Biomechanics applied to incisional hernia repair – Considering the critical and the gained resistance towards impacts related to pressure

  • F. Kallinowski
    Correspondence author at: Senior Surgeon, Hernia Center, General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Department of Surgery, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany.
    General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany

    General and Visceral Surgery, GRN Hospital Eberbach, Scheuerbergstrasse 3, 69412 Eberbach, Germany
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  • Y. Ludwig
    General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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  • T. Löffler
    General and Visceral Surgery, GRN Hospital Eberbach, Scheuerbergstrasse 3, 69412 Eberbach, Germany
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  • M. Vollmer
    Hamburg University of Technology, Biomechanics, Denickestrasse 15, 21073 Hamburg, Germany
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  • P.D. Lösel
    Engineering Mathematics and Computing Lab (EMCL), Interdisciplinary Center for Scientific Computing, Im Neuenheimer Feld 205, 69120 Heidelberg, Germany

    Heidelberg Institute for Theoretical Studies (HITS), Schloss-Wolfsbrunnenweg 35, 69118 Heidelberg, Germany
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  • S. Voß
    Department of Fluid Dynamics and Technical Flows, Otto-von-Guericke-Universität Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany

    Research Campus STIMULATE, Otto-von-Guericke-Universität Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany
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  • J. Görich
    Radiological Center, Kellereistrasse 32-34, 69412 Eberbach, Germany
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  • V. Heuveline
    Engineering Mathematics and Computing Lab (EMCL), Interdisciplinary Center for Scientific Computing, Im Neuenheimer Feld 205, 69120 Heidelberg, Germany

    Heidelberg Institute for Theoretical Studies (HITS), Schloss-Wolfsbrunnenweg 35, 69118 Heidelberg, Germany

    Heidelberg University Computing Centre (URZ), Im Neuenheimer Feld 293, 69120 Heidelberg, Germany
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  • R. Nessel
    General, Visceral and Pediatric Surgery, Klinikum Am Gesundbrunnen, Am Gesundbrunnen 20-26, s Heilbronn, Germany
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      • Reconstructions of incisional hernias can be improved on a biomechanical basis.
      • All elements of an incisional hernia repair can be characterized with a bench test.
      • The biomechanical requirements were adapted to the individual tissue elasticity.
      • A new surgical strategy considers the gained resistance to impacts related to pressure.
      • Patients treated with this strategy show no recurrences and reduced pain levels after one year.



      Incisional hernia repair is burdened with recurrence, pain and disability. The repair is usually carried out with a textile mesh fixed between the layers of the abdominal wall.


      We developed a bench test with low cyclic loading. The test uses dynamic intermittent strain resembling coughs. We applied preoperative computed tomography of the abdomen at rest and during Valsalva's maneuver to the individual patient to analyze tissue elasticity.


      The mesh, its placements and overlap, the type and distribution of fixation elements, the elasticity of the tissue of the individual and the closure of the abdominal defect–all aspects influence the reconstruction necessary. Each influence can be attributed to a relative numerical quantity which can be summed up into a characterizing value. The elasticity of the tissues within the abdominal wall of the individual patient can be assessed with low-dose computed tomography of the abdomen with Valsalva's maneuver. We established a procedure to integrate the results into a surgical concept. We demonstrate potential computer algorithms using non-rigid b-spline registration and artificial intelligence to further improve the evaluation process.


      The bench test yields relative values for the characterization of hernia, mesh and fixation. It can be applied to patient care using established procedures. The clinical application in the first ninety-six patients shows no recurrences and reduced pain levels after one year. The concept has been spread to other surgical groups with the same results in another fifty patients. Future efforts will make the abdominal wall reconstruction more predictable.


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