Safety and efficacy of retromuscular-onlay dual-mesh reconstruction for massive abdominal wall defects secondary to abdominal wall endometriosis resection

Massive abdominal wall defects resulting from radical abdominal wall endometriosis (AWE) resection present a major reconstructive challenge. This study aims to assess feasibility and short-term safety of a standardized retromuscular-onlay dual-mesh repair technique in this setting. In this single-center retrospective study, 9 patients with massive abdominal wall endometriosis underwent radical excision and standardized retromuscular-onlay dual-mesh reconstruction between January 2024 and June 2025. A series of postoperative complications was analyzed, including surgical site infection, symptomatic seroma, hematoma, wound pain and numbness, mesh infection, incisional hernia, and recurrence of abdominal wall endometriosis. All nine patients, with a history of cesarean delivery, were diagnosed with type III AWE. Clinical presentation uniformly featured a palpable abdominal wall mass and pain accompanying the menstrual cycle. Previous surgical intervention for AWE had been undertaken in 22.2% (2/9) of patients. All reconstructive procedures were successfully performed. We recorded a mean specimen diameter of 9.61 ± 2.56 cm, an operative time of 114.00 ± 41.81 min, and an estimated blood loss of 15.70 ± 11.61 mL. The mean postoperative hospital stay was 8.50 ± 2.72 days, and drains were maintained for a mean of 5.00 ± 1.05 days. In this small cohort study, no surgical site infections, mesh infections, hematomas, or symptomatic seromas requiring intervention occurred. At a mean follow-up of 6 months, no clinical recurrence of AWE or incisional hernia was observed. Only one patient (11.1%) reported a slight numbness in the skin of the surgical area. This standardized dual-mesh reconstruction technique appears feasibility and short-term safety for massive AWE-related abdominal wall defects, with encouraging short-term outcomes and low early complication rates in this initial experience. Longer-term follow-up and prospective multi-center studies are needed to confirm durability. Similar content being viewed by others

Abdominal wall endometriosis (AWE) is a relatively uncommon clinical entity, comprising about 1% of endometriosis cases, which typically arises post-cesarean section and presents with cyclical pain and a palpable mass [1,2,3]. The management of AWE often necessitates radical resection, which can result in substantial full-thickness abdominal wall defects. Repairing these defects, particularly those exceeding 5 cm, presents a significant surgical challenge, as primary closure under tension or simple onlay mesh repair is associated with high rates of wound complication, mesh failure, and hernia recurrence. Achieving a durable, functional reconstruction requires a technique that addresses both the structural defect and the biomechanical forces of the abdominal wall. Building upon established principles of complex ventral hernia repair, a dual-plane mesh reconstruction strategy combining the retromuscular (Rives-Stoppa) and onlay positions has been proposed [4]. This approach theoretically distributes intra-abdominal pressure across a broad retro-muscular plane while providing anterior reinforcement to the fascial layer, thereby optimizing stability. However, comparative data on the safety profile and perioperative outcomes of this specific dual-mesh technique versus conventional single-mesh or flap-based reconstructions in the setting of post-excisional AWE defects remain lacking. Therefore, this study aims to assess the feasibility and short-term safety of a standardized retromuscular-onlay dual-mesh reconstruction protocol in a consecutive series of patients with massive abdominal wall defects undergoing AWE resection.

Study design and participants A single-center, retrospective study was conducted on all female patients who underwent surgical treatment for recurrent, histologically confirmed AWE between January 2024 andJune 2025. Inclusion criteria comprised histologically confirmed AWE requiring radical resection and reconstruction performed using the standardized retromuscular–onlay dual-mesh technique. Exclusion criteria involved incomplete medical records or insufficient follow-up data. Institutional review board approval was obtained, and consent for participation was waived due to the retrospective nature of the study. Surgical technique A standardized operative protocol was followed: (1) Radical resection of the lesion en bloc with a ≥ 1 cm macroscopic margin, frequently involving portions of the rectus abdominis; (2) Closure of the posterior sheath and peritoneum with a running barbed suture; (3) Retromuscular placement of a large-pore mid-weight polypropylene mesh, fixed with absorbable sutures after bilateral space development; (4) Onlay placement of a second mesh to bridge the residual fascial defect, with anterior sheath approximation when feasible. A triple-channel negative-pressure drainage system was employed for anatomically layered drainage (Fig. 1). Data collection and outcomes Demographic, clinical, and operative data were extracted from HIS Medical Management System of the Third Affiliated Hospital of Sun Yat-sen University. The primary outcome measure was the incidence of short-term postoperative complications: surgical site infection (SSI) as defined by centers for disease control and prevention (CDC) criteria [5], symptomatic seroma requiring intervention, hematoma, mesh infection, and wound dehiscence. Secondary outcomes included operative time, estimated blood loss, drain duration, length of hospital stay, and clinical evidence of hernia recurrence at follow-up. Statistical analysis Descriptive statistics were used. Quantitative data are presented as mean ± standard deviation or median with interquartile range (IQR) as appropriate, and categorical variables are presented as frequencies and percentages.

