SPECIAL TOPIC

On the Origins of Components Separation

Eric G. Halvorson, M.D.
Chapel Hill, N.C.

Summary: The method of abdominal hernia repair known as components separation, described by Ramirez et al. in 1990, has enjoyed widespread popularity because of the sound anatomical principles it uses and most importantly the clinical success of the procedure. Although the authors who described this technique made no proprietary claims and did not discuss the history of abdominal hernia repair, they have certainly been credited with the development of this procedure. With this article, the author hopes to place components separation in historical perspective, and give credit to Donald Herron Young, who published the concept of external oblique relaxing incisions for repair of epigastric hernias in 1961. Born in Canada, Young studied and worked as a surgeon in England for most of his life. A biographical sketch is included. (Plast. Reconstr. Surg. 124: 1545, 2009.)

ince its description in 1990,1 the components separation technique for repair of ventral hernia has enjoyed widespread popularity. Based on sound anatomical principles, this creative method has greatly improved our ability to close complex ventral hernias. The surgeons who developed, described, and popularized components separation should be recognized for their major contribution to plastic surgery and for improving the lives of so many patients. Perhaps more than any other subspecialty in surgery, our literature is replete with descriptions of surgical technique and, as with every field of study, it is not infrequent that a new method has either been described before or is based on previous experience. In their articles on components separation, Ramirez et al. made no proprietary claims on the technique and did not discuss the history of abdominal wall hernia repair. In fact, the procedure we now call components separation is part of a rich history of abdominal hernia repair that began in the 1920s,25 and an operation with some similarity to one performed today was described in the early 1960s.6

tral hernias developed in the later part of the nineteenth century, as incisions for celiotomy became longer. Early efforts at primary closure of incisional hernias were prone to failure because of tension, poor suture materials, and inadequate prostheses. Subsequently, a number of techniques involving lateral relaxing incisions were described. As early as 1916,3 Charles L. Gibson, a surgeon to

EARLY EFFORTS IN ABDOMINAL HERNIORRHAPHY

Major intraabdominal procedures were possible only after the advent of general anesthesia in 1846. Thus, it makes sense that the repair of venFrom the Division of Plastic and Reconstructive Surgery, University of North Carolina. Received for publication February 21, 2009; accepted May 27, 2009. Copyright 2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181b98ab8
Fig. 1. Gibsons technique from 1916 for plastic repair of the abdominal wall involving relaxing incisions in the lateral anterior rectus sheath. (From Gibson CL. Post-operative intestinal obstruction. Ann Surg. 1916;63:442 451.)

Disclosure: The author has no financial interest to declare in relation to the content of this article.

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the First Cornell Division at The New York Hospital, and one of the first to recognize the difference between paralytic and mechanical postoperative intestinal obstruction, suggested a method for plastic repair of the abdominal wall that involved relaxing incisions in the lateral anterior rectus sheath (Fig. 1). Gibson later published an article in 1920 further describing this technique and reported eight successful cases.4 In 1929, C. F. Dixon modified Gibsons method and instead released the anterior rectus sheath 0.5 cm from its medial border bilaterally, turning over and opposing these fascial flaps in the midline (Fig. 2).5 It was not until the early 1960s that a more sophisticated extension of these techniques was described by Canadian-born Donald H. Young, consultant surgeon at the Warrington Infirmary in England.6 Young recognized the earlier efforts of Gibson and others, who relied on anterior rectus sheath fascial flaps for closure of the midline defect. The method of repair he proposed was based on two principles: (1) the hernia is caused by lateral retraction of the rectus muscles by the

Fig. 2. Dixons 1929 modification of Gibsons technique, releasing the anterior rectus sheath 0.5 cm from its medial border bilaterally, turning over and opposing the fascial flaps in the midline. (From Dixon CF. Repair of incisional hernia. Surg Gynecol Obstet. 1929;48:700.)

Fig. 3. Youngs technique for epigastric hernia repair presented in 1961, separating the transversalis/internal oblique/rectus unit from the external oblique, similar in principletocomponentsseparation.(ReprintedfromYoungD.Repairofepigastricincisional hernia. Br J Surg. 1961;48:514 516, with permission from John Wiley & Sons Ltd.)

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joined anterior and posterior sheaths rather than a defect of the muscle, and (2) just as releasing a curtain loop allows a curtain to fall straight, so muscle, if unimpeded, tends to lie in a straight line. A vertical incision through the external oblique aponeurosis, near the lateral border of the rectus muscle, thus releases the rectus sheath, allowing the rectus muscle to move easily in or near to the midline . . ..6 rating the anterior and posterior rectus sheaths. Next, the lateral border [of the rectus sheath] is incised a fingers breadth medial to the costal margin in the upper epigastrium and the same distance from the lateral edge of the rectus muscle in the lower epigastrium (Fig. 3). Although components separation involves a relaxing incision through the external oblique aponeurosis lateral to the lateral edge of the rectus sheath (Fig. 4), the critical maneuver (releasing the external oblique aponeurosis from the anterior rectus sheath) is the same. The redundant peritoneum is plicated and reduced under a posterior rectus sheath closure, and the anterior sheaths are approximated with figure-of-eight sutures. An important difference between Youngs technique and that described by Ramirez et al. is that the later surgeons

YOUNGS TECHNIQUE
Describing his operation, Young provides a step-by-step description of what seems like a modern hernia repair with components separation. Old scar tissue is excised, cutaneous flaps are elevated, and the medial borders of the rectus muscles are identified. At this point, he advises sepa-

Fig. 4. Cross-sectional diagram of components separation. (Reprinted from Ramirez OM, Ruas E, Dellon AL. Components separation method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg. 1990;86:519.)

