequent Table 4  Multivariate analysis of risk factors for complications after both techniques (36.5%). The ACS technique was P OR 95% C.I related to a significantly higher incidence of wound infec- Low High tion (P = 0.05) and skin necrosis (P = 0.0001). Comparison by grade did not show any difference. More complex hernias BMI > 35 kg/m2 0.015 0.675 0.492 0.927 were correlated with an increased percentage of complica- COPD 0.000 0.527 0.376 0.739 tions (P < 0.0001) (Table 3). Longitudinal diameter > 10 cm 0.001 0.578 0.413 0.808 Significant factors leading to any type of postoperative Midline 0.005 0.531 0.340 0.827 complications in the multivariate analysis are shown in Parastomal 0.017 0.461 0.244 0.870 Table 4. Previous repair 0.038 0.754 0.578 0.985 A minimum follow-up of six months (median ASA III–IV 0.000 0.617 0.470 0.810 14.7 months) was completed in 590 cases (38.4%), and Bowel resection 0.003 0.510 0.326 0.798 the overall recurrence rate was 10.0% (N = 59) without any Simultaneous hernia repair 0.020 0.460 0.239 0.885 significant differences on comparing CSTs (ACS 10.8% vs. Premuscular repair 0.067 1.320 0.981 1.777 PCS 7.5%; P = 0.25). In univariate analysis, immunosup- No glue 0.006 0.659 0.489 0.886 pression (OR = 1.25; CI 0.97–1.61; P = 0.008), emergency Panniculectomy 0.013 0.579 0.375 0.892 repair (OR = 1.28; CI 0.94–1.74; P = 0.007), suture repair Intra-operative complications 0.000 0.138 0.055 0.347 (OR = 10.15; CI 7.95–12.97; P = 0.003), premuscular (onlay) repair (OR 1.05; CI 0.99–1.12), fixation without staples (OR = 2.35; CI 1.03–5.35; P = 0,03), no use of glue Discussion (OR = 2.23; CI 1.10–4.70; P = 0.02), postoperative com- plications (OR = 1.98; CI 1.03–1.16; P = 0.001), seroma To our knowledge, this is one of the largest studies of CST (OR = 1.11; CI 1.01–1.22; P = 0.005), SSO (OR = 1.13; CI for the treatment of IH. A previous larger study (2245 cases) 1.02–1.16; P = 0.004), and operation performed in a non- included all types of ventral hernia (primary and incisional) AWU (OR = 2.05; CI 1.05–4.00; P = 0.035) were related to [19]. The analysis of this series shows that CST is a com- a higher frequency. In the Cox multivariate analysis, non- plex operation, mostly performed in high-risk patients with AWU operation was the only factor significantly associated large major complex hernias, which frequently requires with recurrences (HR 4.903, CI 1.64–14.65; P = 0.004). associated procedures and has a high risk of complications. Table 3  Postoperative 30-day N = 1536 ACS N = 1193 PCS N = 343 P complications Overall, N (%) 560 (36.5) 421 (35.3) 139 (40.5) 0.076 Intra-operative N (%) 45 (2.9) 31 (2.6) 14 (4.1) 0.151 Clavien-Dindo grade Grade I 210 (13.7) 137 (11.5) 73 (21.3) Grade II 254 (16.5) 207 (17.4) 48 (14.0) Grade IIIA 37 (2.4) 33 (2.8) 4 (1.2) Grade IIIB 29 (1.9) 24 (2.0) 5 (1.4) Grade IV 11 (0.7) 4 (0.3) 7 (2.0) Grade V 18 (1.2) 16 (1.3) 2 (0.6) SSO, N (%) 419 (27.3) 320 (26.8) 99 (28.9) 0.455 Seroma, N (%) 228 (14.8) 168 (14.1) 60 (17.5) 0.117 Wound infection, N (%) 150 (9.8) 126 (10.6) 24 (7.0) 0.050 Wound haematoma, N (%) 94 (6.1) 68 (5.7) 26 (7.6) 0.200 Skin necrosis, N (%) 53 (3.5) 52 (4.4) 1 (0.1) < 0.0001 Reoperation, N (%) 41 (2.7) 30 (2.5) 11 (3.2) 0.483 Hernia complexity* Minor, N (%) 56 (24.0) 39 (22.3) 17 (29.3) Moderate, N (%) 175 (30.2) 136 (30.4) 39 (30.0) Major, N (%) 329 (45.3) 246 (43.1) 83 (53.5) *Slater NJ et al. [16] 13 1578 Hernia (2021) 25:1573–1580 Recurrences are comparable to those with the other tech- frequency of skin necrosis (related to the technical charac- niques [12], but when the operation is performed in an elec- teristics) and wound infections. Most of the other risk fac- tive setting, with a mesh and by an AWU, the rate of recur- tors that emerged from our analysis have been previously rences is lower. reported [16, 20–22]. Interestingly, most of them have been In our