Clinical bottom line
For postoperative abdominal wall hernias, current evidence supports the use of mesh repair over primary suture repair to reduce recurrence rates, though mesh placement technique and patient factors influence outcomes. Minimally invasive approaches with mesh, including laparoscopic and robotic-assisted repairs, show promise in lowering postoperative complications and improving recovery, but long-term comparative data remain limited. Careful patient selection and surgical expertise remain critical, and ongoing research is needed to optimize mesh type, placement, and technique.
What the evidence shows
Postoperative abdominal wall hernias, including incisional and ventral hernias, pose a significant surgical challenge due to high recurrence rates and morbidity. Traditional primary suture repair is associated with higher recurrence compared to mesh-based repairs, which provide reinforcement of the abdominal wall and reduce tension (Reinpold et al., 2017). The sublay mesh technique, placing mesh in the retromuscular space, is considered a gold standard for open repair, balancing durability and complication risk (Reinpold et al., 2017).
Minimally invasive mesh repairs, such as laparoscopic intraperitoneal onlay mesh (IPOM) repair, have gained traction due to reduced wound complications and faster recovery. A recent GRADE-assessed systematic review and meta-analysis comparing robotic versus laparoscopic IPOM repair found that robotic repair may reduce postoperative complications and recurrence at 12-24 months, though it is associated with longer operative times (Mirza et al., 2025). These findings suggest robotic assistance could enhance precision in mesh placement and fixation, potentially improving outcomes.
Mesh repair techniques have evolved to include minimally invasive sublay approaches, such as the MILOS technique, which combines the benefits of open sublay mesh placement with smaller incisions, reducing surgical trauma and infection risk (Reinpold et al., 2017). Such approaches may offer improved functional and cosmetic outcomes compared to traditional open repairs.
Pain management adjuncts, including local analgesic formulations like HTX-011, have demonstrated efficacy in reducing postoperative pain and opioid consumption following herniorrhaphy, potentially facilitating enhanced recovery protocols (Viscusi et al., 2019).
While mesh repair reduces recurrence, complications such as seroma, infection, and mesh-related chronic pain remain concerns. Patient factors including obesity, smoking, and comorbidities influence complication risk and should guide surgical planning.
Caveats and uncertainty
Despite advances, several uncertainties persist. Long-term comparative data on robotic versus laparoscopic or open mesh repairs are limited, and cost-effectiveness analyses are lacking. The optimal mesh type and fixation method remain debated, with no consensus on biologic versus synthetic meshes in complex or contaminated fields.
Most studies focus on elective hernias; data on emergency or traumatic abdominal wall hernias are sparse (Azimi-Ghomi et al., 2022). Additionally, loss of domain hernias present unique challenges requiring tailored approaches beyond standard mesh repair (Horne et al., 2026).
The heterogeneity of hernia types, patient populations, and surgical techniques complicates direct comparisons. High-quality randomized controlled trials with standardized outcome measures are needed to clarify best practices.
How this may change practice
Surgeons managing postoperative abdominal wall hernias should consider mesh repair as the preferred approach to minimize recurrence, with sublay placement favored when feasible. Minimally invasive techniques, including laparoscopic and robotic-assisted repairs, may offer advantages in select patients, particularly those at higher risk for wound complications.
Incorporating multimodal pain management strategies such as HTX-011 may improve postoperative recovery and reduce opioid use. Patient optimization addressing modifiable risk factors remains essential.
Surgeons should remain vigilant about mesh-related complications and counsel patients accordingly. Emerging evidence supports expanding the use of robotic platforms, but cost and access considerations must be balanced.
Ongoing education and training in advanced mesh repair techniques, including minimally invasive sublay approaches, may enhance surgical outcomes. Referral to specialized centers for complex cases, such as loss of domain hernias, is advisable.