Use of PERitoneal free flap (PERFF) augmentation in complex ventral hernia repair

In complex ventral hernias, tension-free midline fascial re-approximation may remain unattainable despite posterior component separation (PCS) with transversus abdominis release (TAR). We describe a technique and our initial experience using the entire peritoneal sac as a free flap to augment repair in this setting.

This retrospective single-center study included all consecutive patients who underwent PERitoneal Free Flap (PERFF) reconstruction between January 2024 and January 2025. Demographics, hernia characteristics, operative details, and post-operative outcomes-including complications (Clavien-Dindo classification), surgical site infection, seroma, hematoma, and hernia recurrence-were analyzed.

Eight patients underwent ventral hernia repair using PERFF. The mean age was 68.1 years (range, 57-82), and the mean body mass index was 32.5 kg/m² (range, 27-43). The mean defect width was 6.6 cm (range, 5-15 cm), defect sizes ranged from 5 × 5 cm to 12 × 15 cm, and the Tanaka index ranged from 0.25 to 0.45. Six patients required bilateral TAR and two unilateral TAR. Two patients underwent concomitant small bowel resection. All patients were discharged by post-operative day 3. No post-operative complications or hernia recurrences were observed during a mean follow-up of 17.6 months.

PERFF is a feasible and safe adjunct to augment PCS with TAR in complex ventral hernia repair when midline closure is not achievable. Harvesting the entire peritoneal sac as a free flap provides flexible and durable fascial coverage while maintaining separation of the mesh from visceral and subcutaneous tissues.