Incisional and parastomal hernias after harvesting of Vertical Rectus Abdominis Myocutaneous (VRAM) flaps: incidence, treatment options and outcomes.

Aim: The Vertical Rectus Abdominis Myocutaneous (VRAM) flap is a versatile reconstructive technique but is associated with donor-site morbidity, including incisional hernia (IH) and parastomal hernia (PSH). Our aim was to assess the incidence, treatment options and outcomes of IH and PSH following VRAM flap harvest.

Method: A systematic search was conducted in PubMed, Embase and Scopus (to June 2024) using predefined terms. Studies with at least 10 participants and a follow-up of minimum one year were included. Two reviewers independently performed study selection, data extraction, quality of evidence (GRADE) and risk of bias (ROBINS-I, RoB-2). Primary outcomes were IH and PSH incidence.

Results: 24 studies (2200 patients) were included (19 retrospective cohorts, 3 case series, 2 randomized controlled trials). IH was reported in 10.2% (226/2200) and PSH in 19.2% (219/1143) of patients over a mean follow-up of 31 months (range: 12-66). Studies focused on prophylactic techniques included robotic harvesting (n = 1), fascia-sparing harvesting (n = 5), component separation (n = 6) and mesh-assisted closure (n = 16). Hernia repair involved mesh (n = 3) and primary suture (n = 1).

Conclusion: Despite advances in prophylactic techniques for hernia prevention, significant challenges remain, including high heterogeneity in clinical diagnosis, follow-up duration, and surgical techniques. While some methods, such as fascia-sparing approaches, component separation, and mesh reinforcement show promising outcomes in reducing IH and PSH incidence, a lack of comparative studies prevents reaching a clear consensus. Future research should focus on larger scale studies and expert opinions to develop clinical recommendations for hernia prophylaxis and repair.