Muscle Dysfunction as the Missing Link in Ventral Hernia Pathogenesis: Toward a Functional Herniology Framework

This study aimed to perform a conceptual analytical synthesis of the available evidence on the functional state of the musculofascial system of the anterior abdominal wall in ventral hernia, to appraise the potential contribution of muscular dysfunction and neuromuscular discoordination to pathogenesis and functional recovery, and to formulate a working concept of functional herniology. A structured narrative review with conceptual analytical synthesis was performed using literature retrieved from PubMed/MEDLINE, Embase, ClinicalTrials.gov, and Google Scholar. Two investigators independently screened the publications. Forty publications were included in the synthesis, differing in study design, populations, and methods used to assess anterior abdominal wall function. Quantitative pooling of data and formal risk-of-bias assessment were not performed. The synthesis identified four interrelated domains: the functional organisation of the anterior abdominal wall; the distinction between anatomical and functional outcomes of hernia repair; the influence of different reconstructive techniques on subsequent biomechanics and neuromuscular adaptation; and the potential involvement of muscular dysfunction and discoordination in the multifactorial processes of hernia formation and recovery. The available evidence does not establish muscular dysfunction as a universal causal mechanism but supports the biological plausibility of its interaction with connective-tissue, systemic, and local biomechanical factors. On this basis, we propose a concept of functional herniology in which anatomical reconstruction is complemented by objective functional assessment, individualised prehabilitation, and postoperative rehabilitation. To operationalise this approach, a two-level PFO system is proposed, comprising preoperative assessment of baseline functional reserve and perioperative assessment of changes in the musculofascial system; the proposed thresholds require prospective validation. Ventral hernia may therefore usefully be regarded not only as an anatomical defect but also as a condition in which the functional competence of the anterior abdominal wall may carry independent clinical significance. Functional herniology is not intended to replace surgical treatment but to complement it through the assessment and restoration of muscular function, taking into account hernia type, baseline functional reserve, and individual patient goals. The role of neuromuscular discoordination in ventral hernia development and recovery, as well as the clinical applicability of the PFO system, requires prospective evaluation.