The recurrence rate of ventral abdominal wall hernia repair remains high, partly due to incomplete understanding of biomechanical factors influencing fascial closure. This study aimed to develop and evaluate a patient-specific computational model to predict closure tension in the anterior rectus sheath (ARS) and posterior rectus sheath (PRS) during different steps of the transversus abdominis release (TAR) procedure. A preoperative CT scan of a patient with a 7 × 6cm midline ventral hernia was segmented to reconstruct in 3D abdominal wall structures. Finite element meshes were generated for muscles, fasciae, aponeuroses, and the peritoneum. Tissue properties were assigned from experimental data and the abdominal cavity was modeled as a fluid-filled incompressible volume. The successive surgical steps of retrorectus dissection, incision of the posterior lamella of the internal oblique aponeurosis, and TAR, were simulated. Tension in ARS and PRS was computed and compared with in vivo measurements reported in the literature. Stress distributions in fascial components were also analyzed. The model successfully reproduced clinical trends of tension reduction reported in vivo. PRS tension decreased progressively from baseline to TAR (retrorectus dissection: - 16.7%, posterior lamella of the IO aponeurosis incision: - 60.0%, TAR: - 97.6%), while ARS tension dropped mainly after retrorectus dissection and remained stable thereafter (retrorectus dissection: - 45%, posterior lamella of IO aponeurosis incision: - 53.2%, TAR: - 54.0%). However, predicted baseline tensions appeared overestimated compared to clinical values. Stress analysis revealed redistribution between anterior and posterior fascial components during dissection. This patient-specific computational model replicated in vivo tension trends, while overestimating absolute values. Model assumptions on material properties, fascial thickness, and abdominal cavity incompressibility may explain these discrepancies. A retrospective patient-specific validation study is warranted. Once validated, such models could guide surgical decision-making, help standardize TAR procedures, and enable patient-tailored hernia repair strategies.

• The study focuses on the uniaxial mechanical properties of human linea alba and anterior rectus sheath with two-photon microscopy. • The anterior rectus sheath’s collagen fibers orientations strongly correlates with the tissue’s apparent stiffness. • Elastin is more abundant in the linea alba, consistent with its strain-accommodation role. • These findings support the design of patient-specific bioinspired implants replicating the mechanical conditions for native tissue ingrowth and remodeling. Abdominal wall tissues, including the linea alba (LA) and anterior rectus sheath (ARS), exhibit pronounced structural and mechanical heterogeneity that critically influences function and surgical outcomes. Current hernia repair meshes often fail to replicate this complexity, highlighting the need for a mechanistic understanding linking microarchitecture to tissue mechanics. This study combines uniaxial tensile testing with two-photon confocal microscopy to quantify collagen fiber orientation and elastin distribution in ARS and LA samples from eight human donors. Mechanical testing in longitudinal and transverse directions revealed pronounced anisotropy in ARS, with collagen alignment strongly predicting tissue stiffness (R 2 = 0.79–0.88) and explaining inter- and intra-individual mechanical variability. LA displayed a layered collagen network with higher elastin content, consistent with its role in strain accommodation. By directly correlating microstructural organization with mechanical performance, this work uncovers key design principles for bioinspired implants: anisotropic collagen fiber orientation and elastin distribution must be considered to replicate native tissue mechanics. Specifically, the findings demonstrate that replicating the anisotropic collagen–elastin architecture is essential for achieving biomechanical compatibility in surgical meshes. This study provides a novel framework for engineering heterogeneous materials that faithfully reproduce native tissue mechanics, bridging fundamental biomechanics and translational biomaterials design.

