Biomechanical reconstruction of the anterior abdominal wall and its mathematical modeling in large incisional hernias

Large incisional hernias are a serious problem in modern surgery. Performing separation retromuscular prosthetic hernioplasty for complex ventral hernias is associated with significant injury and high risks of complications. Studying the biomechanics of the anterior abdominal wall may improve the results of surgical treatment of patients with large postoperative ventral hernias.
Objective: to develop and substantiate, using mathematical modeling, an algorithm for performing biomechanical reconstructive hernioplasty for large incisional hernias.
Materials and methods. The theoretical basis of the biomechanical reconstruction was a geometric model of the anterior abdominal wall, formed after transformations, taking into account the restoration of the true size of the abdominal cavity. To create a physically stable line of approximation of a hernial defect, the laws of classical mechanics describing the relationship between body stress and its deformation are used. The presented physico-mathematical model makes it possible to determine the optimal stretching distances for both sides of the muscular-aponeurotic sides of the anterior abdominal wall, at which the forces of elastic deformation will balance each other. To substantiate the presented concept, a prospective single-center study was conducted involving 74 patients with large postoperative ventral hernias. The first group included 33 patients for whom the biomechanical reconstruction model was applied, and the second group consisted of 41 patients for whom this algorithm was not applied.
Results. Both groups had no statistically significant differences at the preoperative stage, and the parametric characteristics of hernias were comparable (p>0.05). Biomechanical reconstruction of the anterior abdominal wall made it possible to reduce the number of bilateral (p<0.001) and increase the number of unilateral posterior separation procedures (p=0.014) in the first group, compared with the second. There was also a reduction in the time of surgery (p=0.021), the length of hospitalization (p=0.037) and the number of complications (p=0.682) in the first group, compared with the second.
Conclusion. The use of biomechanical reconstructive hernioplasty makes it possible to take into account the anatomical and physiological features of the anterior abdominal wall, which is reflected in the creation of a stable suturing line of the hernial defect.

1. Bosanquet D.C., Ansell J., Abdelrahman T., Cornish J., Harries R., Stimpson A., et al. Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients. PLoS One. 2015 Sep 21;10(9):e0138745. https://doi.org/10.1371/journal.pone.0138745

2. Henriksen N.A., Bougard H., Gonçalves M.R., Hope W., Khare R., Shao J., et al. Primary ventral and incisional hernias: comprehensive review. BJS Open. 2024 Dec 30;9(1):zrae145. https://doi.org/10.1093/bjsopen/zrae145

3. Sanders D.L., Pawlak M.M., Simons M.P., Aufenacker T., Balla A., Berger C., et al. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg. 2023 Nov 9;110(12):1732-1768. https://doi.org/10.1093/bjs/znad284. Erratum in: Br J Surg. 2024 Jan 3;111(1):znad349. https://doi.org/10.1093/bjs/znad349

4. Omar I., Zaimis T., Townsend A., Ismaiel M., Wilson J., Magee C. Incisional Hernia: A Surgical Complication or Medical Disease? Cureus. 2023 Dec 15;15(12):e50568. https://doi.org/10.7759/cureus.50568

5. Barbosa C.A., Faria M.H.S., Messias B.A. Predictive factors for complexity in abdominal wall hernias: a literature scope review. Rev Col Bras Cir. 2024 May 6;51:e20243670. https://doi.org/10.1590/0100-6991e-20243670-en

6. Harji D., Thomas C., Antoniou S.A., Chandraratan H., Griffiths B., Henniford B.T., et al. A systematic review of outcome reporting in incisional hernia surgery. BJS Open. 2021 Mar 5;5(2):zrab006. https://doi.org/10.1093/bjsopen/zrab006

7. Gandhi J.A., Shinde P.H., Banker A.M., Takalkar Y. Computed tomography for ventral hernia: Need for a standardised reporting format. J Minim Access Surg. 2023 Jan-Mar;19(1):175-177. https://doi.org/10.4103/jmas.jmas_34_22

8. Tanaka E.Y., Yoo J.H., Rodrigues A.J. Jr, Utiyama E.M., Birolini D., Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia. 2010 Feb;14(1):63-9. https://doi.org/10.1007/s10029-009-0560-8

9. Lesch C., Nessel R., Adolf D., Hukauf M., Köckerling F., Kallinowski F., et al. STRONGHOLD first-year results of biomechanically calculated abdominal wall repair: a propensity score matching. Hernia. 2024 Feb;28(1):63-73. https://doi.org/10.1007/s10029-023-02897-7

10. Culbertson E.J., Xing L., Wen Y., Franz M.G. Loss of mechanical strain impairs abdominal wall fibroblast proliferation, orientation, and collagen contraction function. Surgery. 2011 Sep;150(3):410-7. https://doi.org/10.1016/j.surg.2011.06.011

11. Novitsky Y.W., Elliott H.L., Orenstein S.B., Rosen M.J. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16. https://doi.org/10.1016/j.amjsurg.2012.02.008

12. Gueroult P., Joppin V., Chaumoitre K., Di Bisceglie M., Masson C., Bege T. Linea alba 3D morphometric variability by CT scan exploration. Hernia. 2024 Apr;28(2):485-494. https://doi.org/10.1007/s10029-023-02939-0

13. Hubner P.N.V., Alberti L.R., Carvalho A.C., Soares V.C., Neto C.S., Garcia D.P.C. Morphometric evaluation of the linea alba in fresh corpses. JPRAS Open. 2024 Mar 26;40:238-244. https://doi.org/10.1016/j.jpra.2024.03.005

14. Thankam F.G., Larsen N.K., Varghese A., Bui T.N., Reilly M., Fitzgibbons R.J., et al. Biomarkers and heterogeneous fibroblast phenotype associated with incisional hernia. Mol Cell Biochem. 2021 Sep;476(9):3353-3363. https://doi.org/10.1007/s11010-021-04166-6

15. Thankam F.G., Palanikumar G., Fitzgibbons R.J., Agrawal D.K. Molecular Mechanisms and Potential Therapeutic Targets in Incisional Hernia. J Surg Res. 2019 Apr;236:134-143. https://doi.org/10.1016/j.jss.2018.11.037

16. Nessel R., Löffler T., Rinn J., Kallinowski F. Three-year follow-up of the grip concept: an open, prospective, observational registry study on biomechanically calculated abdominal wall repair for complex incisional hernias. Hernia. 2024 Jun;28(3):913-924. https://doi.org/10.1007/s10029-024-03064-2