Why repeating onlay repair fails in complex hernias: a salvage strategy using open IPOM+ and functional abdominoplasty – a case report

Introduction: We present a rare case of a multiply recurrent ventral hernia following repeated onlay repairs, resulting in significant anatomical distortion and impaired quality of life, which was managed with open intraperitoneal onlay mesh plus suture of the defect (IPOM+) 1 and functional abdominoplasty. Case presentation: A 56-year-old woman with no relevant medical history and a complex surgical history presented with a fourth recurrence of an incisional hernia following repeated subcutaneous onlay mesh repairs, associated with a severe panniculus deformity of the lower abdomen. The presence of multiple overlapping meshes resulted in extensive fibrosis and a large abdominal wall bulge extending toward the right thigh. Computed tomography scan revealed a 5 cm para-umbilical defect with a large hernia sac, an additional supra-umbilical defect, and significant lower abdominal tissue redundancy. The patient underwent open abdominal wall reconstruction. Previous mesh layers were dissected and removed, allowing restoration of native fascial planes. Minimal visceral adhesions facilitated safe dissection. Both defects were repaired using a single dual-layer intraperitoneal mesh, followed by tension-free primary midline closure, obviating the need for component separation. A functional abdominoplasty was then performed through an extended Pfannenstiel incision, including flap elevation to the xiphoid with preservation of the vascular supply, excision of approximately 4 kg of redundant tissue, and creation of a neo-umbilicus. Conclusion: This case supports a shift toward more widely accepted, higher-yield reconstructive strategies that restore midline continuity, such as minimally invasive sublay or overlay repairs, and that change the plane of reinforcement and incorporate soft-tissue optimization to achieve a durable repair.