More than 350 000 ventral hernia repairs are performed annually in the US. Recurrence rates of 40% to 70% have been reported at 5 years¹ translating to an increased need for subsequent surgery.² Component separation, which involves the release of abdominal wall myofascial layers and the medialization of the rectus complex, has been proposed as a technique to reduce recurrence.³

The study by Fry et al⁴ in this issue interrogated data from a national cohort of 218 518 Medicare beneficiaries who underwent ventral hernia repair with and without component separation with a median (IQR) follow-up time of 7.2 (2.7-10) years. At 10 years, the cumulative operative recurrence rates for patients who had component separation were slightly, but statistically significantly, lower at 11.2% (95% CI, 11.0%-11.3%) compared with 12.9% (95% CI, 12.8%-13%) for those who did not undergo component separation.

While these data suggest that component separation should be considered as a part of ventral hernia repair, the study outcomes need to be considered in the context of the study design using secondary data primarily collected for administrative and payment purposes.

The study included all anterior abdominal wall hernias coded in claims as ventral, incisional, umbilical, or epigastric hernia repair. While attempts were made to exclude repairs of recurrent hernias, it did not fully account for hernia size or mesh characteristics, which affect recurrent rates. Recurrence rates are known to be higher in incisional vs primary hernia,² true ventral or incisional hernia rather than an umbilical hernia,² wider hernias,¹ and those using absorbable mesh.^1,3 Inability to adjust for these factors in the analysis is a major limitation of this study.

Notably, the use of mesh was substantially lower in repairs performed without component separation (83.4% vs 65.5%). This is contrary to a substantial body of evidence confirming lower recurrence rates for repairs with permanent mesh compared with suture only, even for umbilical hernias.^1,2,5,6 This raises the possibility that mesh use, rather than component separation itself, may have contributed to the differences in operative recurrences.

Studies based on administrative and payment data are limited by the range of available discharge coding as well as inherent bias introduced when better payment is attached to specific codes.⁷ Nevertheless, these types of studies provide important insight into issues that warrant further investigation. The authors rightly acknowledge this and suggest that collaboration with purposeful hernia registries would provide more surety that these statistically significant differences are also clinically significant.

Corresponding Author: Wendy A. Brown, PhD, Department of Surgery, School of Translational Medicine, Monash University, Alfred Health, 99 Commercial Rd, Alfred Centre, Level 6, Melbourne, VIC 3004, Australia (wendy.brown@monash.edu).

Published Online: November 13, 2024. doi:10.1001/jamasurg.2024.5068

Conflict of Interest Disclosures: Dr Brown reported grants to their institution from Johnson and Johnson, Medtronic, WL Gore, Australian Commonwealth, and Applied Medical; trial funding from Novo Nordisk; and speaking and/or advisory board fees from Novo Nordisk, Eli Lilly, Merck Sharpe and Dohme, Pfizer, WL Gore, and Johnson and Johnson. No other disclosures were reported.