Bridging the gap – a scoping review of anterior abdominal wall structural mechanics and its role in biomechanically-enhanced ventral hernia management

Ventral hernias remain difficult to treat with persistently high recurrence rates. The aim of the paper was to perform a scoping review on the biomechanics of the human anterior abdominal wall and its role in evidence-based ventral hernia management. A scoping review was conducted in line with PRISMA-ScR guidelines. PubMed and Scopus were searched using predefined keyword combinations of abdominal wall, musculature, biomechanics, hernia, mesh and their derivatives. Full-text human studies were included, without language or format restrictions. Animal studies and posterior abdominal wall were excluded. Eligible articles were thematically categorised, and evidence was summarised. Of the 9,715 abstracts screened, 67 full-text papers met the inclusion criteria. Almost all papers (65 of 67) were published after the year 2000, with much of the current work published as technical papers in non-clinical journals. The risk of bias was low for most original research papers. A substantial amount of work has been based on examination of frozen or fixed cadaveric tissue, although the use of finite element modelling (FEM) and radiological imaging is emerging. Clinically relevant themes identified included the composite nature of the midline and lateral wall muscles, implications of midline incision and trocar placement, the role of risk factors and the hernia damage zone (HDZ) concept. Based on the available biomechanical evidence, a hypothesis-generating treatment framework was proposed. The next generation of ventral hernia repairs will likely be guided by individual biomechanics. Future work should validate objective biomechanical metrics and integrate them into clinical practice.