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Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

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Abstract

Purpose

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

Methods

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

Conclusions

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial.

Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

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Acknowledgements

The authors would like to thank Lauren Halligan, CMI, for her work with the illustrations in this article, as well as Greg Dumanian, MD, and Suhail K. Mithani, MD, for their input during the revision process.

Author information

Author notes

  1. Juan Esteban Perez and Michael A. Schmidt have contributed equally to the article.

Authors and Affiliations

  1. Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University, Durham, NC, 27704, US

    J. E. Perez, A. Narvaez, L. K. Welsh, R. Diaz, M. Castro, A. D. Guerron & J. Yoo

  2. Department of Physical Therapy and Occupational Therapy, Duke University, Durham, NC, 27710, US

    M. A. Schmidt

  3. Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, 27710, US

    K. Ansari, R. W. Cason & H. Levinson

  4. Department of General Surgery, New Hanover Regional Medical Center, Wilmington, NC, 28403, US

    J. A. Bilezikian

  5. General Surgery Specialists, New Hanover Regional Medical Center, Wilmington, NC, 28403, US

    W. Hope

  6. Director of Innovation and Entrepreneurship, Associate Professor of Plastic and Reconstructive Surgery, Pathology, Dermatology and Surgical Sciences, Departments of Dermatology, Pathology, and Surgery, Duke University Medical Center, DUMC 3181, Durham, NC, 27710, US

    H. Levinson

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Contributions

HL, JEP, MAS, ANC, LKW, RDJ, MCR, KA, and ADG were involved in the design and conception of the manuscript. HL, JEP, and MAS were involved in the literature review and drafting of the manuscript. HL, JEP, MAS, ANC, LKW, RDJ, MCR, KA, RWC, JAB, WH, ADG, and JY were involved in critically reviewing the content presented in the article.

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Correspondence to H. Levinson.

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Dr. Levinson is the Inventor/Founder, Chief Medical Officer of Deep Blue Medical Advances, the company that commercializes T-Line Mesh. In addition, Dr. Levinson has a patent licensed to Deep Blue Medical Advances. William Hope, MD has received consulting/research honorarium from CR Bard, speaker honorarium from WL Gore, consultant/speaker honorarium from Intuitive Surgery, and consultant honorarium from Medtronic. Jin Yoo, MD has received consultant/speaker honorarium from Alesi Surgical, Medtronic, and WL Gore, and speaker honorarium from ConMed. Alfredo D. Guerron, MD has received consultant honorarium from Levita and Biom'Up, speaker honorarium from WL Gore and Medtronic. The other authors declare that they have no conflict of interest.

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Perez, J.E., Schmidt, M.A., Narvaez, A. et al. Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction. Hernia 25, 1–13 (2021). https://doi.org/10.1007/s10029-020-02304-5

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