First Description of Intermediate Component Separation: A Novel Compartment-Preserving Technique for Medium and Large Incisional Hernia Repair

Complex incisional hernia repair requires effective abdominal wall reconstruction while minimizing anatomical disruption and postoperative complications.We describe a novel compartment-preserving technique, intermediate component separation (ICS), designed for medium-to-large defects.ICS provides broad prosthetic intermuscular coverage while preserving the functional core anatomy, avoiding entry into the peritoneal cavity, and eliminating the risk of neurovascular bundle injury.In this single-center case report, a 65-year-old man presented with a giant midline incisional hernia measuring 16 cm × 25 cm, which developed following multiple open necrosectomies and debridements for severe necrotizing pancreatitis.A subfascial plane was developed bilaterally between the anterior rectus sheath and the rectus abdominis muscle.An incision in the anterior sheath, placed 5 mm medial and parallel to its lateral border, provided direct access to the avascular intermuscular space between the external and internal oblique muscles.Extensive lateral dissection created a continuous subfascial/interoblique compartment capable of accommodating a 45 cm × 30 cm mesh.Anatomical reconstruction of the EIT ambivium was achieved by suturing both cut edges of the anterior lamina of the internal oblique aponeurosis directly to the mesh.Midline restoration was completed through posterior layer suturing, approximation of the rectus muscles, and closure of the anterior sheath using the small-bites technique.The 90-day postoperative follow-up was uneventful.By remaining beneath the anterior rectus sheath and avoiding entry into the peritoneal cavity, ICS is intended to minimize the risk of visceral adhesions and subcutaneous seroma or hematoma formation.The risk of bleeding is limited to minor anterior perforators, while the deep inferior epigastric vessels remain intact.This novel procedure represents a potentially biomechanically sound, compartment-preserving approach to the reconstruction of medium-to-large incisional hernias.