series, patients undergoing CST were an aged compiled by the complexity classification proposed by Slater population with a high proportion of obesity (30.3 kg/m2 et al. [16], and in our series, higher complexity was corre- average BMI) and other comorbidities; one-third of these lated with a higher rate of complications. Our data seem to patients were classified as ASA III or IV, which has been validate this system of classification to predict the develop- shown to contribute to worse outcomes. Our population was ment of complications in terms of the complexity grade. very similar to that in a previous series [10, 20–22]. The main factor related to less recurrences in the mul- It is striking that, of the total registered operations, 13.3% tivariate analysis was an operation performed in an AWU, needed a CST, while in the largest series, the published rate probably due to better selection of patients and technique, was 3.3% [19]. Considering the complexity of cases, 34% for surgeons with a high volume of complex cases and spe- of the hernias had a transverse diameter less than 10 cm, cially involved in abdominal wall reconstruction. The lack reaching 48% in the PCS cases; thus, the area of the defects of correlation between the BMI and recurrence is notewor- was less than that reported in other studies carried out in thy, since other authors have found an association [16, 21, specialized centers [9]. However, when we analyzed the her- 22]. An important appreciation is that age did not influence nias in relation to their complexity classification [16], 85% recurrences; thus, performing CST had a similar safety pro- of the patients had criteria of moderate or major complexity. file in accordance with previous reports [28]. This led us to presume that by using as isolated parameter of complexity, the dimensions of the hernia may be insuf- ficient to predict the need for a CST [10, 20, 23], and other Strengths and limitations factors related to the hernia or the patients should be con- sidered. Adequate knowledge of the degree of complexity In our opinion, this study provides a retrospective and com- is important to avoid the risk of over-treating low-complex prehensive review of patients undergoing IH repair using hernias using components separation. Our results suggest CST, and all patients’ treatment and follow-up were per- that the classification of complexity of Slater et al. [16] is formed prospectively and registered in the largest database more useful to predict accurately the need for a CST than of IH in Spain. The registry itself, as previously shown by the diameter of the defect. registries from other countries [29–31], confirms its use- Most of the operations were elective (96.9%), but the fulness for the collection and analysis of data that can be operations performed as emergencies presented a high pro- applied to the treatment of IHs. portion of complications (51% vs. 36%; P = 0.035), mortal- Nevertheless, we also acknowledge some weaknesses in ity (12.8% vs. 0.8%; P = 0.014), and recurrences (29.4 vs. our study. First, analysis and patient selection relied exclu- 9.4; P = 0.007), and a 51.7% vs. 20.2% (P < 0.0001) of the sively on the EVEREG database, with the inability to study operations were performed in a non-specialized unit. When the entire patient data recorded due to the lack of basic ele- the operations were performed in an AWU, there were fewer ments for analysis or errors in their compilation in some complications (66.7% vs. 28.6%; P = 0.04). These data con- cases. Furthermore, EVEREG is just a sample of reality, firm the risks of urgent IH surgery [24] and support the because our country does not have a universal registry like hypothesis that these techniques should be performed, if other countries, which may lead to biases related to the type possible, by specialized surgeons [13] or should be avoided, of patients