Study Backs Benefits of Component Separation: Less Operative Recurrence

Dana Telem, MD

When The New York Times ran an October 2023 article highlighting the risks and potential overuse of component separation to treat otherwise simple hernias, surgeons like Dana A. Telem, MD, began to worry—not only about patient safety and the fact that some of her peers were performing a complex technique without proper training but also about the portrayal of a procedure that, in the hands of a skilled and well-trained surgeon, had the potential to make a significant positive impact on patient well-being.

Fast-forward 15 months, and Dr. Telem and colleagues have published a study cementing the long-term benefits of component separation on operative recurrence after ventral hernia repair (JAMA Surg 2025;160[1]:10-18). Of note, the study also found that surgeon volume had only a minor influence on operative recurrence rates.

“When the Times article came out, it really blew things up in surgery a little bit by talking about the technique in a negative way and how certain surgeons have been hurting patients by doing unscrupulous things,” said Dr. Telem, the Lazar J. Greenfield Professor of Surgery at the University of Michigan Health, in Ann Arbor. “Hopefully this study will cast the procedure in a bit of a different light.”

As Dr. Telem explained, although component separation—typically used to facilitate midline closure of large or complex ventral hernias—has experienced a surge in popularity in recent years, little research has examined the incidence of the procedure and long-term postoperative outcomes.

With that in mind, she and her colleagues examined 100% Medicare administrative claims data for 218,518 adult patients (mean age, 69.1 years; 58.5% women) who underwent elective inpatient ventral hernia repair between Jan. 1, 2007, and Dec. 31, 2021. The study’s primary outcomes were the incidence of component separation over time and operative recurrence rates up to 10 years after surgery for hernia repairs with and without component separation. As a secondary end point, the researchers stratified operative recurrence rates according to surgeon volume.

“Medicare data isn’t perfect, because we don’t have any information on hernia size and other things, but it still gives us some good population trends,” Dr. Telem told General Surgery News. “But what’s most important is you can get really long-term outcome data that we can’t get from other sources.”

As Dr. Telem reported, 23,768 individuals in the original cohort underwent component separation. Those patients were slightly younger, more likely to be male, more likely to have comorbidities (including obesity) and more likely to undergo open operations and procedures with mesh than their counterparts who did not undergo component separation. Among these, it was found that the proportional use of component separation increased from 1.6% of all inpatient hernia repairs in 2007 (279 patients) to 21.4% in 2021 (1,569 patients).

Over a median follow-up period of 7.2 years (IQR, 2.7-10 years) after the index hernia surgery, the 10-year adjusted operative recurrence rate after component separation was found to be 11.2% among individuals who underwent component separation (95% CI, 11.0%-11.3%), significantly lower than the 12.9% rate among those who had hernia repairs without component separation (95% CI, 12.8%-13.0%; P=0.003).

But what proved most interesting for Dr. Telem was the study’s second finding. Indeed, while operative recurrence was significantly lower for the top 5% of surgeons by component separation volume (11.9%; 95% CI, 11.8%-12.1%) than it was for the bottom 95% of surgeons by volume (13.6%; 95% CI, 13.4%-13.7%; P=0.004), she did not find this difference to be particularly clinically relevant.

“There’s a little bit of an advantage, but not the one that necessarily you think there would be,” she said. “When you think about [it], the push to regionalize the care of more complex cases to higher-volume surgeons isn’t really borne out by this study.

“I think it’s interesting to think of this in the context of some people wanting to create hernia centers of excellence,” she continued. “Do we really need them? Because volume doesn’t really seem to be a great proxy for outcomes, and most procedures are being done by lower-volume surgeons.”

The results also question the use of surgeon volume as a proxy for surgical excellence, Dr. Telem continued. “If you can’t necessarily use volume, then we need to find other ways to determine surgical competency,” she discussed. “And I think that has significant implications as we think about training moving forward and creating artificial limitations on a procedure that the data just don’t support.

“Just because you’re the surgeon who does the most, doesn’t necessarily mean you’re better,” she added.

Matthew I. Goldblatt, MD, a professor of surgery at the Medical College of Wisconsin, in Milwaukee, said he found the results of the trial encouraging. “I think many of us who perform these complex hernia repairs would not be able to get them done without doing a component separation,” he said. “I know there’s been a bit of a push to try to do fewer component separations, but in some of the bigger hernias they are necessary. It’s good to see that there is an improvement in outcomes with the component separation patients.”

That said, Dr. Goldblatt disagreed with Dr. Telem in that he believes case volume to be a reasonable surrogate of surgical competence under most circumstances.

“In theory, the high-volume surgeons get a lot of the toughest cases,” he said. “Personally, I know that the majority of complex hernia repairs I perform are referred to me by other surgeons in the community and around the state of Wisconsin who may not feel comfortable taking them on. Perhaps the people who do fewer hernia repairs do the easier ones as well. There is a selection bias where the people who do the highest volumes also do the most difficult hernias and still have better outcomes; then that’s actually a major difference.”

Dr. Goldblatt reported financial relationships with Corza Medica, Intuitive, Medtronic and W.L. Gore Inc. Dr. Telem reported no relevant financial disclosures.