Modified SCOLA Repair for Large Incisional Hernia With Rectus Diastasis

Postoperative incisional ventral hernias (POIH) can sometimes be avoided and are challenging to repair. If the underlying rectus diastasis (RD) is left untreated, the attenuated linea alba predisposes to hernia formation and recurrence. Guidelines recommend concomitant repair of hernia and RD using mesh, but data on endoscopic subcutaneous onlay techniques for large or complex POIH defects remain scarce. This study reports long‑term outcomes of a modified subcutaneous onlay endoscopic approach (SCOLA) combined with bilateral rectus fascia release (RFR), triple‑action seroma prevention (TASP), and preoperative Botulinum toxin A (BOTOX) injection when needed for large POIH combined with RD.

A retrospective review included adults undergoing SCOLA‑RFR between 2016 and 2024. Forty-five patients met the eligibility criteria for POIH with concomitant RD. Forty-two patients (93.3%) completed the structured telephone survey and constituted the analytic cohort. Endoscopic subcutaneous dissection, bilateral relaxing incisions in the anterior rectus sheath, midline plication, and onlay mesh glue reinforcement were performed. Quilting sutures, hypertonic saline irrigation, and fibrin sealant limited seroma. BOTOX was injected preoperatively for wide or rigid defects. Functional outcomes and satisfaction were assessed by telephone survey with 6 to 108 months of follow‑up.

The cohort (24 males, 18 females; mean age: 55±12 y) had hernia widths of 2 to 12.5 cm and RD widths of 6 to 13.5 cm. Nearly half of hernias (47.6%) followed minimally invasive surgery, and 52.4% followed open surgery. Functional level improved in 88.1%, core strength was preserved or improved in 95.2%, and 95.2% reported no residual pain or urinary/bowel symptoms. The overall complication rate was 21.4% and was limited to seromas occurring before the introduction of the triple‑action protocol; no seromas were noted thereafter. Recurrence occurred in one patient (2.4%). High satisfaction was reported by 88.1%.

Untreated RD may contribute to POIH, including after minimally invasive surgery. SCOLA-RFR combined with TASP and selective BOTOX use may provide a durable, minimally invasive extraperitoneal approach for large POIH with RD, avoiding peritoneal re-entry and muscle transection, with low recurrence and high patient satisfaction.