Open Reconstruction for Massive Abdominal Wall Defect Following Radical Resection of Recurrent Endometriosis: A Novel Retromuscular-Onlay Dual-Mesh Technique

Open Reconstruction for Massive Abdominal Wall Defect Following Radical Resection of Recurrent Endometriosis: A Novel Retromuscular-Onlay Dual-Mesh Technique | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 25 August 2025 V1 Latest version Share on Open Reconstruction for Massive Abdominal Wall Defect Following Radical Resection of Recurrent Endometriosis: A Novel Retromuscular-Onlay Dual-Mesh Technique Authors : Dongbing Ding , Yuan Wang , Rongpu Liang , Jiarong , Qingjian Ye , and Bo Wei 0000-0002-1058-5888 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175610361.10495678/v1 136 views 111 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Abdominal wall endometriosis (AWE), often post-cesarean, can cause massive abdominal wall defects following lesion resection. This report details a novel open technique for recurrent massive AWE in a 32-year-old female involving radical excision with at least 1cm margins and dual-mesh repair with pre- and post-rectus abdominis placement alongside stratified drainage. The operation went smoothly, the patient was discharged on day 6, pathology confirmed the diagnosis, and short-term follow-up showed excellent outcome without complications, demonstrating a safe and effective reconstructive strategy. math_shortcuts Open Reconstruction for Massive Abdominal Wall Defect Following Radical Resection of Recurrent Endometriosis: A Novel Retromuscular-Onlay Dual-Mesh Technique Dongbing Ding 1,# , Yuan Wang 1,# , Rongpu Liang 1 , Jiarong You 1 , Qingjian Ye 2,* , Bo Wei 1,* 1 Department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China. 2 Department of Gynaecology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China. # There authors contribute equally. * Corresponding author. Email address: [email protected] , [email protected] Abstract Abdominal wall endometriosis (AWE), often post-cesarean, can cause massive abdominal wall defects following lesion resection. This report details a novel open technique for recurrent massive AWE in a 32-year-old female involving radical excision with at least 1cm margins and dual-mesh repair with pre- and post-rectus abdominis placement alongside stratified drainage. The operation went smoothly, the patient was discharged on day 6, pathology confirmed the diagnosis, and short-term follow-up showed excellent outcome without complications, demonstrating a safe and effective reconstructive strategy. Keywords : Abdominal wall endometriosis, Abdominal wall reconstruction, Dual-mesh Repair Introduction Abdominal wall endometriosis (AWE) is a rare extrapelvic manifestation of endometriosis, accounting for 1%–3.5% of cases[1]. Over 60% of cases occur post-cesarean section due to direct implantation of endometrial cells during closure, less commonly spontaneously or after laparoscopic procedures. Hormonally driven proliferation leads to cyclic painful masses, occasionally with skin bleeding or pigmentation[2-4]. Preoperative misdiagnosis as hernia, hematoma, or tumor is common. Imaging via ultrasound, CT, or MRI is essential for diagnosis[5]. This article reviews the literature on AWE management and presents a case of recurrent, large-volume AWE to discuss its clinical presentation, diagnostic approaches, and treatment strategies. It specifically highlights the safety, feasibility, and innovation of employing a dual-mesh technique for abdominal wall defect repair, aiming to address the biomechanical limitations inherent in traditional repair methods. Case Report A 32-year-old female with one prior cesarean section and a history of excision for AWE, presented with a recurrent mass at the site of her cesarean scar in the lower abdomen, accompanied by pain synchronized with her menstrual cycle for six months. Physical examination revealed an approximately 8.0 × 5.0 cm soft, mobile mass located within the transverse lower abdominal cesarean scar. CT and color Doppler ultrasound confirmed an 8.0 cm diameter mass in the lower abdominal wall (Fig. 1A-1E). Other investigations were unremarkable. The procedure utilized a dual-mesh technique