The available evidence regarding the sequential performance of gastrointestinal tract restoration and abdominal wall reconstruction in two surgical stages during a single hospitalization is limited and is based primarily on case series. In this study, we present our experience with the aim of describing the outcomes obtained in the repair of complex abdominal wall defects and the restoration of intestinal continuity using a two-stage approach within the same hospital stay. Case series of patients who underwent elective surgery for gastrointestinal tract restoration, followed by abdominal wall reconstruction in a second surgical stage during the same hospitalization. Medical records of procedures performed between 2018 and 2023 were reviewed. All interventions were carried out electively by a multidisciplinary team involving the abdominal wall surgery group and colorectal surgery. A total of 30 patients were included. Both surgical procedures were completed in 73% of cases, with a mean interval of 6.3 days between the two surgeries. In 26% of patients, it was not possible to complete both procedures; the most frequent causes were anastomotic leakage and surgical site infection, each occurring in 9% of cases. The mean length of hospital stay was 14 days. The most common complications were postoperative ileus, anastomotic leakage, intestinal perforation, and deep surgical site infection. Although concomitant surgery is associated with a higher risk of complications particularly in the setting of complex hernias-in appropriately selected patients, sequential procedures performed during the same hospitalization can achieve favorable outcomes, especially in stoma reversal. The implementation of prehabilitation programs and the adoption of shared decision-making models are essential to optimize outcomes and reduce associated morbidity.
Robotic-assisted procedures in hernia surgery are highly standardized, whereas the distance between the ports and the target organ is of critical importance. To date, anthropometric data regarding the distance from the umbilicus to the symphysis and the Abdominal Elevation Angle (AEA) are lacking, both of which may be relevant for preoperative estimation of procedural difficulty and for the standardization of the surgical technique. This study prospectively evaluated anthropometric abdominal wall parameters and their influence on procedural difficulty in robotic-assisted groin hernia repair. Abdominal wall elasticity was assessed by measuring xiphopubic, xiphoumbilical, umbilicopubic, and transversal distances before and after pneumoperitoneum at 12 mmHg. The abdominal elevation angle (AEA) was measured photographically and categorized as narrow (<23.8°), normal (23.9°-40.0°), or wide (>40.1°). Intraoperative anatomical features including intra-abdominal fat, peritoneal thickness, and adhesions were recorded using Likert scales. Sixty-eight consecutive patients (61 male, 7 female; mean age 65 years, mean BMI 25.3 kg/m2) undergoing elective robotic-assisted groin hernia repair were included between July 2020 and April 2021. A total of 96 hernia sides were operated, including 28 bilateral and 8 recurrent cases. All distances increased significantly under pneumoperitoneum (p < 0.0001); the mean umbilicopubic distance with pneumoperitoneum was 16.35 cm. Mean longitudinal elasticity was 13.74% and transversal elasticity 11.73%, with no statistically significant difference between the two directions (p = 0.0844). Neither AEA nor BMI showed a statistically significant correlation with procedural difficulty. However, multiple linear regression analysis identified longitudinal abdominal wall elasticity as an independent predictor of procedural difficulty (p = 0.0139). Surgeon satisfaction with the procedural outcome was consistently high across all patient groups (mean score of 9.76/10), regardless of BMI or AEA. The mean umbilicopubic distance is less than the 20 cm proposed as distance-to-target in robot-assisted procedures; the umbilicus is not ideal for positioning of the endoscope port. Longitudinal abdominal wall elasticity appears to be a relevant factor influencing the difficulty of robot-assisted groin hernia repair, whereas BMI and AEA alone are insufficient predictors.
