Are retromuscular repairs always the best option for ventral hernias? Augmented evidence review

Ventral hernias account for over 600,000 repairs performed annually in the United States, and retromuscular repair has long been considered the technical gold standard for ventral hernia repair (VHR). However, whether its benefits extend uniformly across the full spectrum of hernia complexity remains uncertain. This study employs a novel augmented evidence review (AER) methodology, integrating 3 complementary evidence streams, to evaluate whether retromuscular repair is always the optimal approach.

Three evidence streams were analyzed: (i) a retrospective analysis of 35,625 adult patients undergoing elective VHR with sublay mesh placement in the Abdominal Core Health Quality Collaborative registry; (ii) surgeon polling conducted through the International Hernia Collaboration, an international surgeon social media forum; and (iii) artificial intelligence (AI)-generated literature synthesis using OpenEvidence, with all cited sources manually verified.

Retromuscular utilization increased with defect size, from 5.0% for defects < 3 cm to 59.2% for defects measuring 5 to 10 cm. Despite representing a more complex cohort (larger defects, more recurrent hernias, and greater contamination), retromuscular repair demonstrated lower clinical recurrence at 1 year (6.2% vs 14.1%), but was associated with higher 30-day morbidity, including surgical site infection, readmission, and reoperation. Surgeon polling similarly identified the 5-to-10-cm range as the threshold at which retromuscular repair becomes strongly preferred (67% of respondents). The AI-literature synthesis reinforced this size-dependent pattern, affirming retromuscular repair's superior recurrence profile for large and complex defects while identifying comparable short-term outcomes with preperitoneal or onlay repair, and lower associated morbidity, for small primary hernias ≤ 6 cm.

Retromuscular repair remains an essential technique in ventral hernia surgery and appears to be preferentially utilized for larger and more complex abdominal wall defects. Contemporary evidence, expert opinion, and real-world practice patterns do not support a universal retromuscular strategy for all ventral hernias. Instead, mesh plane selection should be individualized according to hernia characteristics, patient factors, and operative objectives, with retromuscular reconstruction reserved for scenarios in which its unique reconstructive advantages are most likely to improve long-term outcomes.