Patient characteristics This study enrolled nine female patients, whose detailed clinical characteristics are summarized in Table 1. The cohort had a mean age of 32.00 ± 5.01 years and a mean body mass index (BMI) of 19.66 ± 2.41 kg/m². All patients had a history of at least one prior cesarean delivery. Two patients (22.2%) had undergone previous surgery for abdominal wall endometriosis (AWE), while the remaining seven (77.8%) presented for primary surgical intervention. According to the applied classification, all patients were diagnosed with type III AWE. Preoperative clinical presentation uniformly included cyclic pain and a palpable abdominal wall mass. The mean lesion diameter, as measured by preoperative ultrasound, was 7.73 ± 2.07 cm. A comprehensive preoperative evaluation—encompassing symptoms, physical signs, and imaging—confirmed the diagnosis of abdominal wall endometriosis in all patients. After complete preoperative preparation, all patients proceeded to radical surgery and achieved an uncomplicated recovery. Intraoperative and postoperative outcomes The intraoperative and postoperative outcomes of the 9 massive AWE patients are detailed in Table 2. The median diameter of the postoperative specimen was 8.80 cm [IQR 7.20–12.20] resulting in a large abdominal wall defect in muscle layer. The mean operative time was 114.00 ± 41.81 min, with a minimal mean estimated blood loss of 15.70 ± 11.61 mL. Postoperatively, the mean hospital stay was 8.50 ± 2.72 days, and surgical drains were maintained for a mean duration of 5.00 ± 1.05 days. Recovery milestones included a mean time to first flatus of 2.00 ± 1.00 days, the median time to first oral intake of 1.00 days [IQR 1.00–1.00], and the median time to first ambulation of 2.00 days [IQR 2.00, 2.50]. The surgical approach for these extensive defects necessitated component separation technique (CST) in all 9 (100%) cases, specifically involving anterior rectus sheath and external oblique aponeurosis release, to achieve restoration of the abdominal wall’s anatomical continuity. Notably, in this small series, no major postoperative complications were recorded, including surgical site infection (superficial or deep), major hemorrhage, injury to adjacent organs/tissues, or cardiovascular/respiratory complications. These findings suggest that, in this selected cohort, the surgical strategy is safe in the short term. Therefore, for abdominal wall defects following resection of large AWE lesions, the surgical strategy of combining component separation techniques (CST) to maximally restore anatomical integrity with standardized retromuscular-onlay dual-mesh reinforcement to reconstruct the abdominal wall mechanics is safe. Surgical outcomes at the 6-month follow-up The outcomes at the 6-month follow-up are presented in Table 3. At a mean follow-up of six months, one patient (11.1%) reported persistent numbness in the surgical area, while no patients complained of chronic pain at the operative site. Following neurotrophic treatment, the patient experiencing numbness in the surgical area has shown continued symptomatic improvement and will be monitored further. Throughout this follow-up period, no clinical recurrence of abdominal wall endometriosis was observed, and no patient developed an incisional hernia. These short-term outcomes suggest that the retromuscular-onlay dual-mesh strategy may restore abdominal wall integrity and prevent hernia in the early postoperative period.