Hernia surgery requires precise technical skills to ensure successful patient outcomes. Traditional surgical training methods face challenges related to patient safety and limited operative exposure. Simulation training offers a risk-free platform to develop and refine surgical skills. This study evaluates the usefulness of simulation training for surgeons in hernia surgery. To assess the effectiveness of simulation training in enhancing the surgical skills and confidence of surgeons performing hernia repair. A prospective observational study was conducted with 44 surgical trainees undergoing simulation-based hernia surgery training. Technical skills and confidence levels were assessed before and after the training using standardized scoring systems. Participant feedback on the realism and applicability of simulation was also collected. Statistical analysis was performed using paired t-tests and chi-square tests. Technical skill scores improved from a mean of 58.3(SD 8.4) pretraining, with a mean difference of 21.4, (95% Cl: 18.9 to 24.5, p < 0.001, effect size [Cohen's d]∼2.1). Confidence scores increased from a mean of 4.2 (SD 1.5) to 7.8 (SD 1.2), with a mean difference of 3.6 (95% Cl: 3.1 to 4.3, p < 0.001, effect size [Cohen's d}∼2.3). Over 85% of participants agreed that the simulation was realistic and beneficial for skill enhancement. Ninety-five percent recommended simulation training as a regular part of surgical education. In the study Simulation training significantly improves the technical proficiency and confidence of surgeons in hernia surgery. Its incorporation into surgical training programs is recommended to enhance operative readiness but further multicentric studies are needed to validate their results.
To evaluate the completeness and reproducibility of technical reporting in contemporary abdominal wall hernia literature, and to assess the risk of misinterpretation when surgical techniques are classified based solely on titles and abstracts. A descriptive methodological analysis was conducted on original studies published between 2000 and November 2025 reporting abdominal wall hernia repair techniques. The unit of analysis was the surgical technique (surgical arm). Each technique was assessed across five predefined technical domains essential for reproducibility: surgical approach, hernia type, mesh position, mesh type, and fixation method. Techniques were classified as fully reproducible only when all domains were explicitly reported. A secondary analysis evaluated immediate interpretability based on title and abstract information. Terminological variability was explored by identifying distinct acronyms used for identical technical configurations. Two hundred articles comprising 290 surgical arms were analyzed. Surgical approach and hernia type were almost universally reported (≥99%). In contrast, mesh-related domains were inconsistently described, with mesh position and fixation reported in 81.4% and mesh type in 71.7% of arms. Overall, only 51.7% of techniques were fully reproducible based on full-text assessment. When limited to titles and abstracts, complete interpretability dropped to 3.4%, indicating a high risk of technical misclassification. Substantial terminological redundancy was observed, with up to 16 different acronyms used to describe identical technical configurations. Technical reporting in abdominal wall surgery is frequently incomplete, substantially limiting reproducibility, evidence synthesis, and reliable interpretation, particularly when relying on titles and abstracts. Excessive and inconsistent use of acronyms further amplifies ambiguity. The strict reliance on explicit reporting may overestimate non-reproducibility in real-world practice, and the study was not designed for exhaustive literature coverage. Adoption of structured, component-based reporting frameworks may represent a pragmatic pathway toward improving clarity, reproducibility, and methodological rigor in abdominal wall surgery.
The ongoing full-scale war in Ukraine has led to a significant increase in the number of patients undergoing damage control surgery following abdominal shrapnel wounds. These injuries are consistently associated with extensive soft tissue defects of the abdominal wall and secondary wound healing that frequently lead to the formation of large ventral hernias. In such patients, the primary goal is to provide the safest possible treatment and facilitate rapid recovery. The implementation of Enhanced Recovery After Surgery (ERAS) protocols has shown proven benefits in elective surgical settings. However, their use in ventral hernia repair remains insufficiently studied. The aim of this study is to evaluate the safety and effectiveness of adapted ERAS protocols in the management of ventral hernias after damage control surgery. This retrospective cohort study included 62 males divided into two groups based on the treatment period. Patients treated in the period before September 2024 received standard care (non-ERAS group), and those treated between September 2024 and April 2025 received treatment with implementation of ERAS protocols (ERAS group). All surgical procedures were performed using an open approach. Intraoperative and postoperative parameters were compared, including operative time, pain intensity, bowel function recovery, and length of hospital stay. The components of the adapted ERAS protocols included opioid-free pain management, the avoidance of intra-abdominal drains, early feeding, and early mobilisation. The implementation of modified ERAS protocols led to an improvement in clinical outcomes. The mean hospital stay was shorter in the ERAS group (12.07 compared with 16.47 days, p < 0.001). The timing of the first postoperative bowel movement differed significantly between the groups, with 93.3% of ERAS patients passing stool by postoperative day 2 compared with 15.6% in the non-ERAS group (p < 0.001). The mean Visual Analogue Scale score was lower in ERAS group on postoperative day 2 (3.83 compared with 5.47, p < 0.001). No increase in postoperative complications was observed in the ERAS group. The application of modified ERAS protocols was safe and effective for patients with ventral hernias after abdominal injuries and led to a reduced hospital stay, faster restoration of bowel function and decreased postoperative pain.
