How I do it: using physics and progressive defect tensioning to close large hernia defects during MIS ventral hernia repair.

Introduction: Closure of large hernia defects with minimally invasive surgery has long-been a challenge. Barbed sutures have helped us bridge this technical gap, but their off-label use is not well studied.

Materials and methods: We describe a suturing technique for minimally invasive ventral hernia repair (MIS-VHR) termed "progressive defect tensioning" and explore its theoretical advantages. Progressive defect tensioning utilizes barbed sutures to progressively and evenly re-approximate the fascia along the entire defect length. Tension is then sequentially applied to each throw, distributing the load across multiple anchor points along the closure. This redistribution of tension is explained using a physics model to depict its theoretical benefit. We also explore how biomechanical properties, such as tissue creep and hysteresis, impact closure of complex defects.

Results: Our initial, proof-of-concept cohort of 12 patients with hernias larger than 10 cm undergoing MIS-VHR had acceptable perioperative outcomes compared to the literature.

Conclusions: Ultimately, progressive defect tensioning leverages the properties of barbed sutures and the biomechanics of fascia to achieve optimal tension distribution during MIS-VHR.