Predicting fascial non-closure in ventral hernia repair with transversus abdominis release: risk factors, clinical outcomes, and implications for surgical planning.

Background: Posterior components separation with transversus abdominis release (TAR) reduces tension on the anterior and posterior fascial elements in complex ventral hernia repairs, but its use does not ensure complete fascial closure. This study evaluates the relationship between hernia size and anterior fascial closure success rates following TAR and identifies predictive factors for non-closure.

Methods: We retrospectively analyzed 1,677 patients who underwent open ventral hernia repair with TAR and synthetic mesh placement at a single institution from 2014 to 2023. The primary outcome was the rate of overall anterior fascial closure after TAR. Secondary outcomes included the association of hernia size with fascial closure, predictors of fascial closure and wound morbidity.

Results: The overall fascial closure rate was 93.9% (n = 1,574). Hernia width independently predicted fascial closure success, with reduced odds for widths of 15-20 cm (OR 0.39, p = 0.017) and > 20 cm (OR 0.05, p < 0.001), relative to hernias < 15 cm. History of open abdomen (OR 0.33, p < 0.001) and higher ASA classification (OR 0.39, p = 0.042) were associated with non-closure. Fascial non-closure was associated with increased wound morbidity (p < 0.05), while closure independently reduced odds of one-year surgical site infection (SSI) (OR 0.13; p < 0.001) and surgical site infections and occurrences requiring procedural intervention (SSI/O PI) (OR 0.52; p = 0.001).

Conclusions: While excellent overall fascial closure rates were achieved among patients undergoing TAR, specific patient and hernia characteristics significantly impact success. These findings establish a reference point for closure rates by hernia width and identify high-risk populations who may benefit from preoperative adjunctive interventions.