Diep flap with anterior fascial island: The latest fashion for reconstruction of massive soft tissue defects

Compared with traditional deep inferior epigastric perforator (DIEP) flap breast reconstruction procedures, robotic-assisted DIEP (R-DIEP) minimizes abdominal wall morbidity by reducing fascial incision length. Optimal R-DIEP candidates have large perforators with short intramuscular courses, but no large-scale studies have quantified their prevalence. This study aims to identify the proportion of patients who are anatomically eligible for R-DIEP.A retrospective review of patients who underwent magnetic resonance angiography perforator mapping prior to DIEP flap breast reconstruction between 2019 and 2023 was conducted. Patient demographics were collected. "Dominant perforator" was defined as the largest perforator at or below the level of the umbilicus. The intramuscular course of each perforator was calculated as the hypotenuse of a theoretical prism connecting its entry and exit points with respect to the rectus abdominis muscle. Perforator diameter was measured at the anterior rectus sheath. "Conservative" (intramuscular course ≤ 2.5 cm) and "liberal" (intramuscular course ≤ 5 cm) eligibility criteria were applied. Perforator diameter > 2 mm was used as a secondary criterion.A total of 574 dominant perforators were identified in 287 patients. The average intramuscular length of each perforator was 3.8 ± 1.9 cm (range: 0-11.0 cm). Twenty-nine percent of dominant perforators (n = 165) had an intramuscular course length ≤ 2.5 cm, 77% (n = 441) had an intramuscular course length ≤ 5 cm, and 2.3% (n = 13) were paramuscular (no intramuscular course). Forty-six percent of patients (n = 132) had at least one dominant perforator (i.e., left- or right-sided) with an intramuscular course ≤ 2.5 cm, and 93% of patients (n = 268) had at least one dominant perforator with an intramuscular course ≤ 5 cm. Thirty-one percent of dominant perforators (n = 185) had a diameter > 2 mm and an intramuscular course ≤ 2.5 cm, and 49% of dominant perforators (n = 281) had a diameter > 2 mm and an intramuscular course ≤ 5 cm.A substantial portion of the population is anatomically eligible for R-DIEP breast reconstruction, especially when liberal criteria are applied.

Postpartum women often experience abdominal skin laxity and diastasis rectus abdominis. Lipoabdominoplasty, including anterior rectus sheath plication, is commonly performed to address these issues. However, excessive plication may increase intra-abdominal pressure (IAP) and postoperative pain, potentially causing complications. The relationship between plication width, IAP, and postoperative pain remains underexplored. This study aimed to evaluate how plication width impacts IAP and postoperative pain in patients undergoing lipoabdominoplasty. Thirty female patients underwent lipoabdominoplasty with plication of anterior rectus sheath in two-layer suture. IAP was continuously monitored using a urodynamic analysis system (Laborie) throughout the procedure. For analysis, IAP was specifically recorded before and after the plication of the anterior rectus sheath. Postoperative pain was assessed on postoperative day 1 (POD1) using the Numeric Rating Scale for Pain. Plication width, original rectus diastasis width, and corrected distance were recorded and analyzed. Mean IAP increased significantly from 5.7 mmHg pre-plication to 9.3 mmHg post-plication (p<0.05). Infraumbilical corrected distance (D3, 2.1±0.7cm) showed the strongest correlation with increased IAP (R=0.61) and postoperative pain (R=0.5). No significant correlation was found between BMI, rectus diastasis, and pre-plication IAP. No patients exceeded IAP >12 mmHg. Minor complications occurred in 10% (3/30), including two seromas and one wound dehiscence. Anterior rectus sheath plication during lipoabdominoplasty significantly increased IAP, with the infraumbilical corrected distance (D3) demonstrating the strongest influence. In our study cohort, maintaining D3≤3.6 cm (mean: 2.1 cm) consistently kept IAP below the 12 mmHg safety threshold while achieving optimal esthetic outcomes. Continuous intraoperative IAP monitoring provided an objective method for individualized plication tension adjustment. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract Aim Reconstruction of the linea alba is paramount for any large primary or recurrent ventral and incisional hernia repairs for restoration of the abdominal function that often requires an AWR (abdominal wall reconstruction) through EOR (external oblique release)/TAR (transversus abdominis release). We present here a case series where preoperative BTA obviated the need for an AWR. Patients and Method Retrospective analysis of a prospectively collected data of 6 patients that included demographics, ASA, BMI, symptoms, investigations, peri-operative details including complications and follow up of ventral/incisional hernias undergoing preoperative 300units BTA bilaterally to lateral abdominal muscles followed by repair within 4-6 weeks between June 23-August 24 in a large DGH. Results 3:3 M:F, age 65*(45-83) years, ASA II*(I-III), BMI 31*(27-34) with symptomatic 1 and 5 ventral and incisional hernias respectively; transverse defect 8.5*(6.3-12) cm. One had &amp;gt;20% loss of abdominal domain (LOD). Midline access, adhesiolysis, retro-rectus release allowed tension free closure of posterior (PRS) and anterior rectus sheath (ARS), with retro-rectus polypropylene mesh of cross-sectional area 368*(300-700) cm2 fixed to PRS and ARS (as required) with interrupted PDS. Skin closure after significant redundant tissue excision and negative wound vacuum dressing system. No complications, LOS 7 *(4-14) days and follow up 6*(0-15) months with uneventful recovery were recorded. Conclusion Early experience highlights benefit of BTA as an useful adjunct for complex abdominal wall hernia repairs with a good outcome that can avoid an AWR: a procedure associated with significant morbidity and even mortality.

