Multimodal Prehabilitation for Hernia Repair: Linking Metabolic Modulation and Mechanical Methods

Background: Abdominal wall hernias represent a significant global surgical burden, with over 20 million repairs performed annually. The convergence of rising obesity and diabetes rates with complex hernia management has necessitated innovative preoperative optimization strategies that address both metabolic dysfunction and mechanical challenges. Objectives: This comprehensive review synthesizes current evidence on emerging pharmacologic and procedural optimization strategies for patients undergoing abdominal wall hernia repair, with particular emphasis on glucagon-like peptide-1 (GLP-1) receptor agonists, botulinum toxin A (BTA) injections, progressive preoperative pneumoperitoneum (PPP) and biomechanical calculated repair. Methods: We conducted an extensive literature review incorporating recent clinical trials, observational studies, and meta-analyses, focusing on metabolic optimization with GLP-1 receptor agonists, mechanical preparation techniques, and their comparative effectiveness in reducing perioperative complications and hernia recurrence. Results: GLP-1 and GLP-1/GIP agonists demonstrate substantial metabolic benefits including weight reduction (10-20%), improved glycemic control, reduced systemic inflammation, and decreased postoperative complications in surgical populations. Recent evidence suggests reduced surgical site infection, thromboembolic events, and wound dehiscence in GLP-1 receptor agonists users. However, concerns regarding delayed gastric emptying and aspiration risk require careful perioperative management. BTA and PPP remain valuable techniques for mechanical optimization in loss-of-domain hernias, though modern biomechanically calculated repair (BCR) approaches using cyclic load analysis may reduce their necessity in many cases. The GRIP/CRIP concept demonstrates superior outcomes with 5-7% five-year recurrence rates compared to 15% with conventional approaches. Emerging evidence highlights collagen metabolism dysfunction as a fundamental determinant of hernia recurrence, prompting development of collagen-focused prehabilitation programs incorporating nutritional supplementation, aquatic exercise, and targeted physical conditioning. Conclusions: A paradigm shift toward integrated, personalized preoperative optimization is emerging, combining metabolic conditioning with mechanical preparation based on individual patient phenotypes and hernia complexity. Future research should focus on comparative effectiveness trials, optimal timing protocols, and multimodal strategies to maximize surgical outcomes while minimizing complications.