and the hospitals that treat them and the data ana- particularly in higher risk situations, such as emergencies. lyzed has not been audited. To improve this, we are involved Mesh was used in 99% of the operations, as it has been in a project to audit the data on EVEREG registry (Clinical shown to reduce the recurrence rates [5–7]. A CST without Trials.gov ID: NCT03899012). Other potential problems are mesh was strongly related to recurrences (OR 10.15); this that many patients were excluded or lost to follow-up owing result, in our opinion, suggests that a non-mesh repair should to lack of a complete medical record favoring patients that be avoided in these patients, and if the conditions of surgery were more likely to follow-up, and the patient populations preclude the use of mesh, as in emergencies, CST should be might have intrinsic differences and factors predisposing to postponed. complex IH that we are not aware of. The low percentatge of A high rate of complications, as in a previous series [20, long-term follow-up is an issue of our Registry due to its vol- 26, 27], was observed. In a previous multivariate analysis untary nature and the lack of incentives. The implementation of the registry [12], CST itself was a risk factor for com- of reward mechanisms and the involvement of government plications. Overall complications were similar in ACS and institutions is necessary to improve this aspect. Finally, our PCS techniques. However, the ACS technique had a higher 13 Hernia (2021) 25:1573–1580 1579 research, has the same limitations in the interpretation of its adaptation, distribution and reproduction in any medium or format, results from other studies based on hernia registries [32]. as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate By contrast, patients operated with minimally invasive if changes were made. The images or other third party material in this surgery were not included. A previous study shows only a article are included in the article’s Creative Commons licence, unless 11.7% of all types of repairs with laparoscopy [11]. Thus, indicated otherwise in a credit line to the material. If material is not we need a national effort to increase the widespread of included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted minimally invasive techniques to achieve better results. In use, you will need to obtain permission directly from the copyright the future, we must determine if laparoscopy and robotics holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​ contributes to reducing the number of complications and org/​licen​ses/​by/4.​0/. recurrences as previously reported [33]. However, minimally invasive repair is very demanding and requires specialized units and surgeons for both laparoscopy and AWR. References 1. Deerenberg EB, Timmermans L, Hogerzeil DP, Slieker JC, Eilers PH, Jeekel J, Lange JF (2015) A systematic review of the surgical Conclusions treatment of large incisional hernia. Hernia 19:89–101 2. Hoffmann H, Köckerling F, Adolf D, Mayer F, Weyhe D, Reinpold AWR continues to be a challenge. While ACS and PCS W, Fortelny R, Kirchhoff P (2021) Analysis of 4,015 recurrent are effective methods for managing IH, they are complex incisional hernia repairs from the Herniamed registry: risk factors and outcomes. Hernia 25:61–75 surgical techniques with high frequency of complications. 3. Ramirez OM, Ruas E, Dellon AL (1990) “Components separa- Elective mesh repair and treatment in an AWU have better tion” method for closure of abdominal-wall defects: an anatomic recurrence outcomes, reinforcing the real need to improve and clinical study. Plast Reconstr Surg 86:519–526 the status of our patients, create specific abdominal wall sur- 4. Novitsky YW, Elliot HL, Orenstein SB, Rosen MJ (2012) Trans- versus abdominis muscle release: a novel approach to posterior gery units to treat complex hernias, and perform this skilled component separation during complex abdominal wall reconstruc- technique by dedicated surgeons whenever possible. tion. Am J Surg 204:709–716 5. Razavi SA, Desai KA, Thompson PW, Hart AM, Losken A (2018) Acknowledgements Silvia Martínez and Xavier Masramón. SAIL The impact of mesh reinforcement with components separation (Servicio de Asesoría a la Investigación y Logística); Silvia Glahn (B. for abdominal wall reconstruction. Am Surg 84:959–962 Braun). We thank LetPub (www.