Retromuscular techniques of ventral hernia (VH) repair involve division of the posterior rectus sheath, entailing a risk of suture line disruption when the gap is sutured or of abdominal swelling when it is not, or when any type of posterior releasing incision is performed. To prevent these drawbacks, we describe a technique of retromuscular repair preserving the posterior sheath integrity. The technique involved periumbilical skin incision, hernia reduction, suture of the orifice, bilateral incision of the anterior rectus sheath close to the midline, approximating the medial borders of these aponeurotic incisions by suture, retrorectus mesh deployment and approximation by suture of both lateral borders of the aponeurotic incisions over the mesh, thanks to anterior releasing incisions. Perioperative data were assessed on 177 consecutive patients and mid-term evaluation was carried out in the first 134 patients who had at least one year follow-up. The mean hernia diameter was 2.6cm (1-5), the operation duration was 76.4mn (50-120). Twenty-three (13%) uncomplicated seromas, 10 (5.6%) complicated seromas and 4 (2.3%) hematomas occurred. Introducing a quilting procedure amid the study reduced the incidence of complicated seromas from 9.6 to 2.1% (p = 0.031). On 134 patients with at-least 12 months follow-up, 128 (95.5%) were evaluated at a mean follow-up of 14.7 (12-32) months and 6 (4.5%) were lost to follow-up. There were neither recurrences, nor any case of swollen abdomen. CONCLUSION: The MIRS technique provides effective repair of small VH and prevents the potential drawbacks linked to the division of the posterior sheath.

Patient: Female, 22-year-oldFinal Diagnosis: Abdominal scar • cutaneous adhesion • rectus abdominis scarSymptoms: Depressed scarClinical Procedure: —Specialty: SurgeryObjective: Unusual clinical courseBackgroundDepressed abdominal scars resulting from childhood surgical interventions, such as appendectomies, often result in aesthetic and functional impairments due to dermal tissue deficiencies and adhesions to the anterior rectus sheath. Traditional methods, including subcision and fat grafting, have limitations in addressing extensive, adherent scars. This report describes a 22-year-old woman with a post-appendectomy depressed scar and outlines an innovative reconstructive approach involving scar tissue release, abdominal wall reinforcement, bilayered adipofascial flaps, and a W-plasty suturing.Case ReportA 22-year-old woman presented to our institution with an 8×2 cm depressed abdominal scar resulting from a childhood appendectomy complicated by postoperative infection. Preoperative imaging confirmed adipose deficiency, muscular disruption, and fibrotic adhesions. Under general anesthesia, the scarred epidermis was completely excised, and adhesions were released. The de-epithelialized scar tissue was anchored to the medial and lateral borders of the released anterior rectus sheath using interrupted sutures for reinforcement. Bilayered adipofascial flaps, comprising Scarpa and Camper fascia, were transposed to restore volumetric deficit, followed by W-plasty closure to minimize tension. Postoperative evaluations at 2 weeks and 1 year revealed no evidence of scar contracture, hypertrophy, or depression recurrence.ConclusionsThis report demonstrates that bilayered adipofascial flap reconstruction, combined with tension-distributing sutures, provides an effective solution for complex abdominal scars with deep adhesions and tissue deficiency. The technique overcomes key limitations of conventional approaches – including fat resorption and incomplete adhesion release – to achieve durable functional and aesthetic restoration.

