Case Report: Combined posterior and anterior compartment separation in giant incisional hernia repair: balancing feasibility and postoperative complications.

Introduction: The surgical management of giant incisional hernias remains a challenge, particularly in cases involving extensive defects and altered abdominal wall anatomy. The Transverse Abdominis Release (TAR) technique, particularly the Madrid modification, has emerged as a preferred approach for posterior compartment separation, allowing for wide medial mobilization while preserving neurovascular integrity. While anterior component separation (ACS) can further facilitate closure, it is associated with significant postoperative complications, including bulging, herniation, wound dehiscence, and core instability, making its use controversial. This case underscores the importance of proper pre-/post-operative management and surgical technique to avoid further complications. Case report: A 74-year-old male with a history of ruptured abdominal aortic aneurysm repair presented with a giant midline incisional hernia, with a defect measuring 17.5 cm in width, containing the left lobe of the liver and intestinal loops. Preoperative botulinum toxin injections were administered under ultrasonographic guidance, resulting in a 2.5 cm reduction in the fascial defect. A posterior approach was prioritized, utilizing Transverse Abdominis Release (TAR) with PTFE mesh reinforcement. Due to the persistent tension on the anterior sheath, limited anterior compartment separation was performed, but only to the extent necessary, given its association with high morbidity. Results: The patient had an uneventful postoperative recovery, with drain removal on day five and discharge on day eight. A minor seroma at the right costal margin was successfully managed with aspiration. Importantly, by prioritizing posterior compartment separation over extensive anterior release, we minimized the risks of wound-related complications. At 12-month follow-up, no recurrence or major complications were observed. Conclusions: This case highlights the superior role of posterior compartment separation (TAR) in achieving durable and tension-free closure of giant incisional hernias, particularly in complex cases following major vascular surgeries. Although anterior component separation remains an option, its routine use should be reconsidered due to the increased risk of complications. This case reinforces the necessity of a tailored, multidisciplinary approach, emphasizing posterior reinforcement over anterior techniques to optimize patient outcomes.