Best Way to Avoid Trouble With Ab Wall Repair: Don’t Get Into It

Bola Aladegbami, MD

LONG BEACH, Calif.—It may sound like advice from one of our parents, but when it comes to abdominal wall repair, the best way to get out of trouble is to not get into it in the first place. In a presentation at the 2025 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Bola Aladegbami, MD, MBA, shared his strategies for maintaining patient safety and optimizing outcomes after these often complex procedures.

“I think as general surgeons we’re all stoics,” began Dr. Aladegbami. “We prepare to fail and celebrate success. But I change that a little bit by saying if you prepare to fail, you can successfully navigate abdominal wall reconstruction.”

For Dr. Aladegbami, an assistant professor of surgery at Baylor University Medical Center, in Dallas, preparation begins with a comprehensive patient review prior to the clinic visit. As part of this process, he will review referral notes and the patient’s history of present illness. He also obtains and reviews relevant imaging—including wound imaging—particularly those performed in the previous 12 months.

“I’m looking for anything else that might need to be taken care of prior to surgery,” he noted.

Other parts of the preoperative patient review include complete laboratory analyses, including hemoglobin A1c for diabetes; white blood cell, erythrocyte sedimentation rate, and/or C-reactive protein for wounds and infection; Model for End-Stage Liver Disease for cirrhosis; and various nutrition tests.

“Last but not least, I look at their operative report,” he added. “This is where I spend the most time.” This includes a comprehensive analysis of many aspects of prior hernia repairs, including:

• number and type;
• location, size and type of mesh (if any);
• previous mesh removal;
• date of last hernia repair;
• previous mesh infection or wound infection;
• type and extent of component separation (if any); and
• complications from previous repair.

“This last one is important, because if they’ve had complications before, chances are they’ll have them again.”

Once a patient arrives at the clinic, Dr. Aladegbami begins his in-clinic review, a lengthy process whose goal is to first assess the patient’s symptoms and their effects on quality of life. He then uses a physical examination to assess overall functional status and comorbidities, evaluates prior and current CT scans, and orders diagnostic screening as needed.

“Finally, I want to be sure there are no other procedures that need to be done concurrently for these patients,” Dr. Aladegbami noted.

The next part of the process is what Dr. Aladegbami said may be the most important: setting expectations. This begins with determining the patient’s view of success, after which the clinician can offer a likelihood of achieving that success. In setting expectations, he also discusses the probability of attaining fascial closure and restoring core function; the risk for recurrence; and the patient’s postoperative course, including such possibilities as ICU stay, organ dysfunction and hospital length of stay. Finally, setting expectations includes a discussion of bailouts or plans if surgical failure/complications occur, and plans to address recurrence.

As part of the preoperative planning stage, Dr. Aladegbami also seeks to optimize his patients as much as possible. For patients, this work involves smoking cessation as well as initiatives to reduce body mass index, curb diabetes, improve nutrition, bolster activity and cease alcohol consumption. He also likes to use Botox (onabotchulinumtoxinA, Allergan) prior to AWR, particularly in cases where the loss of domain is at least 20% or the defect is greater than 10 cm wide.

And while Dr. Aladegbami recognized these tips may not always result in a textbook case, they offer a thoughtful, methodical approach to help surgeons avoid preventable complications and give complex AWR patients the best possible chance at a successful outcome.

Session co-moderator Kaela E. Blake, MD, agreed that preparation is the key to success in AWR. For surgeons, that means knowing which techniques are going to work and not work, understanding any gastrointestinal problems that may arise, anticipating the abdominal wall closure, and having a backup plan (or plans) for when things do not go as expected.

Preparation also extends to the patient, said Dr. Blake, an assistant professor of surgery at the University of Tennessee Medical Center, in Knoxville. “If we can get patients to lose weight, stop smoking, control their diabetes, and get healthy, that sets them up for more success,” she noted.

And while patients are increasingly open to the idea of preoperative optimization, they also need to be educated on the importance of the steps they’re being asked to take. “If you’re working with a patient who has a BMI of 50 or 60 and they’re coming in for a hernia repair, they need to be educated on why we need to optimize them before jumping in and fixing their hernia,” she said.

At the same time, surgeons need to meet their patients with realistic goals, Dr. Blake added. “If we tell patients to lose 100 pounds before we’ll operate on them without providing them resources to accomplish this requirement, that’s not reasonable,” she said. “And if the patient is having real problems related to their hernia, then I think we need to be reasonable, meet them with realistic expectations, and thoroughly educate them on the complications that could happen if they’re not fully optimized.

“And as long as they are educated and totally understand potential complications, then I think we need to operate in an elective setting to avoid risking emergent hernia repairs.”

Dr. Aladegbami reported no relevant financial disclosures. Dr. Blake reported a financial relationship with Gore.