Abstract Hydrocephalus is the accumulation of cerebrospinal fluid in the ventricles. Shunting is considered a standard procedure linked with several complications. We present a 47-year-old obese female diagnosed with idiopathic intracranial hypertension and underwent a thecoperitoneal programmable shunt. After 2 years, she noticed upper abdomen wall swelling at the site of the shunt distal end. On computed tomography abdomen, fluid-filled sac in the abdomen with the coiled distal end of the shunt was found. The shunt was replaced inside the peritoneal cavity and fixed to the anterior rectus sheath to prevent re-migration. This is the first case reported in the literature, and one must be aware of this in addition to the myriad complications that can occur after shunting. The fixation to the anterior rectus sheath is a tip that can prevent remigration.

Refining the abdominal wall perforasome with clinical application.

In 1863, Dr John Wood published the use of the pedicled superficial inferior epigastric artery (SIEA) flap for reconstruction of a forearm burn scar contracture. The first successful cutaneous free flap reported by Taylor and Daniel in 1973 was an SIEA free flap. Many thought mistakenly this first "groin flap" was based on the superficial circumflex iliac artery (SCIA). Although Taylor and Daniel planned on using the SCIA, it was quite small and the SIEA was much larger and more suitable for anastomosis to the recipient artery. The first SIEA flap for breast reconstruction was at Charity Hospital in New Orleans in 1989. We present our experience with 408 SIEA flaps for breast reconstruction. Our methods and techniques have continually evolved over the years. The SIEA breast reconstruction is the only technique using abdominoplasty territory that does not involve opening the anterior rectus sheath or the oblique fascia and muscles, resulting in the least donor-site morbidity of all abdominal based breast flaps. Our SIEA flap survival rate has been 97% over the past 35 years. The superficial inferior epigastric system is the key to understanding the blood supply of the lower abdomen. A retrospective review of 408 SIEA breast reconstructions performed since 1989 was conducted. Patients were selected based on preoperative Doppler assessment of the SIEA, with 1.2-1.5 mm considered adequate. A subset underwent surgical delay to enhance arterial caliber. Outcomes assessed included flap survival, complications, and failure rates. Flap survival was 97%. The SIEA flap can be used in 40% of patients based on our experience. Delayed SIEA flaps had no failures and reduced fat necrosis (0% vs 15%). Complications included partial ischemic necrosis (4%) and donor-site seromas or hematomas. A dual-plane approach with SIEA and DIEP flaps was used when increased volume of flap perfusion was needed. The SIEA flap offers minimal donor-site morbidity but is limited by absent or inadequate artery diameter in approximately 60% of patients. The delay phenomenon increases flap vascularity and territory. Our findings support its integration into reconstructive practice, alone or combined with DIEP flaps, to optimize outcomes.

