The scale of the underlying problem is considerable. Incisional hernias, which occur when tissue pushes through a healed surgical scar, affect an estimated 10 to 50 percent of patients after open abdominal surgery. Even after repair, recurrence rates between 8.7 and 32 percent have been reported. Simple suture repair of the fascia, the tough connective tissue layer that holds the abdominal contents in place, carries recurrence rates as high as 60 percent according to long-term randomized trial data. Adding mesh to reinforce the repair reduces that figure to around 24 percent, which is why mesh has become a standard part of modern hernia surgery. But mesh introduces its own dilemma when the surgical field is contaminated.

Synthetic prosthetic mesh, typically made of permanent polymer materials, performs well in clean surgical environments and reduces recurrence effectively. In contaminated fields, however, it carries serious long-term risks: mesh infection, wound dehiscence, and the formation of enterocutaneous fistulas, in which bowel abnormally connects to the skin. Biologic mesh, made from processed collagen scaffolds of human or animal origin, was developed partly to address this. Because the material is decellularized collagen rather than plastic, it is far more resistant to infection and can become integrated into the patient’s own tissue through revascularization and cellular ingrowth. The trade-off is cost: biologic mesh can cost up to 200 times more than a synthetic equivalent, a disparity that has fueled an ongoing debate about whether the clinical benefits justify the expense.

The case report centers on a 73-year-old woman who arrived with nausea, vomiting, and abdominal pain. Her history was complicated: hypertension, high cholesterol, a heart attack two decades earlier treated with stenting, coronary bypass surgery, and a hysterectomy thirty years before that had been complicated by infection and a temporary colostomy. On examination, she had a large, non-reducible hernia in her left lower abdomen with what surgeons call loss of domain, meaning so much bowel had migrated into the hernia sac that returning it to the abdominal cavity would be difficult. Her laboratory values told a worrying story: an elevated white blood cell count of 15.5 thousand per microliter, impaired kidney function, and a prealbumin level of 10 milligrams per deciliter indicating significant malnutrition. A CT scan revealed a 7.8-centimeter abdominal wall defect packed with loops of small and large bowel.

What the surgical team found in the operating room was worse than the imaging suggested. After beginning the procedure robotically and encountering dense adhesions, they converted to an open laparotomy. The hernia contained the entire cecum and roughly 140 centimeters of small intestine. Buried within the defect was old permanent mesh from a repair the patient did not know she had received, and stuck to that mesh was a chronic fistulous tract surrounded by infectious material. The team resected the diseased segment of bowel, created a side-to-side anastomosis to restore continuity, removed necrotic hernia sac and ulcerated skin, and irrigated the field copiously. With a 15-centimeter fascial defect remaining and the patient becoming hemodynamically unstable on vasopressor medications, definitive reconstruction was judged too risky. Instead, they placed an AbThera negative pressure dressing, a temporary wound vacuum system, and transferred her to the surgical intensive care unit, intubated and sedated.

Two days later, with her white blood cell count improving and her ventilator requirements minimal, the team returned to the operating room for the second stage. This is the technical heart of the report. Because the bowel could not be reduced through the fascial defect, the surgeons performed a left-sided anterior component separation, a technique first described by Ramirez and colleagues in 1990. The procedure involves releasing the external oblique muscle from the internal oblique along the lateral abdominal wall, which allows the rectus abdominis muscles to slide medially and gain several centimeters of closure. In this patient, releasing the external oblique yielded roughly 8 centimeters of immediate fascial mobilization. Even so, the fascial edges could not be brought together without tension, so the team bridged the gap with a 20 by 25 centimeter piece of XenMatrix, a porcine-derived, non-crosslinked collagen mesh, sutured in an underlay position beneath the fascia using running absorbable sutures, with the skin loosely approximated over a wound vacuum.

The choice of underlay placement and non-crosslinked material reflects deliberate biomechanical reasoning. Underlay mesh, positioned beneath the abdominal wall, distributes forces across a larger area than mesh placed on top of the fascia, and published series report recurrence rates of 7 to 30 percent with this configuration. The Rives-Stoppa retrorectus technique, in which mesh is sandwiched between well-vascularized tissue planes, may be more durable but is often technically impossible in patients with multiple prior surgeries because those planes have been obliterated by scar tissue. The absence of cross-linking in XenMatrix allows tissue integration within about two weeks and, critically, permits safe direct contact with bowel. In this case, the mesh lay directly on the intestine with no fistulization at twelve-month follow-up, a feared complication that did not materialize.

The recovery was not smooth, and the report is candid about that. The patient required wound vacuum changes three times weekly for a month, an operative debridement of necrotic skin edges three weeks after the index operation, temporary dialysis through a permacath, intravenous antibiotics, and total parenteral nutrition to optimize healing. Her kidney function eventually normalized, the dialysis catheter was removed, and she tolerated a low-fiber diet without nutritional supplementation before discharge to a skilled nursing facility. At outpatient follow-up, her wound shrank progressively with granulation tissue filling in under a portable wound vacuum, and she has had no readmissions for postoperative infection. She remains ambulatory and satisfied with her quality of life.

The authors situate their result within a genuinely contested literature. A randomized trial by Rosen and colleagues found a 20.5 percent recurrence rate with biologic mesh versus 5.6 percent with synthetic mesh at two years in contaminated single-stage repairs, alongside the stark cost differential, leading some surgeons to argue synthetic mesh remains preferable. Carbonell and colleagues, by contrast, found nearly identical mesh-removal rates for infection, around 4 to 5 percent, between the two materials. Studies of bridging repairs consistently show higher recurrence than repairs achieving fascial closure, because biologic mesh stretches under prolonged tension due to its inherent elasticity. Here, even after component separation, a 3 to 4 centimeter midline gap remained, so the surgeons recreated a pseudo-midline by suturing the anterior sheath to the mesh with at least 5 centimeters of overlap, a recognized salvage maneuver. Multistaged approaches, such as removing infected mesh, treating with antibiotics, and repairing later, have produced recurrence rates around 19 percent at 32 months.

The report’s honest limitations are as instructive as its success. Twelve months is a short follow-up interval; most hernia recurrences appear within two to four years, so the absence of recurrence so far is encouraging but not definitive. The authors themselves note that in hindsight, definitive closure might have been delayed further to allow a longer antibiotic course in the contaminated field. They conclude that non-crosslinked porcine biologic mesh combined with anterior component separation is a safe and reasonable option for high-risk patients with contaminated wounds, particularly those too unstable for a single-stage repair, and they call for prospective randomized trials with larger samples and longer follow-up to settle the questions of mesh type, placement, and cost-effectiveness. For now, the case adds a practical, well-documented template: achieve source control first, let the infection clear, then rebuild with a technique that respects both the biology of healing and the mechanics of the abdominal wall.

Subject of Research: Dual-stage abdominal wall reconstruction for contaminated incisional hernia using component separation and biologic mesh

Article Title: Dual-stage abdominal wall reconstruction using component separation and bridging underlay biologic mesh in a contaminated incisional hernia: a case report and literature overview

Article References: Bland, S., & Wood, B. (2025). Dual-stage abdominal wall reconstruction using component separation and bridging underlay biologic mesh in a contaminated incisional hernia: a case report and literature overview. BMC Plastic and Reconstructive Surgery, 1(1), Article 4. https://doi.org/10.1186/s44452-025-00003-7

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00003-7

Keywords: incisional hernia, abdominal wall reconstruction, component separation technique, biologic mesh, XenMatrix, contaminated surgical field, enterocutaneous fistula, underlay mesh placement, negative pressure wound therapy, hernia recurrence, case report, general surgery