SURGICAL MANAGEMENT OF COMPLEX HERNIAS: UPDATE ON MESH TECHNIQUES AND MATERIALS

Abstract

INTRODUCTION: Complex abdominal wall hernias represent one of the greatest challenges in reconstructive surgery due to their high recurrence rate, infectious complications, and technical difficulties in wall closure. In recent decades, advances in reconstructive techniques, especially posterior component separation with Transversus Abdominis Release (TAR), and the development of new mesh materials, have transformed the management of these cases. The incorporation of laparoscopic and robotic approaches, combined with the rational use of synthetic, biological, and biosynthetic meshes, has enabled safer and more durable reconstructions. OBJECTIVES: To critically review the recent evidence on the surgical management of complex hernias, addressing reconstructive techniques, mesh positioning, types of materials used, and their clinical outcomes, based on the most recent publications from PubMed and the Cochrane Library. METHODS: An integrative literature review was conducted between September and October 2025 in the PubMed/MEDLINE and Cochrane Library databases, including studies published between 2015 and 2025. The descriptors used were: complex abdominal wall hernia, ventral hernia repair, transversus abdominis release, surgical mesh materials, and biosynthetic mesh. Clinical trials, systematic reviews, and observational studies involving adults undergoing complex hernia repair were included. RESULTS: A total of 38 studies were included in the analysis. TAR has established itself as the technique of choice for extensive reconstructions, with recurrence rates below 10%. The robotic (r-TAR) and eTEP-RS versions showed lower morbidity and faster recovery. Retromuscular (sublay) positioning showed the best functional results and a lower incidence of infection. Low-density synthetic meshes demonstrated greater cost-effectiveness and lower recurrence than biological meshes, even in contaminated fields. Resorbable biosynthetic hernias (P4HB) showed intermediate and promising results. Adjuvant strategies, such as botulinum toxin A, progressive pneumoperitoneum, and negative pressure therapy, reduced complications and favored primary closure. CONCLUSION: The management of complex hernias requires a multidimensional, evidence-based, and personalized approach. The combination of advanced reconstruction techniques, optimized materials, and perioperative optimization results in greater safety, fewer recurrences, and improved abdominal function. The future points to the integration of robotic surgery, smart biomaterials, and three-dimensional planning, consolidating a new paradigm in abdominal wall reconstruction.