Objective: To evaluate the feasibility and preventive efficacy of a fascia- locking circular continuous suture ostomy technique in reducing parastomal hernia incidence. Methods: This technique was applied to patients undergoing permanent colostomy following radical rectal cancer resection. Surgical steps included: (1) A circular incision was made 1-2 cm medial to the intersection of the lateral margin of the rectus abdominis muscle and the line connecting the umbilicus to the left anterior superior iliac spine. Subcutaneous tissues were dissected vertically to expose the anterior rectus sheath, followed by blunt separation of the rectus abdominis after longitudinal incision of the sheath. The posterior rectus sheath and peritoneum were similarly incised. (2) Eight equidistant interrupted sutures (anchoring knots) were placed through the anterior rectus sheath, partial rectus abdominis, posterior rectus sheath, and peritoneum. (3) The terminal colon was exteriorized, and continuous sutures were applied to secure the anchoring knots and seromuscular layers of the bowel between knots, forming a circular locking mechanism by tying the terminal suture to the initial knot's tail. (3) The skin and seromuscular layers of the bowel margin were intermittently sutured (8-12 stitches) to achieve mucosal eversion. Results: From February to October 2023, 13 patients (11 males, 2 females; age: 67 ± 10 years; BMI: 23.8 ± 4.0 kg/m²) underwent this technique at the Second Affiliated Hospital of Army Medical University. Mean stoma creation time was 15.7 ± 3.0 minutes. During a follow-up of 14.6 ± 3.1 months, physical examinations and abdominal CT scans identified parastomal hernias in 2 male patients at 10 and 7 months postoperatively. Only one patient experienced a Clavien-Dindo grade ≥Ⅲ complication, which resolved with treatment. No stoma-related complications (e.g., infection, stenosis, or prolapse) occurred in any patient. Conclusion: The fascia-locking circular continuous suture ostomy technique is safe and feasible, demonstrating potential efficacy in preventing parastomal hernia following colostomy.

Breast cancer surgery involves a minimally invasive approach with the assistance of robotic technology. Robots can be used for harvesting free deep inferior epigastric artery perforator (DIEP) flaps for breast reconstruction to minimize donor-site morbidity. For the first time, the authors' team applied robot-assisted surgery using the oncoplastic entirely robot-assisted (OPERA) approach for both mastectomy and free DIEP flap harvesting. A retrospective chart review identified 14 patients with unilateral breast cancer who underwent robot-assisted mastectomy and robot-assisted free DIEP flap harvesting for breast reconstruction. Patient demographics and mastectomy and flap characteristics were reviewed. Eleven nipple-sparing mastectomies, 1 areolar-sparing mastectomy, and 2 skin-sparing mastectomies were performed with breast cancer stage ranging from ductal carcinoma in situ to the more advanced stage of T3N2aM0. The size of the mastectomies ranged from 155 to 647 g, with an average of 376.9 g. No mastectomy-related complications occurred. Eighteen deep inferior artery and vein pedicles were dissected with the assistance of robotic arms, and the incision length of the anterior rectus sheath was 2.6 ± 0.9 cm. The average length of the harvested pedicle was 10.3 ± 2.2 cm. The harvested flap sizes ranged from 310 to 1213 g (average, 659.3 ± 298.1 g). All flaps were transferred successfully. With a follow-up period of 19.1 ± 15.6 months, none of the patients presented with local recurrence, distant metastasis, or late donor-site morbidities. The OPERA approach has demonstrated feasibility in patients with suitable indications.

INTRODUCTION: Abdominal anterior cutaneous nerve entrapment syndrome (ACNES) is characterized by chronic, undifferentiated abdominal wall pain. ACNES is caused by compression of cutaneous branches of one or more intercostal nerves (T7-T12) at the fascial foramen of the rectus sheath. Surgical techniques have only described neurectomy at the anterior and posterior rectus sheath above the arcuate line where both an anterior and posterior rectus sheath are present. METHODS: We provide a detailed anatomical description of the anterior cutaneous nerves below the arcuate line including the ACNES surgical approach for treating anterior cutaneous nerves arising from T11 and/or T12. RESULTS: The arcuate line is approximately one-half the distance from the umbilicus to the pubic symphysis. Above this line the internal oblique fascia divides into two lamina, surrounding the rectus abdominus, providing a robust anterior and posterior rectus sheath. Across this line, the posterior lamina migrates anteriorly, fusing with the anterior fascia. The anterior cutaneous nerves course between the internal oblique and transversus abdominis muscles, piercing both layers of the rectus sheath anteriorly. Above the arcuate line, this may lead to compression at the anterior or posterior rectus sheath. Below the arcuate line, there is no significant posterior rectus sheath, leaving a single site of compression. CONCLUSIONS: The course of anterior cutaneous nerves and the anatomy of the abdominal wall are anatomically unique below the arcuate line which becomes important when treating lower abdominal pain when in patients with T11 or T12 nerve ACNES. There is debate in the literature as to when an anterior or posterior decompression are needed, however, given the above anatomical constraints, decompression below the arcuate line likely only requires addressing compression at the level of the anterior rectus sheath.