The Da Vinci Single Port (SP) robotic platform has recently been approved for general surgery in the European Union. However, its application in abdominal wall hernia repair remains largely unexplored. This study focuses on the development of a novel suprapubic single-port extraperitoneal approach (SP2 eTEP) for ventral hernia surgery. Following the IDEAL framework for introducing new surgical procedures, this study details the preclinical exploration and technical development of SP2eTEP using the Da Vinci SP system. The research included procedural development on human cadavers and skills training using a porcine model. Instrument reach and maneuverability were first evaluated using a silicone abdominal wall model. The model showed minimal reach loss between the 27 mm-SP metal cannula (29 cm straight, 27 cm articulated) and the collapsed SP small access port (28 cm straight, 26 cm articulated). Cadaveric sessions confirmed that the SP Access Port, placed suprapubically, allowed successful dissection in the preperitoneal, the retrorectus, and the subcutaneous planes. Additionally, bilateral component separation by transversus abdominis release was achieved using a bottom-up approach. The porcine model for inguinal hernia repair proved to be a suitable adjunct to simulator-based training for developing the necessary skills for subsequent clinical application. This preclinical (pre-IDEAL stage) exploration and procedural development demonstrate the feasibility of SP2 eTEP for ventral hernia repair with the Da Vinci SP platform. The findings support progression to clinical evaluation of this novel robotic approach for abdominal wall hernia repair.
Botulinum toxin A (BTA) is increasingly used for preoperative conditioning in patients with large or complex abdominal wall hernias. Injection into the lateral abdominal muscles 4-6 weeks before surgery induces temporary muscular relaxation and facilitates primary fascial closure, even in extensive defects (EHS W3), potentially reducing the need for component separation. While surgical outcomes are well documented, data on patient-reported experiences during the preoperative period remain limited. This retrospective study evaluated patient-reported symptoms between BTA injection and surgery and analyzed surgical results in this cohort. Between 2018 and 2024, 50 patients with complex abdominal wall hernias received preoperative BTA treatment followed by surgical repair. Demographic and surgical data, as well as BTA-related complications, were analyzed descriptively. A retrospective questionnaire assessed subjective experiences from injection to surgery, focusing on pain, physical changes (e.g., abdominal contour, trunk stability), and functional impairments (e.g., breathing, urination, defecation). The study included 31 men and 19 women (mean age 63.5 years, BMI 28 kg/m2). The mean transverse defect width was 12.06 cm, with an average area of 170.24 cm2. Thirty eight patients had W3 hernias according to EHS (≥10 cm), while BTA was also used in selected cases with smaller defects with complicating factors. No major BTA-related complications occurred; minor hematomas were observed. The mean interval between injection and surgery was 39 days. Primary fascial closure was achieved in all patients. Mesh reinforcement was used in all cases, most commonly in sublay position (n = 47). A transversus abdominis release was performed in 28 cases (52%), and anterior component separation in five. Twenty-two patients (44%) completed the questionnaire. Injection pain ranged from NRS 1-8, typically resolving within 1-3 days; three patients reported no pain. Eight noticed abdominal contour changes, and two reported altered trunk function. One patient experienced mild shortness of breath and another constipation; no urinary issues occurred. Preoperative BTA conditioning is a safe and effective adjunct for abdominal wall reconstruction in complex hernias. The treatment facilitates fascial closure, avoids major complications, and causes only minor, short-lived discomfort or functional limitations, maintaining overall quality of life in the preoperative phase.
