Are Retromuscular Repairs Always the Best Option for Ventral Hernias? Augmented Evidence Review

Area of Science:

• Abdominal surgery
• Hernia repair
• Surgical outcomes

Background:

• Ventral hernia repair (VHR) is common, with over 600,000 procedures annually in the US.
• Retromuscular repair is considered the gold standard but its universal applicability is debated.
• This study evaluates retromuscular repair across diverse ventral hernia complexities.

Purpose of the Study:

• To determine if retromuscular repair is always the optimal approach for ventral hernia repair.
• To assess the efficacy and safety of retromuscular repair across a spectrum of hernia sizes and complexities.
• To compare retromuscular repair outcomes with other mesh placement techniques.

Main Methods:

• An Augmented Evidence Review (AER) integrating three data streams: registry analysis (35,625 patients), surgeon polling, and AI-driven literature synthesis.
• Retrospective analysis of elective VHR with sublay mesh placement from the Abdominal Core Health Quality Collaborative (ACHQC) registry.
• Surgeon polling via the International Hernia Collaboration and AI literature synthesis with manual verification.

Main Results:

• Retromuscular repair utilization increases with defect size (5.0% for <3cm to 59.2% for 5-10cm).
• Retromuscular repair showed lower 1-year recurrence (6.2% vs 14.1%) but higher 30-day morbidity (SSI, readmission, reoperation).
• Surgeons prefer retromuscular repair for defects 5-10cm; AI synthesis confirms superior recurrence for large defects but comparable short-term outcomes with lower morbidity for smaller defects (≤6cm).

Conclusions:

• Retromuscular repair is crucial for complex ventral hernias.
• A universal retromuscular strategy is not supported; mesh plane selection should be individualized.
• Retromuscular reconstruction should be reserved for cases where its benefits significantly improve long-term outcomes.