Abdominal wall endometriosis (AWE) is a rare condition representing 1% of patients operated for endometriosis. We describe a case of a 26-year-old woman, with a history of cesarean delivery, who presented with cyclical pain and a subcutaneous mass in the lower abdomen. Where most AWE lesions may be surgically managed by a single surgeon, imaging revealed an unusually large lesion (13 × 4 × 10 cm) involving the rectus abdominis muscle. Plastic, gynecologic, and general surgeons combined their expertise to conduct AWE excision combined with miniabdominoplasty in a single procedure. After resection, a retrorectus mesh (Rives-Stoppa technique) reinforced the primarily closed posterior rectus sheath and an inlay mesh bridged the defect left in the anterior rectus sheath. The patient was discharged 3 days postoperatively, had minimal pain complaints, and was satisfied with cosmetic results at 1-month and later follow ups. One year postoperatively, she gave uncomplicated vaginal birth. We conclude that, in select cases, management of a large, symptomatic AWE may benefit from a multidisciplinary approach, where symptom relief and an aesthetically pleasing result for the patient can be achieved in a single procedure. We distinctively describe double mesh repair as a viable consideration for reconstruction in AWE and review current considerations in mesh repair of the abdominal wall. Further studies into this topic are warranted.

Introduction: Diastasis recti (DR) is defined by the European Hernia Society (EHS) as an abnormal separation between the rectus abdominis muscles &gt;2 cm caused by thinning and widening of the linea alba. 1 Common in postpartum women and middle-aged men, it causes abdominal pain and cosmetic concerns, impacting quality of life. Conservative treatments include physiotherapy and abdominal binders. Surgical management is indicated for persistent symptoms, concomitant hernias, or cosmetic reasons. Traditionally, DR was surgically managed by plastic surgeons as part of abdominoplasty. However, with the advent and increasing expertise in minimal invasive techniques, other procedures, such as SCOLA (Laparoscopic Subcutaneous Onlay Aponeuroplasty), eTEP (enhanced Total Extra Peritoneal), ELAR (Endoscopic Linea Alba Reconstruction), and REPA (Pre-Aponeurotic Endoscopic Repair), have been attempted in specific cases. SCOLA is technically easy to perform and feasible. The current EHS and Swedish guidelines suggest plication +/− mesh repair either through open or minimally invasive approach, to be a recommended option for repair, in patients with postpartum status, presence of symptoms, a large defect size (&gt;5 cm), completion of core strengthening exercises for a minimum period of 6 months, and completed family. 1 , 2 Methodology: We report the case of a 32-year-old postpartum female presenting with a complaint of abdominal bulge for 2 years, which was more pronounced on straining, standing, coughing, and resolved on lying down. It was associated with recurrent dull aching pain, with acute severe episodes since the last 6 months. No history of nausea, vomiting, abdominal distension or fecal/urinary incontinence. She had two normal vaginal deliveries, the last was 4 years ago. She had been doing abdominal strengthening exercises for over a year. Clinical examination revealed a 10 × 8 cm bulge predominantly in the lower abdomen tapering in the supraumbilical region, with a positive cough impulse. A computed tomography scan demonstrated an inter-rectus distance of 6 cm, with a small umbilical hernia of leading to a diagnosis of DR. The condition was classified using the EHS classification system as T1 (postpartum), D3 (&gt;5 cm inter-rectus distance), and H1 (with umbilical hernia). 1 Per EHS guidelines, this patient was deemed a suitable candidate for repair of DR, as she was symptomatic for divarication with umbilical hernia, completed family, last child 4 years ago, and no resolution despite core strengthening exercises. She was planned for SCOLA with mesh repair. Results: This video demonstrates the Laparoscopic Subcutaneous Onlay Aponeuroplasty (SCOLA) technique for repairing DR. Key steps include creating a subcutaneous pocket anterior to the anterior rectus sheath, closing the hernial defect, followed by plication of the diastasis using non-absorbable braided sutures, mesh reinforcement (mid-weight polypropylene of 20*10 cm 2 ), and umbilicus fixation. Each step is thoroughly illustrated, highlighting key anatomical landmarks, technical nuances, and critical points to optimize outcomes. The patient recovered well; her drain was removed on postoperative day 2, and she was discharged on the same day. At 21 months of follow-up, she is doing well without any recurrence. Conclusion: The SCOLA technique offers a safe and feasible minimally invasive option for treating DR, providing both functional and aesthetic benefits over traditional methods. All India Institute of Medical Sciences, New Delhi. The authors declare that there have been no commercial associations, financial relationships, or other conflicts of interest over the past 2 years that could be perceived as influencing or creating a conflict in connection with the content of this video. The authors have received and archived patient consent for video recording and publication in advance of video recording of the procedure. Runtime of video: 9 min 38 secs