This study demonstrates that the standardized retromuscular-onlay dual-mesh reconstruction appears feasibility and short-term safety for the repair of massive full-thickness abdominal wall defects following radical resection of abdominal wall endometriosis (AWE). In this small cohort study, no surgical site infections, mesh infections, hematomas, or symptomatic seromas occurred, and no hernia recurrence was observed during a mean follow-up of six months. The success of this technique relies on an integrated protocol encompassing three key principles: preoperative planning, operative execution, and postoperative management. Radical excision with adequate surgical margins is the cornerstone for preventing disease recurrence and ensuring successful reconstruction. AWE is a benign but locally infiltrative condition, and incomplete resection is a primary cause of recurrence. In all cases, en bloc resection with a macroscopic margin of ≥ 1 cm was performed, adhering to oncologic principles [6, 7]. This approach aims to completely remove ectopic endometrial tissue that may invade the fascia or muscle, along with the associated pro-fibrotic and pro-angiogenic inflammatory microenvironment. Adequate margins also create a healthy recipient bed for synthetic mesh placement, which is crucial for preventing mesh infection. The retromuscular-onlay dual-mesh reconstruction is designed to restore biomechanical continuity of the abdominal wall [8, 9]. For massive defects, conventional primary closure or single-layer mesh repair often fails due to excessive tension or insufficient coverage [10]. Our strategy achieves robust reconstruction through synergistic action across different anatomical planes: The deep (retromuscular) mesh, placed in the Rives-Stoppa space between the posterior rectus sheath and peritoneum, serves as the core load-bearing layer. Its primary function is to widely and evenly distribute intra-abdominal pressure to the healthy myofascial tissues laterally, achieving a physiological “tension-distribution” repair and reestablishing the posterior mechanical barrier [4, 11]. The superficial (onlay) mesh, placed over the anterior rectus sheath, serves several key purposes. First, it reinforces the fascial closure line. Even after mobilization and approximation, the suture line remains mechanically weak, and the onlay mesh provides essential anterior reinforcement. Second, it covers secondary weak zones created by the component separation technique (CST) [12, 13]. To achieve tension-free midline closure, we routinely perform CST by releasing the anterior rectus sheaths or external oblique aponeuroses. However, these released areas themselves become new potential weak points. The onlay mesh, with its wide coverage, effectively spans and reinforces these lateral regions, thereby compensating for the mechanical compromise induced by CST and providing a dual assurance of both “midline reinforcement” and “lateral coverage.” Finally, it offers mechanical redundancy. This two-layer construct forms a composite reinforcement system in which, should one layer experience minor failure, the other continues to provide substantial support, significantly enhancing the overall reliability of the reconstruction. A standardized multi-layer drainage protocol is a critical adjunct for ensuring surgical safety and promoting healing [14]. Postoperative fluid accumulation and infection are common complications after complex abdominal wall reconstruction. The multi-layer negative-pressure drainage system used in this study—one drain placed in the preperitoneal/retromuscular space anterior to the deep mesh, and two placed in the subcutaneous space—represents an anatomy-based, targeted drainage strategy. This drainage strategy utilizes a preperitoneal drain to evacuate exudate from the retromuscular space, reducing fluid risk behind the mesh, while dual subcutaneous drains manage the overlying dead space. This system promotes healing by ensuring close tissue apposition and minimizing dead space, and may further stimulate granulation tissue formation via micro-mechanical stimulation [15]. As a result, this protocol—when integrated with meticulous hemostasis and radical excision—was entirely effective in preventing postoperative seromas or hematomas requiring intervention, thereby underpinning the safety profile and low early complication rate. The limitations of this study must be acknowledged. Its retrospective nature, along with a modest sample size and limited follow-up period (mean 6 months), precludes a meaningful assessment of long-term outcomes such as procedural durability, chronic pain development, and rates of late recurrence. AWE and hernia recurrences typically manifest beyond one year postoperatively, therefore, longer follow-up is essential to validate the durability of this reconstruction technique. Furthermore, the fact that all procedures were conducted by a single, albeit experienced, surgical team may affect the generalizability of our results, necessitating future validation through multi-center studies.

Our initial experience indicates that the retromuscular-onlay dual-mesh reconstruction is a feasible and safe strategy for massive abdominal wall defects secondary to endometriosis resection, with minimal short-term complications and encouraging early outcomes. This protocol thus provides a potential reconstructive option in this complex condition. Definitive confirmation of its advantages and long-term durability awaits prospective, multi-center trials with direct comparison to traditional repair methods. Data availability Data are available from the corresponding author upon reasonable request.

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To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. About this article Cite this article Ding, D., Wang, Y., Wang, H. et al. Safety and efficacy of retromuscular-onlay dual-mesh reconstruction for massive abdominal wall defects secondary to abdominal wall endometriosis resection. Updates Surg (2026). https://doi.org/10.1007/s13304-026-02673-z Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s13304-026-02673-z