Robotic ventral hernia repair (VHR) has enabled minimally invasive management of complex abdominal wall hernias. As robotic procedures involve distinct technical demands and require progressive skill acquisition, understanding learning curves (LCs) is essential to define proficiency thresholds, optimize surgical training, and ensure safe implementation of these techniques. This systematic review compared LCs in robotic VHR across surgical techniques. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of major medical databases (PubMed/MEDLINE, EMBASE, Web of Science, Lilacs, and the Cochrane Library) was performed through August 2025, including cohort studies on adult patients undergoing elective robotic VHR. Seven retrospective cohort studies were included, comprising six single-surgeon series: one robotic intraperitoneal underlay mesh (rIPUM), one robotic transversus abdominis release (rTAR), one robotic transabdominal preperitoneal (rTAPP), three robotic enhanced-view totally extraperitoneal (r-eTEP), and one population-based analysis including 12,609 cases. The single-surgeon series predominantly involved patients with class I obesity (mean body mass index range: 31.0-33.0 kg/m2). LC assessment was heterogeneous, employing cumulative sum (CUSUM), risk-adjusted CUSUM (RA-CUSUM), chronological case grouping, and multivariable regression modeling. Across single-surgeon studies, operative efficiency improved earlier than complication-adjusted or technical quality outcomes. Operative-time (OT) proficiency thresholds were reported at 26 cases for rIPUM, 29-38 for r-eTEP, 46 for rTAPP, and 49 cases for rTAR. However, stabilization of complication-adjusted performance required higher volumes, ranging from 51 to 64 cases. Prior experience substantially shortened the LC, reducing OT proficiency for r-eTEP to just 8 cases. In contrast, population-level analysis suggested that 16-19 robotic cases were required to achieve recurrence-related reoperation rates comparable to open or laparoscopic repair. LCs in robotic VHR follow a two-phase, technique-dependent pattern. While operative efficiency is achieved earlier, optimal patient outcomes require higher case volumes.

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 28kg/m2). The mean transverse defect width was 12.06 cm, with an average area of 170.24cm2. Thirty eight patients had W3 hernias according to EHS (≥10cm), 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.

IntroductionBotulinum 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.MethodsAn 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.ResultsSeventy 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.ConclusionThis 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.

The operative management of complex abdominal wall hernias in nonagenarians entails significant risk, with emergent repair associated with mortality rates approaching 40%. We report the case of a functionally independent 90-year-old male presenting with a 48 h history of abdominal pain, obstipation, and emesis, consistent with an acute-on-chronic incarcerated ventral hernia. Despite advanced age and elevated perioperative risk, multidisciplinary evaluation supported surgical intervention. Laparotomy revealed a 22 × 18 cm hernia sac harboring an elongated sigmoid and approximately 150 cm of small intestine with signs of compromised perfusion secondary to an internal constriction band. Following adhesiolysis and decompression, bowel viability was restored, and a mesh repair was performed. The postoperative course was notable for transient respiratory failure necessitating reintubation and ICU management; however, full recovery was achieved by one-month follow-up. This case demonstrates that comprehensive assessment, rather than chronological age, should guide operative decision-making in nonagenarians and underscores the feasibility of complex abdominal wall reconstruction in this cohort when supported by multidisciplinary care and perioperative resources.

Preoperative interventional radiology-led botulinum toxin for complex abdominal wall hernia reconstruction: early outcomes and experiences from a UK district general hospital