Abstract C-section Hernia is a particular type of intra-parietal defect. The first caesarean was performed 1000 year ago and has evolved significantly in the last century. Pfannenstiel described the incision for caesareans in 1900, aiming to reduce hernias and have better cosmesis. It became the standard for C-sections. The technique was modified and now obstetricians tear the rectus muscles and posterior sheath apart and don’t reapproximate this layer. As consequence, it leaves a gap between both recti which allows herniation of abdominal contents between the anterior rectus sheath and muscle. The aim is describing its typical clinical and radiological features, propose a classification and awareness strategy. A prospective observational study was conducted on 38 patients, between January 2020–2024. Data collected was entered in a proforma, tabulated, and analyzed. Most of patients presented with discomfort, swelling, intermittent nausea and all reported a bulge. Three patients presented with small bowel obstruction. All the images were reviewed and match with intraoperative findings to create a classification. Surgical strategy were different for each grade. Conclusion C-section hernia has typical clinical and radiological features commonly under recognized as some signs may be subtle. Awareness by surgeons and radiologists is the first step to avoid this condition being missed or overlooked. All the hernias societies should call for its registry. Finally it is preventable by understanding the importance of posterior layer below the arcuate line usually described as peritoneum only and changing the practice by closing the posterior layer at the index operation may be the end of this problem.

Abstract Purpose C-section hernia has typical clinical and radiological features commonly under recognized as some signs may be subtle. Awareness by surgeons and radiologists is the first step to avoid this condition being missed or overlooked. A classification for C-section hernias is needed to allow comparison of publications and future studies on these hernias as well as to purpose a selective approach. It is important to know whether the populations described in different studies are comparable. Methods Based on the radiological features and intraoperative findings of the first an prospective observational study of this type of hernia, the author developed and propose a classification for C-sections hernias. Results Five distinct presentations were found:Type 1—Small defect on posterior layer exposing anterior rectus muscle with or without peritoneal adhesion but no herniationType 2—Defect on posterior layer with abdominal content herniating between the rectus musclesType 3—Defect on posterior layer with abdominal content herniating between and anterior to the rectus muscles unilaterallyType 4—Defect on posterior layer with abdominal content herniating between and anterior to the rectus muscles bilaterallyType 5—Defect on posterior layer with abdominal content herniating between and/or anterior to the rectus muscles bilaterally associated with a small defect on anterior rectus sheath. Conclusions A classification for C-section Hernia and a division into 5 types, concerning the localisation of the defect and herniation, was formulated and helps the futures publications to talk about the same problem and offer selective approach.

Objectives: The aim of this study is to present a new method for creating a deep umbilicus in pediatric umbilical hernias.

Transplantation of chemically induced pluripotent stem-cell-derived islets under abdominal anterior rectus sheath in a type 1 diabetes patient