Approaches to Ventral Hernia Repair: A Narrative Review

Ventral hernia repair is a significant and evolving challenge in general surgery, encompassing a wide spectrum of primary and incisional abdominal wall defects of varying complexity. The burden of ventral hernia continues to rise globally due to increasing rates of abdominal surgeries, aging populations, and the growing prevalence of risk factors such as obesity and metabolic disorders. Despite advances in surgical techniques, recurrence and postoperative complications remain important concerns, necessitating continuous refinement of management strategies. This narrative review synthesizes contemporary evidence on ventral hernia repair, focusing on mesh-based techniques, classification systems, patient optimization, and evolving surgical approaches. Mesh reinforcement remains the cornerstone of modern hernia repair, with strong evidence supporting the superiority of synthetic mesh over biologic mesh for recurrence outcomes, even in contaminated settings. Advances in mesh design, particularly the adoption of lightweight materials, have improved patient-reported outcomes by reducing chronic pain without compromising durability. Patient-related factors such as obesity significantly influence perioperative outcomes, highlighting the importance of individualized treatment strategies. The concept of loss of domain has emerged as a critical determinant of surgical complexity, with imaging-based volumetric assessment playing a key role in preoperative planning. Prehabilitation and multidisciplinary optimization have gained prominence as essential components of care. Evidence demonstrates that structured preoperative interventions, including exercise, nutritional support, and risk factor modification, reduce complications and improve recovery. Adjunct techniques such as botulinum toxin injection and progressive pneumoperitoneum further enhance outcomes in complex hernia repair by facilitating tension-free closure. Minimally invasive approaches, including laparoscopic and robotic techniques, have transformed ventral hernia surgery. Laparoscopic repair is associated with reduced wound complications and shorter hospital stays compared to open repair while maintaining similar recurrence rates. Robotic surgery offers additional technical advantages and improved short-term outcomes, although concerns regarding operative time and cost remain. Advanced techniques such as enhanced-view totally extraperitoneal repair and transversus abdominis release have expanded the surgical armamentarium for complex cases. Perioperative strategies continue to evolve, with emerging evidence questioning the routine use of surgical drains. Overall, ventral hernia repair has transitioned toward a patient-centered, evidence-based approach that integrates surgical innovation with perioperative optimization. Future research should focus on long-term outcomes, cost-effectiveness, and personalized treatment strategies to further improve patient care.