IntroductionPrehabilitation strategies for patients with complex abdominal wall hernias primarily target physical optimization. However, existing psychological factors like anxiety, depression, and post-traumatic stress disorder are commonly observed in this population. Despite this, they remain underexplored notwithstanding their impact on recovery, complications, and quality of life. This study investigates the prevalence of psychological comorbidities in patients undergoing complex abdominal wall repair (CAWR).MethodsIn this prospective cohort study, consecutive patients planned for CAWR (September 2024-June 2025) were recruited. Complex hernias were predefined. Preoperative assessments focused on the presence of anxiety, depression, post-traumatic stress disorders, self-efficacy and quality of life by validated questionnaires: HADS, Mastery and PCL-5. Associations between psychological factors and postoperative pain scores, opioid use, length of stay and complications were explored.ResultsA total of 16 (46%) out of 35 eligible patients completed all preoperative psychological questionnaires. Sixty-nine percent of patients screened positive for at least one psychological risk factor: sixty percent for anxiety and/or depression, thirteen percent for PTSD and fifty-three percent of patients had low self-efficacy. Median QoL score was 47/120.ConclusionThis study identified that the threshold to participate in this study was very high. Secondly, two-thirds of patients assessed experienced one or more psychological comorbidities. A relation in these patients with prolonged postoperative pain was observed. These findings suggest that psychological comorbidities may represent a clinically relevant risk factor. Further research is warranted to better understand their role and to evaluate whether targeted psychological prehabilitation could improve outcomes.

PurposeRepairing complex abdominal wall hernias is challenging, often requiring component separation techniques (CST) for tension-free closure. Adjuvant therapies, such as botulinum toxin type A (BTA), preoperative progressive pneumoperitoneum (PPP), and intraoperative fascial traction (IFT), may reduce the need for CST by improving abdominal wall compliance and reduce the complexity of the hernia. There is limited knowledge about the effects of their combined use. Our aim is to evaluate the rate of CST in abdominal wall reconstruction for complex midline hernias after adjuvant therapies.MethodsA cross-sectional study was conducted on patients who underwent surgery for correction of midline complex abdominal hernias between June 2020 and June 2024. Patients submitted to BTA, PPP, or/and IFT were included. Exclusion criteria were non-midline hernias, non eletive surgeries and less than 3 months of follow-up.ResultsAmong the 44 patients studied, 61.4% underwent abdominal wall reconstruction without requiring CST. Traditional predictors like component separation index and rectus/defect ratio were not associated with a higher rate of CST after adjuvant therapies. 45.5% of patients underwent a combination of adjuvant techniques (BTA + PPP or BTA + IFT). The early and late complication rates were 20.5% and 9.1%. A recurrence rate of 4.5% was reported after a median follow-up of 13 months.ConclusionThis study suggests that adjuvant therapies may influence the surgical approach to abdominal wall reconstruction. The synchronous application of adjuvant therapies, both preoperatively and intraoperatively, could enhance their effect and contribute to the use of less disruptive techniques.

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 >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.

There are two conventional approaches to abdominal wall hernia repairs that aim to achieve anatomical restoration. Open approaches have the advantage of complete hernial sac excision with freedom of mesh placement. In comparison, the advantages of the laparoscopic approach involve shorter hospital stays, less postoperative pain, and fewer postoperative complications. More recently, the hybrid approach, which combines the two techniques, has gained popularity as a way to potentially reap the benefits of both. Our aim was to determine whether this hybrid approach can achieve the same benefits, irrespective of hernia size, age, and body mass index (BMI). Primary outcome of interest was hernia recurrence. Secondary outcomes included postoperative complications, pain, and quality of life (QoL). Medical records of all patients who underwent hybrid laparoscopic hernia repair (HLHR) with transabdominal partially extraperitoneal (TAPE) mesh fixation between 2017 and 2023 were retrieved from a prospectively maintained institutional database and retrospectively analyzed. Intra- and postoperative complications, as well as hernia recurrence, were recorded. QoL was assessed using the Carolinas Comfort Scale (CCS). There were 37 patients (21 women, 56.8%) with a mean age of 66 years and BMI of 34.2 kg/m2 who underwent hybrid hernia repair. Of them, 34 (91.9%) were incisional hernias, of which 50% were recurrent. Mean hernia defect size was 96.8 cm2. Of the patients, 12 (32.4%) received preoperative chemical component separation with botulinum toxin A (BTA); this group had a significantly higher BMI and hernia size compared to the no BTA group (37.7 vs. 32.5; p = 0.048; 174.5 cm2 vs. 59.5 cm2; p = 0.0002). There were no intraoperative complications; however, there were 8 (21.6%) minor postoperative complications. After a mean follow-up of 40 months, we recorded one hernia recurrence at 23 months postoperatively (2.7%). In addition, out of 29 (78.4%) patients assessed for QoL, the median and mean scores were reported as 0 out of 115 and 2.6 out of 115 points scale, respectively. HLHR with TAPE mesh fixation is safe, with satisfactory mid- to long-term outcomes, irrespective of hernia size and BMI.

