I am sure once in a while you stumble into a large defect hernia that fails to all the conventional repair.
Typically, these hernias have huge lateral displacement of the rectus abdominis and a consequent contraction thus making it impossible to reinforce the midline or perform safe mesh placement. Add to it the collagen weakness and an obese patient, and the possibility of failure looms large.
These hernias would not be served well with a laparoscopic hernioplasty because of a high failure rate and mesh expulsion. Neither would an open onlay hernioplasty serve due to high wound complications. Retromuscular Stoppa repair may bridge the defect but is unlikely to approximate the midline.
In these circumstances a posterior component separation technique with transversus abdominis release (TAR) would be a great alternative. The surgery has become increasingly popular in recent times due to its efficacy and decreased wound complication rate.
Here is how we do it!