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undermined the external oblique muscle to allow further advancement of the rectus abdominis/internal oblique/transversalis complex, and to permit increased mobility of the external oblique/skin composite flap. Young presented a series of 15 patients (12 men), with a median age of 53 years (range, 37 to 69 years), in whom he used this technique for epigastric hernia repair, with only one recurrence at a median follow-up of 3.6 years (range, 4 months to 10 years).6 The recurrence, he believed, was secondary to wound infection. Most patients in the series had prior cholecystectomy or wound infection following partial gastrectomy. Fifteen years later, James Maguire reported and analyzed Youngs experience with 32 cases.7 He reported six recurrences, five caused by hematoma and/or wound infection and one related to obesity and chronic bronchitis. Two of these recurrences were repaired again successfully. Five patients required repeat laparotomy for other indications and, of these, only one recurred because of wound infection. Young initially questioned whether the releasing incision would result in lateral weakness and subsequent hernia formation; however, in the larger series, this was not noted. The overall recurrence rate, including both series of patients, was seven of 43 (16 percent), which compared favorably with the literature then as it does today, although one must consider the fact that his patients had varied problems and the length of follow-up was short.

Fig. 5. Donald Herron Young on graduating from Queens University School of Medicine in 1930 (with permission from Marjorie Young).

A TRANSATLANTIC CAREER
Born in 1906 in New Liskeard, northern Ontario, Donald Herron Young was educated at Queens University in Kingston, Ontario. After graduating from medical school in 1930 (Fig. 5), Young traveled to England to obtain further medical education in London and Edinburgh.8 10 He received his F.R.C.S.(Ed.) in 1932, and then worked in Scotland and England until 1939.10 In the early years of World War II, Young enlisted as a major in the British Armys Royal Army Medical Corps. He was sent to Egypt in 1940, and later worked in hospitals on the battlefields of Europe. Three weeks after D-Day, he helped set up a 1200bed hospital on the road to Bayonne, where he performed over 200 operations in 14 days. He received the Order of the British Empire in 1944 for his role in treating more than 5000 wounded soldiers at the Battle of Falaise Gap.8 10 After the war, Young returned to his adopted home and in 1948 began practice at Warrington Infirmary, where he remained until his retire-

ment in 1971. Perhaps his most significant contribution to medicine was his description of the association between obstructive epididymitis and lung disease, now known as Young syndrome. He later returned to Canada, although his retirement from surgery did not keep him away from clinical medicine. From 1974 to 1976, Young worked for Cunard, and served as principal medical officer for the first around-theworld cruise of the Queen Elizabeth II. In 1977, he started work as an emergency room physician at Grace Hospital in Windsor, Ontario, and later he worked as a general practitioner before truly retiring in 1994 at age 88.8 10 Young had been a member of the International Wine and Food Society since 1947. A selfdescribed offal cook and walking stomach, Young enjoyed wine, cooking, and trying new foods (Fig. 6).10 When asked about the secret to a long life, he credited taking a glass of red wine daily, preferably Portuguese.8,10 Young died in Windsor of congestive heart failure on November 7, 2002, at age 96. He is survived by his wife Marjorie, three children, five grandchildren, and 13 great-grandchildren.10

COMPONENTS SEPARATION IN HISTORICAL CONTEXT

The patients described by Ramirez and colleagues in their landmark article in this Journal

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oblique muscle, which Young did not perform. Nevertheless, Donald Herron Young deserves credit for contributing the concept of external oblique relaxing incisions as described and for providing an innovative step on the path to modern abdominal wall reconstruction.
Eric G. Halvorson, M.D. Division of Plastic and Reconstructive Surgery University of North Carolina Chapel Hill, N.C. 27599-7195 eric_halvorson@med.unc.edu

REFERENCES
1. Ramirez OM, Ruas E, Dellon AL. Components separation method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg. 1990;86:519526. 2. Munson JL. Recurrent hernias of the abdominal wall. Probl Gen Surg. 1985;2:589. 3. Gibson CL. Post-operative intestinal obstruction. Ann Surg. 1916;63:442451. 4. Gibson CL. Operation for cure of large ventral hernia. Ann Surg. 1920;72:214217. 5. Dixon CF. Repair of incisional hernia. Surg Gynecol Obstet. 1929;48:700. 6. Young D. Repair of epigastric incisional hernia. Br J Surg. 1961;48:514516. 7. Maguire J, Young D. Repair of epigastric incisional hernia. Br J Surg. 1976;63:125127. 8. This Is Cheshire. Available at: http://archive.thisischeshire. co.uk. Accessed October 27, 2008. 9. Obituary. Br Med J. 2003;326:226. 10. Young M. Personal communication. 2008.

Fig. 6. Donald Herron Young (1906 to 2002) on his 90th birthday (used with permission from Marjorie Young).

had significant abdominal wall defects with loss of domainmost likely a far greater problem than the epigastric hernias Young treated. Skin grafting the intestines, not uncommon in the modern era of damage control surgery, adds to the complexity of subsequent abdominal wall repair. Ramirez et al. also described undermining the external

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