The literature recommends that patients with complex abdominal wall hernias (CAWH) and severe obesity should be managed with staged treatment, undergoing metabolic and bariatric surgery (MBS) before hernia repair. However, CAWH with loss of domain (LOD) presents a more challenging situation. This study presents the feasibility of Laparoscopic Sleeve Gastrectomy (LSG) in patients with CAWH and LOD. This is a retrospective cohort of unselected consecutive patients with CAWH and LOD defined based on Tanaka and Sabbagh's criteria who underwent LSG from 2016 to 2023. We documented a 90-day complication rate according to the Clavien-Dindo classification. Sixteen patients, aged 55 ± 10.6years with a mean BMI of 41.75 ± 4.75kg/m2, met the inclusion criteria. The median hernia sac volume (HSV) was 3331.0ml (IQR 2647.25-3616.25), achieving a median volume ratio of 44.69% (IQR 33.58-55.69) and 30.88% (IQR 25.14-34.70) according to Tanaka's and Sabbagh's criteria, respectively. There were no intraoperative complications or conversions. Three patients experienced major 90-day complications, with two requiring reoperations. There was no 90-day mortality. LSG in patients with severe obesity and CAWH with loss of domain is safe and feasible but has a higher-than-expected rate of serious morbidity due to the complexity of this patient population.

OBJECTIVES To evaluate and compare the outcomes of the Posterior Component Separation (PCS) technique with and without Transversus Abdominis Release (TAR) in the management of complex abdominal hernias, focusing on recurrence rates, complications, and overall surgical effectiveness. METHODOLOGY This retrospective cohort study was conducted at Hayatabad Medical Complex, Peshawar, from January 2020 to April 2023. A total of 87 patients with complex midline and lateral hernias were included. Complex hernias had defects >8 cm, >20% abdominal domain loss, multiple defects, or recurrence. Lateral hernias were post-open cholecystectomy incisional hernias. Data on demographics, comorbidities, and surgical details were analysed using SPSS v20. Chi-square and Fisher’s exact tests were applied for categorical variables, and an independent t-test was used for continuous variables (p<0.05 considered significant). RESULTSOf 87 patients, 42 (48.3%) underwent PCS-TAR, while 45 (51.7%) had PCS without TAR. The mean operative time was 120 ± 10.6 minutes. Complications occurred in 24 (27.6%) patients, significantly higher in the TAR group (38.1% vs. 17.8%, p=0.034). Recurrence was observed in 7 (8%) patients. Seroma formation was more common in the TAR group (16.7% vs. 2.2%, p=0.009). Mortality occurred in one patient due to pulmonary embolism. CONCLUSION Posterior component separation technique with or without transversus abdominis release is a neoteric surgical procedure for managing large complex hernias. It has an excellent outcome with minimal complications, resulting in improved quality of life for the patients.