​letpub.​com) for its linguistic assis- 6. Kokotovic D, Bisgaard T, Helgstrand F (2016) Long-term recur- tance during the preparation of this manuscript. rence and complications associated with elective incisional hernia repair. JAMA 316:1575–1582 Funding Open Access funding provided thanks to the CRUE-CSIC 7. Sandvall BK, Suver DW, Said HK, Mathes DW, Neligan PC, Del- agreement with Springer Nature. B. Braun funds the cost of design and linger EP, Louie O (2016) Comparison of synthetic and biologic hosting of the EVEREG database. mesh in ventral hernia repair using components separation tech- nique. Ann Plast Surg 76:674–679 8. Aliotta RE, Gatherwright J, Krpata D, Rosenblatt S, Rosen M, Data availability The datasets analyzed during the current study are Gurunluoglu R (2019) Complex abdominal wall reconstruction, not publicly available due to contracts with the hospitals providing to harnessing the power of a specialized multidisciplinary team to the database. improve pain and quality of life. Hernia 23:205–215 9. Blair LJ, Cox TC, Huntington CR, Groene SA, Prasad T, Lincourt Declarations AE, Kercher KW, Heniford BT, Augenstein VA (2017) The effect of component separation technique on quality of life (QOL) and Conflict of interest JA Pereira, A Bravo, B Montcusí, P. Hernández, V. surgical outcomes in complex open ventral hernia repair (OVHR). Rodrigues and M. López-Cano declare no personal conflict of interest. Surg Endosc 31:3539–3546 10. Naran S, Shakir S, Shestak KC, Russavage JM, Nguyen VT (2018) Ethics approval The local ethics committee approved the study proto- Components separation for abdominal wall reconstruction in the col of EVEREG Registry (2012/4908/I). recalcitrant, high-comorbidity patient: a review of 311 single- surgeon cases (2018). Ann Plast Surg 80:262–267 Human and animal rights This article does not contain any studies 11. Pereira JA, López-Cano M, Hernández-Granados P, Feliu X, en with human participants or animals performed by any of the authors. representación del grupo EVEREG (2016) Initial results of the national registry of incisional Hernia. Cir Esp 94:595–602 Informed consent Informed consent was obtained from all individual 12. Pereira JA, Montcusí B, López-Cano M, Hernández-Granados participants included in the EVEREG Registry. P, Fresno de Prado L, Miembros del registro EVEREG (2018) Risk factors for bad results in the incisional hernia repair. Les- Consent for publication All authors have approved the manuscript and sons learned from the National Registry of Incisional Hernia meet the requirements for authorship. (EVEREG). Cir Esp 96:436–442 13. Pereira JA, Bravo-Salva A, Montcusí B, Pérez-Farre S, Fresno de Prado L, López-Cano M (2019) Incisional hernia recurrence after Open Access This article is licensed under a Creative Commons open elective repair: expertise in abdominal wall surgery matters. Attribution 4.0 International License, which permits use, sharing, BMC Surg 19:103 13 1580 Hernia (2021) 25:1573–1580 14. Obesity: preventing and managing the global epidemic. Report of 25. Torregrosa-Gallud A, Sancho Muriel J, Bueno-Lledó J, García a WHO consultation (2000) World Health Organ. Tech Rep Ser Pastor J, Iserte-Hernandez J, Bonafé-Diana S, Carreño-Sáenz 894:1–253 O, Carbonell-Tatay F (2017) Modified components separation 15. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Cham- technique: experience treating large, complex ventral hernias at a pault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, University Hospital. Hernia 21:601–608 Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Sim- 26. Nockolds CL, Hodde JP, Rooney PS (2014) Abdominal wall mermacher RK, Simons MP, Smietański M, Sommeling C, Tol- reconstruction with components separation and mesh reinforce- lens T, Vierendeels T, Kingsnorth A (2009) Classification of pri- ment in complex hernia repair. BMC Surg 14:25 mary and incisional abdominal wall hernias. Hernia 13:407–414 27. Maloney SR, Schlosser KA, Prasad T, Kasten KR, Gersin KS, 16. Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Colavita PD, Kercher KW, Augenstein VA, Heniford BT (2019) Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Twelve years of component separation technique in abdominal Towfigh S, van Geffen E, Conze J, van Goor H (2014) Criteria for wall reconstruction. Surgery 166:435–444 definition of a complex abdominal wall hernia. Hernia 18:7–17 28. Docimo S Jr, Bates A, Alteri M, Talamini M, Pryor A, Spaniolas 17. Ibarra-Hurtado TR, Nuño-Guzmán CM, Echegaray-Herrar JE, K (2020) Evaluation of the use of component separation in elderly Robles-Vélez E, González-Jaime JJ (2009) Use of botulinum toxin patients: results of a large cohort study with 30-day follow-up. type A before abdominal wall hernia reconstruction. World J Surg Hernia 24:503–507 33:2553–2556 29. Israelsson LA, Smedberg S, Montgomery A, Nordin P, Span- 18. Dindo D, Demartines N, Clavien PA (2004) Classification of sur- gen L (2006) Incisional hernia repair in Sweden 2002. Hernia gical complications: a new proposal with evaluation in a cohort 10:258–261 of 6336 patients and results of a survey. Ann Surg 240:205–213 30. Helgstrand F, Rosenberg J, Bay-Nielsen M, Friis-Andersen H, 19. Desai NK, Leitman IM, Mills C, Lavarias V, Lucido DL, Karpeh Wara P, Jorgensen LN, Kehlet H, Bisgaard T (2010) Establish- MS (2016) Open repair of large abdominal wall hernias with ment and initial experiences from the Danish ventral hernia data- and without components separation. An analysis from the ACS- base. Hernia 14:131–135 NSQIP database. Ann Med Surg 7:14–19 31. Bisgaard T, Kehlet H, Bay-Nielsen MB, Iversen MG, Wara P, 20. Ghazi B, Deigni O, Yezhelyev M, Losken A (2011) Current Rosenberg J, Friis-Andersen HF, Jorgensen LN (2009) Nationwide options in the management of complex abdominal wall defects. study of early outcomes after incisional hernia repair. Br J Surg Ann Plast Surg 66:488–492 96:1452–1457 21. Kaoutzanis C, Leichtle SW, Mouawad NJ, Welch KB, Lampman 32. Schwab R, Dietz UA, Menzel S, Wiegering A (2018) Pitfalls RM, Wahl WL, Cleary RK (2015) Risk factors for postoperative in interpretation of large registry data on hernia repair. Hernia wound infections and prolonged hospitalization after ventral/inci- 22(6):947–950. https://​doi.​org/​10.​1007/​s10029-​018-​1837-6 sional hernia repair. Hernia 19:113–123 33. Balla A, Alarcón I, Morales-Conde S (2020) Minimally invasive 22. Owei L, Swendiman RA, Kelz RR, Dempsey DT, Dumon KR component separation technique for large ventral hernia: which (2017) Impact of body mass index on open ventral hernia repair: is the best choice? A systematic literature review. Surg Endosc a retrospective review. Surgery 162:1320–1329 34(1):14–30 23. Helgstrand F, Rosenberg J, Kehlet H, Jorgensen LN, Bisgaard T (2013) Nationwide prospective study of outcomes after elective Publisher’s Note Springer Nature remains neutral with regard to incisional hernia repair. J Am Coll Surg 216:217–228 jurisdictional claims in published maps and institutional affiliations. 24. Martínez-Serrano MA, Pereira JA, Sancho JJ, López-Cano M, Bombuy E, Hidalgo J, the Study Group of Abdominal Hernia Surgery of the Catalan Society of Surgery (2010) Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement. Langenbecks Arch Surg 395:551–556 13