Damage control surgery (DCS) has become the standard of care in the management of severe abdominal trauma, particularly in military settings. Although this approach improves survival, it frequently results in significant disruption of the anterior abdominal wall and subsequent development of large ventral hernias. Reconstruction in this context is technically challenging due to adhesions, distorted anatomy, and loss of normal tissue planes. While open retromuscular repair is generally preferred, it is often not feasible following DCS. Laparoscopic intraperitoneal on-lay mesh repair with primary fascial closure (IPOM plus) may offer an alternative. However, evidence in post-traumatic populations remains limited. This study aimed to compare the feasibility, safety, and short-term outcomes of laparoscopic IPOM plus and open repair techniques in patients undergoing ventral hernia repair after DCS. A retrospective cohort study was conducted at a single military centre between June 2022 and December 2025. A total of 79 male patients with large ventral hernias following abdominal shrapnel injuries were included. Patients underwent either open repair (sub-lay or on-lay, n = 46) or laparoscopic IPOM plus repair (n = 33). Baseline characteristics were comparable between groups. Early postoperative outcomes within 90 days were analysed, including operative time, length of hospital stay, postoperative pain, time to recovery of bowel function, and complication rates. Laparoscopic IPOM plus repair was feasible in all cases, with successful primary fascial closure achieved in every patient. Operative time did not differ significantly between groups. The laparoscopic approach was associated with a significantly shorter hospital stay (p < 0.001), lower early postoperative pain on postoperative days 1 and 2 (p < 0.05), and earlier recovery of bowel function (p < 0.01). Rates of postoperative complications, including seroma formation, were lower following laparoscopic repair but did not reach statistical significance. No surgical site infections, reoperations, or readmissions were observed in either group. In patients with large ventral hernias following DCS, laparoscopic IPOM plus repair appears to be a feasible and safe alternative to open reconstruction. It is associated with improved early postoperative recovery without an increase in short-term complications. Further prospective studies with long-term follow-up are required to confirm these findings.
Hernia repairs are one of the commonest operations performed in the world. In Europe and the United States of America more than half of patients undergoing hernia surgery are overweight or obese; body weight is therefore key modifiable risk factor before surgery. We aimed to identify, appraise, and synthesise the randomized controlled trial (RCT) evidence for any weight loss interventions before any form of hernia surgery. A search was performed in April 2025 of the PubMed, EMBASE and CENTRAL databases. Meta-analysis was performed using random effects to assess mean difference in weight, and fixed effects for odds ratio of complications. Bias was assessed using the Cochrane Rob2 tool. Certainty effect was assessed using GRADE methodology. This review was registered with PROSPERO (ID 1024784). 1,707 studies were screened, 20 retrieved, and 4 reports of 3 RCTs included. A total population of 219 patients largely underwent ventral hernia repair, although 2 RCTs also included patients undergoing non-hernia surgery. Interventions comprised very low calorie diets (VLCD), and a multidisciplinary programme. Meta-analysis for VLCD did not show a reduction in weight loss (3.64 kg [95% confidence interval -2.07 - 9.35]) or complications [odds ratio 0.36 (0.1-1.28)]. Risk of bias was "high," and certainty of effect "very low." Despite the prevalence and importance of obesity in patients undergoing elective hernia repair, and the popularity of weight loss as part of prehabilitation, the randomized evidence of how to effect weight loss, and whether this translates into an improvement in clinical outcomes is minimal. This highlights the urgent need for large and robust RCTs to determine if weight loss before hernia repair is effective in improving outcomes for patients, and how this is best achieved.
Suture repair of abdominal wall defects is prone to failure due to suture pull-through. In contrast, planar mesh reinforcement improves durability but is limited by increased foreign body burden, need for additional tissue dissection, and challenges in contaminated fields. Mesh suture offers a potential alternative combining both the ease of suture repair with improved load distribution and early tissue integration, characteristics of planar mesh repairs. This review summarizes the biomechanical rationale, histologic characteristics, and early clinical experiences with mesh suture to date. A narrative review of preclinical and clinical literature regarding mesh suture was performed using a targeted search of PubMed and Google Scholar with key terms ("mesh suture" or "Duramesh"). Studies were included if they evaluated mesh suture in biomechanical, preclinical or clinical contexts. A proposed clinical algorithm based on institutional experiences is presented to illustrate patient selection and technique. Preclinical studies demonstrate favorable mechanical performance and early fibrovascular incorporation. Early clinical data from registries and institutional cohorts suggests mesh suture is feasible even in contaminated settings with outcomes that compare to both standard suture and planar mesh repairs. Mesh suture may offer a reinforcement strategy that balances mechanical support with tissue preservation in abdominal wall reconstruction. Current clinical evidence remains preliminary, and additional prospective, randomized studies are needed to more definitely evaluate its clinical performance over time.