This scoping review aimed to systematically map the existing evidence on the surgical management of complex abdominal wall hernias (CA), focusing on patient-specific factors, hernia characteristics, contamination and operative strategies to their management, in order to identify research gaps and areas for clinical improvement. A comprehensive literature search was conducted in PubMed and Scopus, covering publications from January 2015 to June 2024. A total of 6,445 articles were identified, of which 357 met inclusion criteria (303 primary studies and 54 systematic reviews). Studies were classified into three categories: patient-related factors (P), hernia-specific features (H), and contamination (W). Patient-related factors, particularly obesity and associated comorbidities, were consistently related to higher rates of morbidity and hernia recurrence despite prehabilitation and bariatric surgery were evaluated, results were inconclusive. Hernia-specific features, including large defect size and loss of domain, were associated with increased complication rates. Midline restoration and its achievement with component separation or preoperative botulinum toxin injections, were extensively studied, showing potential benefits. In contaminated settings, synthetic meshes outperformed biologic alternatives, demonstrating lower recurrence and morbidity rates in recent trials. Research in biosynthetic mesh is still needed. Surgical management of CA remains a highly demanding clinical scenario with significant variability in outcomes influenced by patient factors and hernia characteristics. Techniques such as component separation and the use of synthetic meshes hold promise, but further high-quality, randomized trials are required to establish standardized protocols and optimize clinical outcomes in this challenging patient population.

Abstract Incisional hernias are a common complication and can be very challenging to manage. The incidence is about 20–25% after a major operation. We present our experience of Complex Abdominal Wall Reconstruction (CAWR) at a District General hospital (DGH). Methods The team comprises 2 Upper GI surgeons, anaesthetists who help optimise the high-risk patients and a radiologist. All patients are initially discussed in the CAWR MDT that takes place weekly. The CT scans are reviewed with the radiologist. Results Data from 24 patients was analysed from 2021 to 2024. The mean age of the patients was 59 (44–77) years and the average BMI was 32 (28–46). All patients had a pre-op CT scan to delineate the anatomy and were discussed in the MDT. Open Rives-Stoppa repair was performed in 20 patients (83.3%), Transversus abdominus release in 3 (12.5%) and component separation in 1 patient (4.1%). 22 patients (91.6%) had a planned elective operation whereas 2 (8.3%) underwent emergency repair due to bowel obstruction. Prolene mesh was used in 20 patients (83.3%), 3 (12.5%) had Phasix mesh and 1 (4.1%) had Permacol mesh. 1 patient (4.1%) developed a mesh infection requiring re-operation and excision of mesh, 2 patients (8.3%) had superficial wound infection that was treated with antibiotics and respiratory complications were seen in 2 (8.3%) patients. Conclusion Our experience and outcomes indicate that CAWR is feasible at a DGH with a dedicated team. The follow-up shows good outcomes with only one recurrence so far. Patients report a better quality of life.

Abstract Incisional hernias can affect up to 20% of patients after midline laparotomy. Those at higher risk include patients with obesity, a smoking history, and poor glycaemic control. These individuals often experience poorer outcomes in elective hernia repair. Pre-optimizing these patients can decrease the risk of post-operative complications and hernia recurrence. This paper examines the benefits of a pre-optimization pathway for patients with complex abdominal wall hernias requiring repair. Recognizing the importance of pre-optimization, each patient was assessed for modifiable risk factors at their initial consultation, focusing on diabetes, smoking, and weight. Targets were established collaboratively between patient and clinician, aiming for weight loss, good diabetic control, smoking cessation, or a combination of these. Patients were then enrolled in a pre-optimization program, which included tri-monthly telephone clinics with an advanced clinical practitioner. Resources were provided to support goal achievement, such as healthy lifestyle advice, exercise and diet guidance, and referrals to specialists like weight management services or diabetic teams. Over the past year, 49 patients were enrolled in the pre-optimization program: 8 for smoking cessation, 45 for weight loss, and 13 for diabetes control, with some patients needing multiple interventions. During the same period, 42 patients underwent surgery; 22 required pre-optimization—19 for weight loss, 2 for diabetes control, and 6 for smoking cessation, some needing a combination of interventions. The majority of patients undergoing incisional hernia repair will need some form of pre-optimisation. Close follow-up increases the likelihood of patients achieving pre-surgery goals, thus reducing the risk of post-operative complications.

