Technique and outcomes of posterior layer supplementation in retromuscular ventral hernia repair

Contemporary abdominal wall reconstruction places a strong emphasis on optimizing extraperitoneal mesh placement. When the posterior layer is insufficient for closure, adjuncts such as hernia sac, omentum, or Vicryl mesh have been described. The outcomes of various posterior layer supplementation (PLS) materials, both autologous and non-autologous, have not been well examined. We aim to evaluate the outcomes of patients undergoing ventral hernia repair with extraperitoneal mesh placement who undergo PLS and compare how PLS materials impact these outcomes.

All patients who underwent a retromuscular hernia (RM) repair with PLS between Jan 2021 and Jan 2025 at a single center were reviewed. Patient demographics, preoperative characteristics, intraoperative factors, and postoperative outcomes were evaluated. Descriptive statistics and comparative tests including Mann-Whitney U test, Student's t-test, and Fisher's exact test were utilized.

Sixty-seven patients underwent RM repair with PLS. Supplement materials used included hernia sac, omentum, falciform ligament, prior mesh, new biologic, and biosynthetic coated mesh. Fifty-two percent (n = 35) of the repairs were retrorectus only and 48% (n = 32) were transversus abdominus releases. The average length of follow-up was 189 days with a recurrence rate of 3%. Sixty percent of PLS was performed with autologous material with 40% utilizing new biologic or biosynthetic coated meshes. SSI, SSO, and SSOPI were similar between the autologous and non-autologous supplementation groups (p = 1, p = 0.16, p = 0.29, respectively). There were more postoperative bowel obstructions in the non-autologous group (n = 4) as compared to the autologous group (n = 0) (p = 0.02). All the bowel obstructions were managed nonoperatively.

Our findings suggest that outcomes are acceptable with minimal morbidity when comparing autologous tissue to biologic and biosynthetic coated mesh for PLS. The low recurrence rates observed, regardless of the material used, support the continued adoption of this approach. Proactive supplementation of the visceral sac may decrease need for lateral myofascial release.