to reconstruct and reinforce the large abdominal wall defect resulting from wide excision of the recurrent AWE, overcoming the biomechanical and structural deficiencies associated with interrupted suture tissue closure[6, 7]. Multiple tissue spaces negative pressure drainage to minimize the risk of surgical site and patch infection. Fig. 1. Preoperative imaging examination. Ultrasound showed a mass in the lower abdominal wall, with a range of approximately 6.7cm×4.2cm (A, B). Computed tomography showed a mass in the lower abdominal wall, suggested endometriosis of the abdominal wall, with a range of approximately 8.0cm×5.0cm (C-E). Methods Following induction of general anesthesia, the patient was positioned supine. The surgical field was prepared and draped aseptically. A 12.0 cm incision was made along the previous lower abdominal scar. The skin and subcutaneous tissues were incised in layers, and superior and inferior skin flaps were elevated to the level of the umbilicus and pubic symphysis, respectively. This exposure revealed an 8.0 × 5.0 cm lesion infiltrating the bilateral rectus abdominis muscles and their anterior and posterior sheaths (Fig. 2B). The anterior rectus sheath was incised circumferentially approximately 1.0 cm beyond the lesion margins. The involved segments of the rectus muscles, posterior rectus sheath, extraperitoneal fat, and peritoneum were resected en bloc, and the specimen was removed (Fig. 2C). Upon entering the peritoneal cavity, adhesions between the omentum and the previous incisional peritoneum were lysed, and meticulous hemostasis was achieved. No other endometriotic lesions were identified within the peritoneum or abdominal cavity. The peritoneum was closed using a running 3-0 barbed suture (Fig. 2D). The plane between the posterior rectus sheath/transversalis fascia and underlying structures was developed circumferentially: superiorly to the umbilicus, inferiorly to the Retzius space (prevesical space), and laterally to the lateral borders of the rectus muscles. Hemostasis was secured (Fig. 2E). A 15.0 × 12.0 cm mesh was positioned in the retromuscular space (posterior to the rectus abdominis) and fixed with interrupted 3-0 absorbable sutures (Fig. 2F). A 14 mm negative pressure drainage tube was placed anterior to this mesh and exteriorized through a separate stab incision in the left flank (Fig. 2G). The medial edges of the residual rectus muscles and anterior rectus sheaths were partially approximated using a running 1-0 barbed suture. A significant defect remained in the anterior rectus sheath under tension, precluding primary closure. Consequently, a 10.0 × 8.0 cm mesh was placed in the onlay position (anterior to the rectus abdominis and residual anterior sheath). This mesh was fixed with interrupted 3-0 absorbable sutures (Fig. 2H). The running 1-0 barbed suture closure of the anterior sheath was then completed over the onlay mesh, incorporating it into the repair. Final hemostasis was confirmed. Two additional 14 mm negative pressure drainage tubes were placed in the subcutaneous space and exteriorized through separate stab incisions in the right and left flanks. The subcutaneous tissue and skin were closed layer by layer (Fig. 2I). Fig. 2. Details of surgical procedures. AWE lesion area (A). Intraoperative AWE lesion area (dotted line) (B). Radical resection of AWE lesion (C). Display of abdominal wall defect and normal anatomical structure after AWE lesion resection (D). Expand the extraperitoneal space (E). Posterior rectus abdominis mesh (F). A negative pressure drainage tube was placed in the preperitoneal space (G). Anterior rectus abdominis mesh (H). Two negative pressure drainage tubes were placed subcutaneously, and the subcutaneous fascia and skin were closed layer by layer (I). Total operative time was 125 minutes, with an estimated blood loss of 10 mL. Postoperative pathological report confirmed that there were endometrial glands and stroma in abdominal wall smooth muscle tissue (Fig. 3B). The patient recovered well, was discharged on postoperative day 6, and achieved primary wound healing by day 14 (Fig. 3C), with no postoperative complications. Fig. 3. Postoperative specimen examination and wound