Complex abdominal wall hernias pose a difficult problem due to their higher rates of morbidity and recurrence. Using botulinum toxin injections as a potential treatment to stretch the patients' muscles and promote primary fascial closure has been suggested. This study focuses on the effectiveness of preoperative botulinum toxin injections for patients with complicated abdominal wall hernias.

Purpose: This study aimed to examine the effectiveness of preoperative image guided botulinum toxin A injection in achieving fascial closure and reducing recurrence rates after repair of complex incisional abdominal wall hernias.Material and Methods: A total of 32 patients, consisting of 14 males and 18 females, with complex incisional hernias who underwent image guided botulinum toxin A injection at a median 33 [28-38.3] days before surgery were included in this retrospective study. Their mean age was 59.4 ± 11.2 years. Abdominal computed tomography imaging was obtained prior to botulinum toxin A administration to characterize the hernia defects of 26 patients (81.3%, 26/32). The transverse and vertical abdominal wall defects were measured and recorded. Three-dimensional objects of the hernia sac and peritoneal cavity were created based on the delineated borders, and volumes were calculated. The loss of domain was determined using the following formula: where x represents the hernia sac volume and y represents the peritoneal volume. Under ultrasound guidance, the abdominal wall musculature was injected with 300 units of botulinum toxin A across six sites. The fascial closure rate and rate of hernia recurrence were the principal outcomes investigated.Results: Fascial closure was achieved in 29 patients (90.6%, 29/32). Recurrence was observed in two patients (6.3%, 2/32) over an average followup of 2.5 ± 1.5 years (maximum 6.5). Fascial closure was obtained in 12 out of 14 patients with previous hernia repairs (85.7%, 12/14). One botulinum toxin A related complication was observed―a weakened cough that resolved without further treatment.Conclusions: Botulinum toxin A is safe and effective in improving rates of fascial closure and reducing instances of reoccurrence in patients with complex incisional hernias.

IntroductionPreoperative botolinum toxin A (BTA) administration to the lateral abdominal wall has been widely used since its introduction for treating complex abdominal wall defects and loss of domain (LOD) hernias. Intraoperative fascial traction (IFT) is an established technique for complex abdominal wall hernias exceeding a width of 10 cm and has also shown auspicious results. We present our single center data including 143 consecutive cases combining both techniques from 2019 to 2023. Aim of the study was to develop an algorithm for a tailored approach for very large and complex ventral abdominal wall hernias.MethodsConsecutive patients treated with preoperative BTA and IFT from August 2019 to December 2023 were identified in our prospectively maintained database and reviewed retrospectively. Metrics included intraoperative findings and short-term (30 days) postoperative outcomes.Results143 patients were included in our retrospective analysis. The mean age was 58.9 years and 99% of all patients had an ASA Score of II or III with a mean body mass index of 32.4 kg/m2. The mean intraoperative reduction of fascia-to-fascia after BTA and IFT was 9.81 cm. 14 patients either had a lateral defect or a combination of a midline and lateral hernia. An additional uni- or bilateral transverse abdominis release (TAR) was necessary in 43 cases (30.1%). The overall surgical site occurrence rate (SSO) was 30.1% of which 13.8% were surgical site infections (SSI). Re-operation and SSO rates were significantly higher if an additional TAR was performed (both p = 0.001; α = 0.05).ConclusionsIFT in combination with BTA is a transformative and clinically proven tool in the surgeons’ toolbox. It might be an easier, and less invasive alternative to other available techniques in many cases, but it should not be looked at as an ultimate stand-alone method to treat all complex W3 hernias.

