Transversus abdominis release (TAR) versus preperitoneal repair (PPR) in complex, open abdominal wall reconstruction

The evolution of abdominal wall reconstruction has produced multiple effective techniques for hernia repair. Transversus abdominis release and preperitoneal repair allow for the placement of large mesh constructs. The outcomes of these techniques have not been compared, and this was the aim of this study.

Prospective data from 3,783 open abdominal wall reconstructions underwent a 1:1 propensity-score match for elective transversus abdominis release and preperitoneal repair using comorbidities, wound class, and defects. Standard descriptive and comparative statistics were applied.

Propensity-score matching produced 347 pairs. There was no difference in age, body mass index, tobacco use, diabetes, American Society of Anesthesiologists score, wound class, or number of comorbidities. Patients who underwent transversus abdominis release had more recurrent hernias (69.2% vs 53.9%; P < .001). Preoperative Botox injections used for chemical component separation were similar (8.1% vs 9.8%; P = .425). These hernias were large and complex, with more than 22.3% being contaminated. Transversus abdominis release involved larger defects (247.8 ± 137.2 vs 223.4 ± 152.3 cm²; P = .003) and mesh sizes (994.5 ± 417.5 vs 845.7 ± 412.4 cm²; P < .001) with greater use of synthetic versus biologic mesh (70.6% vs 62.0%; P = .019). Fascial closure was not significantly different (98.6% vs 96.3%; P = .056). Transversus abdominis release had longer operative time (209.6 ± 69.6 vs 184.9 ± 75.6 minutes; P < .001), but operating room charges were similar ($18,565 ± 11,792 vs $18,209 ± 11,847; P = .390). There were no differences in infection (6.6% vs 6.9%), seroma intervention (12.7% vs 8.4%), or mesh infection (1.7% vs 0.6%) (all P > .05). Patients who underwent transversus abdominis release experienced greater wound breakdown (7.8% vs 4.0%; P = .036) and overall wound complications (25.6% vs 18.4%; P = .022). With an average follow-up of 21.8 ± 31.9 and 29.1 ± 36.1 months, there was no difference in hernia recurrence (2.9% vs 2.9%; P > .999).

Compared with transversus abdominis release, preperitoneal abdominal wall reconstruction demonstrated equivalent hernia recurrence rates with fewer wound complications. Preperitoneal repair represents an effective approach to complex hernia repair for large defects, facilitating wide mesh placement while mitigating wound morbidity.