Transversus abdominis release in incisional hernia repair: a comprehensive review

Incisional hernia remains a significant challenge following abdominal surgery, necessitating robust repair strategies to mitigate recurrence and wound complications. While the introduction of synthetic mesh has improved durability, complex defects with significant loss of domain or lateral extension often exceed the limitations of traditional repair techniques. The transversus abdominis release (TAR) has emerged as a cornerstone technique in abdominal wall reconstruction, offering a physiological solution by mobilizing the posterior rectus sheath and creating a wide retromuscular plane for extensive mesh reinforcement. This review provides a comprehensive overview of the TAR procedure, encompassing anatomical considerations, current classification systems, and specific indications. We detail the surgical technique, emphasizing critical steps such as neurovascular preservation and the recent "Madrid modification" for enhanced outcomes. Furthermore, we compare the established open TAR with the emerging robotic TAR, highlighting the latter's benefits in reducing wound morbidity and hospital stay, as evidenced by recent meta-analyses. The review also addresses long-term outcomes, contrasting patient-reported bulges with clinical recurrence, and underscores the importance of patient-reported outcome measures for evaluating true surgical success. Finally, we discuss the evolving role of TAR in Korea, emphasizing the need for cost-effectiveness studies and structured training programs to establish it as a standard of care. This article aims to provide surgeons with an expert-level update on TAR, facilitating its optimal application in complex hernia repair.