Abstract Background Prehabilitation is known to enhance postoperative outcomes after different surgical procedures, but no such evidence is found in abdominal wall surgery. Our aim is to analyse the complications and need for reconsultation in patients undergoing weight optimization prior to abdominal wall hernia surgery. Methods Prospective observational study including all patients diagnosed with complex abdominal wall hernia and IMC > 30 kg/m2 between January 2019 and December 2022. Patients were included in a pre-intervention weight optimization circuit. The need for reconsultation to the emergency room or outpatient clinic during the prehabilitation period was analysed, as well as the surgical results and post-surgical complications of those patients who underwent elective or emergency hernia repair. Results 83 patients were included (56 female, mean age 62 years, 18 patients with Charlson ≥3). The primary hernia defect averaged 7.9 cm (SD 3.9), with 4.8% having a primary ventral hernia and 37.2% having recurrent hernias. During prehabilitation, 22.9% of patients reconsulted in the outpatient clinic, while 31.3% consulted in the emergency service. 37.3% underwent surgical hernia repair, with 12.9% of them requiring emergency surgery. Postoperative complications, classified according to the Clavien-Dindo system as >IIIa, occurred in 6.2% of cases. One patient (3.2%) required readmission after emergency hernia repair. After a median follow-up of 15 months, a recurrence rate of 3.2% was observed in the emergency hernia repair group. Conclusion Preoperative weight loss prehabilitation is associated to high outpatient-clinic consultation, emergency consultation and emergency hernia repair rates. Patients with a need for emergency surgery have worse postoperative outcomes.

Abstract Introduction We present a case of a 58-year-old woman with history of severe sepsis after a perinatal abscess. This necrotising fasciitis lead to a partial destruction of the abdominal wall and required multiple surgical debridement (with partial removal of recuts muscle), colostomy and hyperbaric treatment. After controlling the infectious process, we performed a progressive surgical closure with a planned ventral hernia with phasic prosthesis and dermoepidermic graft. Methods This patient had her follow up appointment to prepare for reconstructive surgery with weight loss and biofeedback. She did a CT that demonstrated a ventral hernia (89 × 90 mm) between recuts muscle and transversus. This hernia classified as M2-M5+W3 on the right and L4+W3 on the left. We used adjuvant therapy with botulinum toxin and subcutaneous expansor. Results The reconstruction was performed in two steps. First, we performed a colostomy closure with no complications. After one week we performed an abdominal wall reconstruction with transversus abdominal release. Due to some skin necrosis and risk of infection identified during surgery we decided to differ the closure with a prosthesis with double layer (one reabsorbable and one synthetic) and a dermoepidermic flap. Conclusion Complex abdominal wall hernia are difficult cases to treat due to anatomical changes and infectious complications associated. New materials are being developed that can help to overcome some difficulties that we face.

Abstract Aim To review the clinical outcomes of complex abdominal wall reconstructions (AWR) with cross-linked acellular dermal matrix1 (CADM) implants over 23 years and how the indications to its use may have changed overtime. Materials and Methods Retrospective analysis of patients who underwent complex abdominal wall hernia surgeries with the use of CADM between September 2000 to June 2023, including elective and emergency procedures. Results 95 procedures were performed in 88 patients. 24% of patients had 1 or 2 comorbidities, 66% had at least 3 comorbidities. BMI was 30 or above in 75% of patients. Overall, 27 (31%) procedures were performed as an emergency, 73% of which were performed since 2020. Fascial closure was achieved in 60% of patients; however, in the emergency group, fascial closure was 10%. Postoperative events occurred in 62% of cases. Postoperative mortality was 3%. 81 patients were available for long-term follow up, the median length of which was 64 months (range 0–214 months). Clinical recurrence was present in 25 (28%) patients and in all cases it presented in the first 2 years. Twenty-one patients had died of unrelated causes during follow up. Two patients required further intervention for unrelated causes and no adverse mesh related events were recorded in the long-term. Conclusions CADM biologic implants for AWR are safe and early results appear to be maintained overtime without long-term adverse events. CADM seems to perform well in particularly challenging situations like emergencies which appears to be becoming its main clinical application.