Abdominal wall reconstruction (AWR) creates biomechanical and physiological changes, impacting the respiratory system. We assessed how dynamic lung compliance (LC) changed in response to intra-abdominal pressure (IAP) and closure forces. Secondarily, we investigated if patient, radiological, or biomechanical factors were identifying predictors of physiological changes. We performed a prospective observational study in patients undergoing complex ventral hernia repair. LC was measured during 3 intra-operative stages after full muscle relaxation. Primary outcome was change in LC between completion of adhesiolysis and closure. Additionally, we measured force and distance required for midline closure. Nineteen patients (median age 63) underwent AWR. Median hernia volume was 437 cm3 (IQR, 233-1,608). Mean LC change was -6.8 mL/cmH2O (±6 SD). Mean IAP increase was 3 mmHg (±1.7 SD). LC reduced and IAP increased between adhesiolysis and skin closure, significantly (P < 0.001). Increased midline closure distance was positively associated with increased closure force (P = 0.03, 0.12N, 95% CI 0.21-4.0). There was no evidence that increased closure force reduced LC or raised final IAP. Preoperative FEV1 and BMI were associated with reduced final LC (P = 0.05, 6.23L 95% CI 0.05 to 12.4; P = 0.03, -0.74 kg/m2, 95% CI -1.4 to -0.07). There was no evidence of an association between radiological measurements and change of LC or IAP. Reduced LC is positively associated with increased IAP. However, there is no evidence increased closure forces affect final LC or IAP. Pre-operative optimisation of BMI or pre-operative FEV1 may have more impact than hernia morphology on LC reduction.
Botulinum Toxin A is increasingly used as a preoperative adjunct in the management of complex abdominal wall hernias, particularly in those with wider defects and/or loss of domain. While its anatomical and surgical benefits have been documented, patient-reported outcomes remain underexplored. An international, retrospective, observational study was conducted using a structured, anonymised survey available in five languages (German, English, Polish, French, Spanish). The survey included nine closed-ended and one open-ended question assessing pain perception, mobility, respiratory, gastrointestinal, and urinary function, and changes in abdominal contour. It was distributed by medical teams and through patient support forums between 2024 and 2025. Patients included had received BTA injections 4-6 weeks prior to elective hernia surgery. Seventy patients from multiple European centres completed the survey. Pain during injection was minimal in 71.5% of cases, with 85.7% reporting complete resolution of pain within 1-3 days. Most respondents (74.3%) experienced no breathing difficulties and only mild symptoms in 18.6%. Mobility remained unchanged in 80%, while 15.7% noted slight deterioration. Changes in urinary and bowel function were uncommon and mostly transient. Over half of patients reported visible changes in abdominal shape. No severe complications were identified. This international patient survey suggests that BTA injections as preoperative preparation for complex hernias is well tolerated, with limited perceived side effects and functional disruption. These findings support its continued use and prompts further prospective data collection.
Amyand's hernia is defined by the presence of the appendix in the sac of an inguinal hernia. Its treatment poses two problems: the risk of infection associated with the presence of the appendix and the choice of surgical technique, which must reduce the risk of infection while minimising the risk of recurrence. In this article, we present two patients treated for a strangulated inguinal hernia containing the appendix and caecum and review the literature for evidence that may guide the choice of treatment. We present two male patients, aged 37 and 44, admitted to our department for a strangulated right inguinal hernia. During surgical exploration, the hernia sacs of both patients contained the appendix and caecum, which were inflamed without necrosis. Both patients underwent appendectomy with protection of the surgical site and instillation of povidone-iodine into the surgical site to reduce the risk of infection. Both were treated using the Lichtenstein procedure. The postoperative course was uneventful in one patient, while the other had oedema of the cord, which responded well to enzymatic anti-inflammatory treatment made of on trypsin, pancreatic ribonuclease and chymotrypsinogen. Examination of the surgical specimens confirmed appendicitis. Most Amyand hernias are diagnosed during the treatment of a complicated hernia. There are no specific signs, hence the importance of systematically opening the hernia sac when treating a complicated hernia. During surgery, the surgeon must choose an appropriate technique based on the risk of infection and perform a routine appendectomy, followed by an examination of the surgical specimen. The role of hernioplasty according to the Desarda procedure could be evaluated for this indication. The Losanoff-Basson classification should be constantly updated as treatment procedures and available resources evolve.
