Can large defects be closed laparoscopically without component separation?

Czech version

Authors: J. Vrbka; T. Paseka; M. Páral; J. Molnár; K. Abukhovich; P. Diviš
Authors‘ workplace: Chirurgické oddělení, SurGal Clinic s. r. o., Brno
Published in: Rozhl. Chir., 2026, roč. 105, č. 7, s. 369-372.
Category: Case Report
doi: https://doi.org/10.48095/ccrvch2026369

Overview

The reconstruction of large incisional abdominal wall hernias presents a significant surgical challenge, particularly in patients with a history of repeated laparotomies, recurrent hernias, or unfavorable anatomical conditions. In recent years, techniques have been developed to achieve primary fascial closure without the need for extensive component separation. These procedures include the preoperative administration of botulinum toxin into the lateral abdominal wall muscles and intraoperative fascial traction. Concurrently, minimally invasive approaches are evolving; while their benefits for convalescence are evident, they encounter technical limitations regarding defect closure. The combination of fascial traction and a minimally invasive approach has not yet been described in the literature, and according to the manufacturer’s data, only a handful of such operations have been performed worldwide.

The authors present a case report of a patient with a large midline incisional hernia following polytrauma, who underwent a two-stage treatment comprising botulinum toxin application and subsequent minimally invasive reconstruction using the eTEP Rives-Stoppa technique combined with fascial traction using the fasciotens^®Hernia system. The procedure led to a successful defect closure without the necessity of component separation, resulting in a highly satisfactory functional outcome.

The discussion addresses the feasibility of incorporating this combination of techniques into the surgical portfolio for advanced abdominal wall defect management.

Keywords:

botulinum toxin A – fascial traction – incisional hernia – Fasciotens – eTEP – Rives-Stoppa

Sources

1. Shankar DA, Itani KM, O’Brien WJ et al. Factors associated with long-term outcomes of umbilical hernia repair. JAMA Surg 2017; 152 (5): 461–466. doi: 10.1001/jamasurg.2016.5052.

2. Dabbas N, Adams K, Pearson K et al. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep 2011; 2 (1): 5. doi: 10.1258/shorts.2010.010071.

3. Henriksen NA, Montgomery, A, Kaufmann R et al. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg 2020; 107 (3): 171–190. doi: 10.1002/bjs.11489.

4. Kulaçoğlu H. Current options in umbilical hernia repair in adult patients. Ulus Cerrahi Derg 2015; 31 (3): 157–161. doi: 10.5152/UCD.2015.2955.

5. Bedewi MA, El-Sharkawy MS, Al Boukai AA et al. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study.Hernia 2012; 16 (1): 59–62. doi: 10.1007/s10029-011-0863-4.

6. Heniford BT, Lincourt AE, Walters AL et al. Carolinas comfort scale as a measure of hernia repair quality of life: a reappraisal utilizing 3788 international patients. Ann Surg 2018; 267 (1): 171–176. doi: 10.1097/SLA.0000000000002027.

7. Heniford BT, Walters AL, Lincourt AE et al. Comparison of generic versus specific quality-of-life scales for mesh hernia repairs. J Am CollSurg 2008; 206 (4): 638–644. doi: 10.1016/j.jamcollsurg.2007.11.025.

8. Nielsen K, Poelman MM, den Bakker FM et al. Comparison of the Dutch and English versions of the Carolinas Comfort Scale: a specific quality-of-life questionnaire for abdominal hernia repairs with mesh. Hernia 2014; 18 (4): 459–464. doi: 10.1007/s10029-013-1173-9.

9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240 (2): 205–213. doi: 10.1097/01.sla.0000133083.54934.ae.

10. Mayo WJ. VI. An operation for the radical cure of umbilical hernia. Ann Surg 1901; 34 (2): 276–280. doi: 10.1097/00000658-190107000-00021.

11. Shrestha D, Shrestha A, Shrestha B. Open mesh versus suture repair of umbilical hernia: meta-analysis of randomized controlled trials. Int J Surg 2019; 62 : 62–66. doi: 10.1016/j.ijsu.2018.12.015.

12. Melkemichel M, Stjärne L, Bringman S et al. Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation. Hernia 2022; 26 (6): 1483–1489. doi: 10.1007/s10029-021-02509-2.

13. Earle D, Roth JS, Saber A et al. SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc 2016; 30 (8): 3163–3183. doi: 10.1007/s00464-016-5072-x.

14. Looft P, Alfarawan F, Bockhorn M et al. Beyond traditional repair: comparing eTEP and open sublay for ventral hernia repair. J Clin Med 2025; 14 (8): 2586. doi: 10.3390/jcm14082586.

15. Sanders DL, Pawlak MM, Simons MPet al. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg 2023; 110 (12): 1732–1768. doi: 10.1093/bjs/znad284.

16. Belyansky I, Daes J, Radu VG et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018; 32 (3): 1525–1532. doi: 10.1007/s00464-017-5840-2.

17. Holt AC, Bamarni S, Leslie SW (eds). Umbilical Hernia. Treasure Island (FL): StatPearls Publishing 2024.

18. Madsen LJ, Oma E, Jorgensen LN et al. Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis. BJS Open 2020; 4 (3): 369–379. doi. 10.1002/bjs5.50276.

19. Helgstrand F, Jørgensen LN, Rosenberg J et al. Nationwide prospective study on readmission after umbilical or epigastric hernia repair. Hernia 2013; 17 (4): 487–492. doi: 10.1007/s10029-013-1120-9.

20. Bencini L, Sanchez LJ, Bernini M et al. Predictors of recurrence after laparoscopic ventral hernia repair. Surg Laparosc Endosc Percutan Tech 2009; 19 (2): 128–132. doi: 10.1097/SLE.0b013e31819cb04b.

21. Zucker BE, Simillis C, Tekkis P et al. Suture choice to reduce occurrence of surgical site infection, hernia, wound dehiscence and sinus/fistula: a network meta-analysis, Ann R Coll Surg Engl 2019; 101 (3): 150–161. doi: 10.1308/rcsann.2018.0170.

22. Salminen P, Kow L, Aminian A et al. IFSO consensus on definitions and clinical practice guidelines for obesity management –⁠ an International Delphi Study. Obes Surg 2024; 34 (1): 30–42. doi: 10.1007/s11695-023-06913-8.