healing. AWE lesion gross specimen (A). Postoperative pathology (B). Wound healing 14 days after operation (C). Discussion Ensuring complete resection of the lesion is a key strategy in this case. Recurrence of abdominal wall endometriosis (AWE) is directly associated with inadequate surgical resection margins. Literature consensus supports a ≥1 cm lesion-free margin as the foundation for radical cure[8, 9]. In this case, under open surgical visualization, the involved rectus abdominis muscle and its sheath were resected en bloc with a 1 cm margin beyond the lesion edge, aligning with international guideline recommendations[10]. Crucially, patients with concurrent uterine adenomyosis require extended resection margins: Piriyev et al.’s (2023) multicenter study demonstrated that AWE lesions coexisting with adenomyosis are significantly larger (3.34±1.4 cm vs. 2.55±1.33 cm, P=0.016) and exhibit a higher propensity for deep fascial infiltration (42% vs. 19%, P=0.03)[3]. This patient’s history of uterine adenomyosis corroborates this increased risk. Biomechanical advantages and technical nuances of dual-mesh reconstruction in this case. Traditional single-layer mesh repair of large abdominal wall defects carries inherent biomechanical weaknesses[11]. This case innovatively employed a ”Retromuscular and Onlay” dual-mesh design (a ”dual-reinforcement” strategy). Specifically, the posterior mesh (utilizing the Rives-Stoppa technique) was placed in the retro-rectus space, leveraging intra-abdominal pressure to secure the mesh against the abdominal wall and effectively distribute tension[12, 13]. The anterior (Onlay) mesh covered the residual anterior fascial defect, resisting abdominal wall shear forces[9]. Benedetto et al. (2022) reported a hernia recurrence rate as high as 18.2% for defects >3 cm repaired by primary suture[8], whereas the dual-mesh technique achieved zero recurrence in this case with an 8.0 × 5.0 cm defect. This approach aligns with the rationale of Chen et al. (2024), who used an anterior polypropylene mesh for high-tensile support and a posterior large-pore non-absorbable mesh to minimize adhesions. Studies confirm that using biological mesh alone results in hernia recurrence rates of up to 56%, whereas synthetic-biological composite meshes effectively balance strength and biocompatibility[14, 15]. Preventive value of layered drainage for complications in this case. Seroma formation and infection are the primary complications following AWE surgery, with reported incidences ranging from 4.5% to 35.3%[8]. Our protocol implemented a triple-channel negative-pressure drainage system: one drain placed anterior to the inner mesh (in the preperitoneal space) and two drains placed subcutaneously, achieving anatomically layered drainage. Literature indicates that a drainage output of <50 mL per 24 hours constitutes a safe threshold for drain removal[9]. In this case, layered drainage achieved this target by postoperative day 5, significantly reducing the risk of seroma compared to traditional single-drain approaches. Furthermore, intraoperative measures including timely instrument changes, meticulous peritoneal closure, and positioning drain exit sites remote from the surgical incision effectively prevented contamination of the mesh and operative field. Conclusion The successful treatment of this case confirms that radical resection for recurrent massive abdominal wall endometriosis (AWE) requires a ≥1 cm lesion-free margin, with consideration for extended margins in patients complicated by adenomyosis. The dual-mesh mechanical reconstruction (posterior pre-muscular and anterior onlay) overcomes the mechanical limitations of traditional sutures through a synergistic anti-tension mechanism, providing both anatomical and functional repair for defects >5 cm. Layered negative pressure drainage serves as a key adjunctive strategy to prevent seroma and infection. This integrated protocol achieved excellent outcomes with no postoperative complications, establishing a reproducible surgical paradigm for complex AWE abdominal wall reconstruction. Future prospective studies are needed to validate the long-term durability of the retromuscular-onlay dual-mesh technique and standardize drainage protocols. math_shortcuts Conflicts of interests The authors have no conflict of interest to declare. Funding All authors do not receive any sources of funding. Ethical approval Ethical approval is exempt at our institute. Authors’ contributions Dongbing Ding, Rongpu Liang, Jiarong You, Yuan Wang = Study concept, Data collection, and surgical therapy for the patient Yuan Wang = Writing- original draft preparation Dongbing Ding, Yuan Wang = Editing and writing Bo Wei, Qingjian Ye = senior author and manuscript reviewer All the authors read and approved the final manuscript. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this journal. Guarantor Bo Wei is the guarantor of this paper. Acknowledgement Not applicable. References 1. Carsote M, Terzea DC, Valea A, Gheorghisan-Galateanu AA: Abdominal wall endometriosis (a narrative review) . Int J Med Sci 2020, 17 (4):536-542.2. Foley CE, Ayers PG, Lee TT: Abdominal Wall Endometriosis . Obstet Gynecol Clin North Am 2022, 49 (2):369-380.3. Piriyev E, Namazov A, Mahalov I, Mamedova A, Gemer O, Schiermeier S, Römer T: Clinical and Surgical Characteristics of Abdominal Wall Endometriosis: A Multicenter Case Series of 80 Women . In Vivo 2023, 37 (2):756-762.4. Khan Z, Zanfagnin V, El-Nashar SA, Famuyide AO, Daftary GS, Hopkins MR: Risk Factors, Clinical Presentation, and Outcomes for Abdominal Wall Endometriosis . J Minim Invasive Gynecol 2017, 24 (3):478-484.5. Allen SE, Rindos NB, Mansuria S: Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management . Curr Opin Obstet Gynecol 2021, 33 (4):288-295.6. 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Grigore M, Socolov D, Pavaleanu I, Scripcariu I, Grigore AM, Micu R: Abdominal wall endometriosis: an update in clinical, imagistic features, and management options . Med Ultrason 2017, 19 (4):430-437.11. Chen Y, Wu L, Qian C, Wu W, Chu B, Dong J: Application of the mesh bridging technique in the excision of abdominal endometriosis lesions: Case report and literature review . Int J Gynaecol Obstet 2025, 168 (2):449-455.12. Hartog F, Sneiders D, Darwish EF, Yurtkap Y, Menon AG, Muysoms FE, Kleinrensink GJ, Bouvy ND, Jeekel J, Lange JF: Favorable Outcomes After Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Noncomplex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-analysis . Ann Surg 2022, 276 (1):55-65.13. Tasdelen HA, Karapolat B: Extended totally extraperitoneal Rives-Stoppa technique for incisional hernia repair - a video vignette . Colorectal Dis 2020, 22 (4):475.14. Zhao R, Wang XJ, Song KX, Zhu L, Li B: Mini-abdominoplasty combined with mesh used for abdominal wall endometriosis . Chin Med J (Engl) 2012, 125 (9):1614-1617.15. Li J, Qiu L, Li X, Zhou T, Chen S: Laparoscopic treatment of abdominal wall endometriosis: A case series . Case Rep Womens Health 2024, 42 :e00616. Supplementary Material File (figure.pdf) Download 3.04 MB Information & Authors Information Version history V1 Version 1 25 August 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords endometriosis: basic science endometriosis: diagnosis endometriosis: surgery gynaecological surgery Authors Affiliations Dongbing Ding Affiliated Hospital of Sun Yat-sen University View all articles by this author Yuan Wang Affiliated Hospital of Sun Yat-sen University View all articles by this author Rongpu Liang Affiliated Hospital of Sun Yat-sen University View all articles by this author Jiarong Affiliated Hospital of Sun Yat-sen University View all articles by this author Qingjian Ye Affiliated Hospital of Sun Yat-sen University View all articles by this author Bo Wei 0000-0002-1058-5888 [email protected] Affiliated Hospital of Sun Yat-sen University View all articles by this author Metrics & Citations Metrics Article Usage 136 views 111 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Dongbing Ding, Yuan Wang, Rongpu Liang, et al. Open Reconstruction for Massive Abdominal Wall Defect Following Radical Resection of Recurrent Endometriosis: A Novel Retromuscular-Onlay Dual-Mesh Technique. Authorea . 25 August 2025. DOI: https://doi.org/10.22541/au.175610361.10495678/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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