Suturing is a fundamental component of surgical procedures, wherein training emphasises the significance of gentle tissue handling. The suturing process involves the pressure exerted by the forceps onto the tissue, as well as the medial traction force applied to stabilise the tissue during the needle bite. This study examined the forces involved in tissue handling during suturing, comparing a novel suturing device for standardised abdominal closure with two sizes of curved suture needles (NDS). A model was developed to measure suturing forces. The study introduction comprised both a written letter and an oral explanation. Participants performed 10x3 needle pull-throughs, using a large needle (36 mm, LN) and a small needle (26 mm, SN). Maximum forceps pressure and maximum medial traction forces were recorded. Additionally, needle pull-through time and the area under the curve (AUC) were calculated for both forceps pressure and medial traction pressure. The study involved 20 specialists, ten scrub nurses, and five surgical trainees. Of these participants, 22 were female, the average glove size was 6.9, and two were left-handed. The use of SutureTOOL resulted in significantly less force exerted with forceps (p < 0.001) when compared to NDS, and a shorter needle pull-through time (p < 0.001). No differences were observed in maximum traction force; however, the medial traction force AUC was lower for SutureTOOL and SN compared to LN (p = 0.025). The study revealed that SutureTOOL required less forceps pressure and exerted either less or comparable traction force to perform needle pull-throughs, compared to traditional methods. We conclude that this innovative suturing technology did not increase the forces measured in the model. However, the impact on abdominal wall related complications requires further study.
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Ventral hernia repair (VHR) in high-risk, complex obese patients often presents a technical challenge for surgeons. Performing a panniculectomy (PAN) at the same time as the VHR may be an acceptable option for enhancing hernia exposure, improving cosmetic outcomes, and improving subsequent quality of life (QoL). However, this approach remains controversial due to the theoretical increase in postoperative complications. The objective of this study was to evaluate the relevance of combining PAN with VHR in complex obese patients in a specialised centre in France. A retrospective single-arm study was conducted, including all patients who underwent VHR with PAN from January 2020 to December 2024 at a high-complexity referral hernia centre in Reims, France. Preoperative, intraoperative, and postoperative data were collected and analysed. Complications were categorised according to the Surgical Site Occurrences (SSOs), Surgical Site Infections (SSIs) and Clavien-Dindo classifications. Emergency hernia repairs were excluded. A total of 45 patients were included. The maximum median BMI was 40.26 kg/m2. All patients had at least one comorbidity, more than half had a loss of domain or a stoma, and more than 70% were classified as 2 or 3 according to the VHWG classification. The component separation technique was necessary for 42% of patients. The SSO and SSI rates were 58% and 7%, respectively, with an unplanned reoperation rate of 15%. After a median follow-up of 31 weeks, 11% of patients developed a hernia recurrence. Combining PAN with VHR in complex obese patients increases the risk of minor wound complications but does not significantly affect the rate of major complications or recurrence. PAN may introduce additional morbidity for complex VHR in obese patients and should be considered in selected cases after a thorough risk-benefit evaluation.
Botulinum toxin type A (BTA) is a valuable adjunct in abdominal wall reconstruction (AWR). Chemical component relaxation (CCR) involves injecting BTA into the lateral abdominal wall, leading to muscle paralysis and elongation which facilitates primary fascial closure during surgery without the need for extensive dissection. There are currently no standardised protocols for BTA administration in the perioperative period for AWR. We present a standardised protocol for CCR from our tertiary hernia unit and report our outcomes following surgery. A retrospective analysis of a prospective dataset of all patients undergoing standardised pre-operative CCR between 1st May 2021 and 30th April 2024 for AWR were included in this study. Analysis of pre-operative multi-disciplinary team (MDT) planning, BTA administration, surgical procedure and outcomes were performed. During the 3-year-period, 35 patients underwent CCR with subsequent AWR. The median age was 58 and median BMI was 32. Median hernia defect width was 8 cm. Anterior and posterior sheath closure was achieved in 91% of cases. In total, 39% with defect size >8 cm did not require component separation and were considered "downstaged". There were no complications following CCR, and the surgical site occurrence rate following AWR was 26%. Hernia recurrence occurred in 1 patient. The presented protocol of pre-operative BTA appears to be a safe method of CCR. We demonstrate that its use may reduce the need for component separation and is associated with good post-operative outcomes.
