in the era of aging population and increasing obesity , the repair of incisional hernia has become a major concern .
when the size of incisional hernia is too large , it could be insufficient , and occasionally , even impossible to be repaired with mesh . despite the advancement of surgical techniques and prosthetics , repair of large midline incisional hernia and reconstruction of
ramirez et al .   invented a novel technique for reconstruction of abdominal wall defect without using prosthesis in 1990 .
basically , this technique was performed by enlargement of the abdominal wall surface with separating the space without vessels and nerves , and advancement of the muscular layers .
de vries reilingh ts et al .   further developed this technique by adding separation of the posterior rectus sheath from the rectus abdominis muscle , and reported the " component separation technique ( cst ) " in 2003 . through our successful experience ,
we intended to introduce cst for repair of a large ( 35  20 cm ) midline incisional hernia .
multiple small bowel and mesenteric injuries , liver laceration , and right diaphragmatic laceration were identified .
laceration wounds at liver and right diaphragm were repaired , and segmental resection of injured small bowel with mesenteries were performed .
the abdominal wall was closed in whole layer with non - absorbable interrupted 1 - 0 polyester ( green polyester ( r ) , ailee , busan , korea ) sutures due to wound contamination .
the post - operative course was uneventful , and the patient was transferred to department of neuro - psychiatry on 8th post - operative day , for evaluation and treatment of post - traumatic stress disorder .
abdominal wall sutures were removed on 21st post - operative day , and no abnormal finding on abdominal wound was identified .
when the patient visited outpatient clinic for follow - up on 3rd post - operative month , a large incisional hernia , 35  20 cm in size , was detected .
after midline skin incision , large hernia sac was taken down , and adhesions between peritoneum and small bowels were meticulously dissected until rectus muscles were entirely exposed .
the abdominal skin was elevated at midline and was dissected from anterior surface of rectus sheath to exposure of external abdominal oblique muscles by 5 cm . at 2 cm lateral from rectus sheath ,
the aponeurosis of external abdominal oblique muscle was longitudinally transected , superiorly to the level of costal margin , and inferiorly to the symphysis pubis .
the avascular plane between external abdominal oblique muscle and internal abdominal oblique muscle was separated . by releasing bilateral external abdominal oblique muscle attachments ,
a gap of 7 to 10 cm between rectus abdominis muscles could be bridged at waist line .
the posterior rectus sheath was released with further longitudinal relaxing incision , and additional approximation of rectus abdominis muscle by 2 to 4 cm could be attained .
tension free closure of the abdominal wall defect was achieved using polydioxanone continuous running sutures ( fig .
two closed suction drains were placed at subcutaneous space , and the skin was approximated with 2 - 0 interrupted nylon sutures .
the patients recovered well without significant problems , except for minor periumbilical wound infection ( about 4 cm ) which was detected on 7th post - operative day .
there was no evidence of fascial infection , and the skin was re - approximated after 3 days of wound dressing .
the patient discharged on 25th post - operative day , and has no further problems at current 17th post - operative month of follow - up .
the incidence of incisional hernia after abdominal surgery is reported as 9 to 19% in other series .
burger et al .   estimated that 4% of patients after laparotomy , in general , needed additional surgical repair of incisional hernia .
the reported recurrence rate of incisional hernia is 33.3% for suture repair and 16.4% for mesh repair . due to high recurrence rate after suture repair , burger et al
.   postulated that mesh repair ( prolene , ethicon , amersfoort , the netherlands ; marlex , bard benelux , nieuwegein , the netherlands ) was superior to suture repair ( prolene no.1 , ethicon ) in their prospective randomized controlled trials .
mesh repair has reduced the recurrence rate of incisional hernia , however , predisposed to further complications   which attribute to lack of evidence for safety and long - term reliability of prosthetic materials , and consequently , only about 52% of current surgeons use mesh for incisional hernia repair . since first introduced in 1990 , outcomes of cst has been continuously reported .
it can be used in reconstruction of a large , complex , and contaminated abdominal wall defects with autologous innervated and vascularized tissue .
.   reported relatively high rates of wound complication ( 12 to 67% ) including hematoma , seroma , skin necrosis , and infection , which was compared to 12 to 27% of mesh repair .
since the skin and subcutaneous tissue need to be mobilized over a large area , long operative time and excessive dissection might predispose to the above - mentioned wound complications .
we considered cst for our patient with huge abdominal wall defect , instead of mesh repair , for following reasons .
first , we concerned about tensile strength when several combined meshes were used to cover the whole defect , and intestinal erosion or adhesion due to direct contact with the mesh .
second , mesh shrinkage during wound contraction could lead to infection , fistula formation , and ultimately , mesh removal .
the patient could not afford to pay expensive cost of several meshes , and furthermore , when mesh infection did occur , prolonged antibiotics treatment and length of hospital stay could result in distress to our patient .
cst , in general , has advantages in patient with large incisional hernia , since both the patient and surgeon are relatively free from concerns about mesh infection , recurrence , wound pain , and cost problem .
long operative time and risk of wound complication due to excessive dissection should be considered simultaneously .
it could be an alternative option in complicated situations , and in accordance with heterogenic study results , various risk factors and associated conditions need to be estimated individually . in our conclusion ,
relative risks and benefits need to be determined when considering cst as a treatment option .
 repairing large incisional hernia with abdominal wall reconstruction is a technically challenging problem for surgeons . 
 we report our experience of large midline incisional hernia which was repaired successfully with components separation technique . a patient with incisional hernia , 35  20 cm in size , underwent operation following standard components separation technique . 
 the aponeurosis of the external abdominal oblique muscle was longitudinally transected from the rectus sheath , and the external abdominal oblique muscle was separated from the internal abdominal oblique muscle . with further separation of the posterior rectus sheath from the rectus abdominis muscle , closure of the abdominal wall was attained without tension . 
 the post - operative course was uneventful with minor wound seroma . 
 the patient discharged safely , and no further complication in terms of recurrence and wound problem has occurred . 
 components separation technique could be a possible and effective treatment option for repair of large abdominal wall defect . 
INTRODUCTION
CASE REPORT
DISCUSSION