Incisional hernia (IH) is a frequent and expensive complication of laparotomy, occurring in up to 50% of high-risk patients. Although prophylactic mesh placement has been proposed as an effective preventive strategy of IH, its adoption remains limited due to concerns about mesh-related complications and the heterogeneity and variable quality of the available evidence. This umbrella meta-analysis aimed to synthesize the existing evidence to evaluate the efficacy and safety of prophylactic mesh reinforcement for IH prevention. A systematic search of multiple databases was performed until June 2025 to identify meta-analyses comparing the use of prophylactic meshes versus primary closure in adults undergoing laparotomy. Methodological quality was assessed with the AMSTAR-2, and the data were reanalyzed with random or fixed effects models. Heterogeneity (I2), study overlap (CCA), publication bias, and robustness of the results were evaluated. Twenty-one meta-analyses were included. Prophylactic mesh reinforcement was associated with a significant reduction in the odds of incisional hernia (OR = 0.29; 95% CI: 0.22-0.38); this effect was consistent across different surgical settings. Mesh use was also associated with an increased risk of surgical site infection (OR = 1.17; 95% CI: 1.04-1.30) and seroma formation (OR = 2.31; 95% CI: 1.99-2.67). No significant differences were observed in abdominal wound dehiscence or hematoma. Overall, the evidence demonstrated a large and consistent effect, although substantial heterogeneity and signs of publication bias were present. Prophylactic mesh reinforcement is associated with a reduced likelihood of incisional hernia but an increased risk of seroma and surgical site infection. Its use should be considered selectively in high-risk patients, balancing potential benefits against known complications. Further studies are needed to optimize patient selection and evaluate strategies to reduce mesh-related adverse outcomes, as well as to assess cost-effectiveness and quality-of-life outcomes.
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Ventral hernia repair has traditionally been performed laparoscopically using the intraperitoneal onlay mesh (IPOM) technique, which is simple and widely available but carries the drawback of mesh-viscera contact. Extraperitoneal approaches such as transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair have emerged as alternatives that avoid this limitation, allowing the use of standard meshes without fixation. However, evidence comparing these techniques remains scarce. We conducted a retrospective comparative analysis of a prospectively collected database at a single centre between January 2023 and December 2024. Patients undergoing laparoscopic repair of primary ventral or W1 incisional hernias smaller than 4 cm, with or without rectus diastasis, were included. Demographic data, operative details, and postoperative outcomes were recorded. Pain was assessed using the visual analogue scale (VAS). Complications were graded according to Clavien-Dindo. Follow-up was at least 12 (twelve) months for all patients. Thirty-three patients were analysed, 18 in the TEP group and 15 in the TAPP group. Baseline demographic and comorbidity characteristics were comparable. Operative time was significantly longer for TAPP (96.1 ± 14.8 vs. 84.7 ± 13.1 min, p=0.029). Mesh area was larger in TEP (242.9 ± 110.3 vs. 166.9 ± 49.9 cm2, p=0.015). Rectus diastasis was present in a similar proportion of patients (55.6% vs. 53.3%), but correction was achieved only in TEP (11 of 18 cases, 61.1%). There was one conversion to IPOM in TAPP. Postoperative pain scores, hospital stay (18.2 vs. 15.3 h, p=0.119), and 30-day complication rates (13.3% vs. 22.2%, p = 0.665) were comparable, consisting mainly of minor seromas or haematomas. No recurrences were observed at 1 year. Both TAPP and TEP are safe and effective minimally invasive approaches for small ventral and W1 incisional hernia repair. TAPP is associated with longer operative times due to peritoneal flap creation, while TEP enables broader mesh placement and ergonomic correction of rectus diastasis. Despite the small sample size and retrospective design, our findings add to the growing evidence supporting extraperitoneal approaches as valuable alternatives to IPOM in abdominal wall surgery.