Purpose

Typical use

• Large midline ventral/incisional defects, often EHS W3, commonly over 10 cm
• Loss of domain or difficult medialization of rectus-fascial edges
• Used after safe adhesiolysis and mobilization of the abdominal wall
• Usually combined with a retromuscular/sublay mesh repair
• May be combined with preoperative adjuncts such as botulinum toxin A in selected patients

Evidence

Important limitations / precautions

• It is a specialist abdominal-wall reconstruction adjunct, not a replacement for sound hernia principles: optimization, adhesiolysis, tension assessment, appropriate mesh plane, and infection-risk control.
• Avoid forced closure if it causes excessive intra-abdominal pressure, impaired ventilation, reduced perfusion, or abdominal compartment physiology.
• The choice between traction, posterior component separation/TAR, anterior component separation, botulinum toxin, progressive pneumoperitoneum, or combinations should be individualized using CT-based assessment of defect width and loss of domain.
• Evidence remains mostly retrospective and device-specific; comparative long-term recurrence and quality-of-life data are limited.

Fasciotens® Hernia technique for a large ventral/incisional hernia

Operative sequence

1. Preoperative planning
   • CT assessment of defect width, hernia contents, loss of domain, muscle quality, and prior mesh.
   • Optimize smoking cessation, diabetes, nutrition, weight where feasible, and pulmonary status.
   • Consider adjuncts such as preoperative botulinum toxin A for very wide or loss-of-domain defects.
2. Exposure and adhesiolysis
   • Open the previous scar or make an incision adequate to expose the whole defect.
   • Reduce hernia contents and perform careful adhesiolysis.
   • Free the abdominal wall sufficiently to permit medial movement of the fascial edges.
   • Evaluate whether posterior reconstruction or retromuscular dissection is planned.
3. Assess the fascial gap
   • Measure the true fascial separation intraoperatively.
   • IFT has mainly been reported for wide defects, often greater than 8-10 cm.
   • Do not attempt a forceful direct closure before traction, because excessive tension risks tissue injury and raised intra-abdominal pressure.
4. Place traction sutures
   • A reported technique uses 12 heavy absorbable braided U-sutures, six on each side.
   • Sutures are placed in the anterior rectus sheath approximately 1 cm lateral to each fascial edge, with bites about 2-3 cm long.
   • Ensure secure full-thickness fascial purchase. Weak, scarred, or friable fascia can tear under traction.
5. Attach to the Fasciotens frame
   • Clamp the traction sutures into the retention frame so the pull is diagonal and anterior.
   • Maintain complete neuromuscular relaxation during traction.
   • Controlled, symmetrical traction is applied and increased only as tolerated by the tissues.
6. Traction phase
   • Published series describe about 30 minutes, commonly 30-35 minutes, of traction.
   • A cohort using Fasciotens Hernia reported forces of approximately 14-18 kg, with sutures re-tensioned around every 2 minutes. This is a reported protocol, not a universal setting.
   • Continuously inspect for suture pull-through, fascial tearing, skin pressure injury, hemodynamic compromise, or ventilation problems.
7. Reassess and reconstruct
   • Release traction and reassess the ability to approximate the midline with low to moderate tension.
   • If closure is still unsafe or impossible, add an appropriate release, commonly posterior component separation/transversus abdominis release (TAR), based on the reconstruction plan.
   • Avoid converting an unsafe closure into a high-tension closure simply because the gap has narrowed.
8. Fascial closure and mesh reinforcement
   • Close the linea alba/anterior fascial layer with an appropriate slowly absorbable or permanent suture strategy.
   • Reinforce with mesh, ideally in a well-vascularized retromuscular/sublay plane when feasible.
   • In the 50-patient Fasciotens series, all closures included sublay mesh reinforcement. The study reported a 90% fascial closure rate after 30-35 minutes of IFT. Retrospective 50-case study
9. Safety check before final closure
   • Assess airway pressures, ventilation, abdominal compliance, tissue perfusion, and hemodynamic status.
   • If there is concern for excessive intra-abdominal pressure or abdominal compartment physiology, do not persist with a tight closure.

Key practical points

Evidence perspective

Fasciotens vs TAR vs preoperative botulinum toxin A

1. Fasciotens® Hernia

• Preserves lateral abdominal-wall anatomy if TAR can be avoided.
• May reduce the extent of dissection and subcutaneous wound morbidity.
• Immediate effect, useful when preoperative BTA was not used.
• Can be used as a step before committing to TAR.

• Requires adequate fascial quality for traction sutures.
• Risk of suture pull-through or fascial tearing if force is excessive.
• Does not solve severe loss of domain by itself.
• Does not replace safe assessment of intra-abdominal pressure after reduction.
• Little high-quality comparative or long-term recurrence evidence.

2. TAR

• Reliable option for large defects and difficult abdominal-wall anatomy.
• Allows broad mesh overlap outside the peritoneal cavity.
• Particularly useful for recurrent hernia, scarred abdominal wall, very wide defect, and when traction or BTA does not give sufficient advancement.
• Can be performed open or robotically in appropriate units.

• Permanent myofascial dissection, technically demanding, and not a minor escalation.
• Open TAR meta-analysis reported pooled surgical-site occurrence of 21.7%, surgical-site infection of 9.1%, and recurrence of 1.6%, although study heterogeneity was substantial. Risk rises with larger defects, higher BMI, smoking exposure, co-morbidity, and recurrent hernia. Open TAR meta-analysis
• If expertise and anatomy permit, robotic TAR may have lower short-term complication and SSI rates than open TAR, but the evidence is based largely on non-randomized comparisons and patient selection differs between groups. Open vs robotic TAR review

3. Preoperative botulinum toxin A

• No additional incision or permanent muscle division.
• Useful for elective complex hernia repair, particularly when defect width is over 10 cm or loss of domain is present.
• May reduce closure tension and, in some patients, avoid or reduce the need for TAR.
• A 2023 systematic review found mean lateral-muscle advancement of about 4.1 cm. BTA systematic review

• Requires planning several weeks before surgery, so it is not useful for urgent repair.
• It does not provide instant mechanical release.
• Clinical benefit is less certain than its radiological effects because published protocols, populations, and repair methods vary.
• Consider pulmonary reserve carefully: weakening the abdominal wall may be poorly tolerated in patients with severe respiratory compromise or neuromuscular disease.
• It should not be viewed as a substitute for mesh reinforcement or safe assessment of post-reduction pressure.

Patient selection

Baseline selection for all three strategies

• Defect width greater than 8-10 cm
• Recurrent incisional hernia
• Loss of domain
• Prior mesh infection, enterocutaneous fistula, stoma, skin loss, prior open abdomen, or active/previous abdominal-wall infection
• Previous component separation or major abdominal-wall reconstruction
• Poor soft tissue envelope
• Major patient risk factors: smoking, obesity, diabetes, malnutrition, steroid/immunosuppressive therapy, significant cardiopulmonary disease

1. Defect width and location
2. Hernia sac contents
3. Quality and retraction of lateral muscles
4. Prior mesh and adhesions
5. Hernia-sac volume relative to abdominal-cavity volume
6. Feasibility of retromuscular mesh placement

Choose Fasciotens when

• Elective or planned complex repair with a wide but potentially closable midline defect.
• Complete reduction and standard retromuscular dissection have been achieved, but direct closure remains moderately tight.
• Fascia is sufficiently robust to hold traction sutures.
• The surgeon wishes to attempt closure while preserving lateral muscles and avoiding TAR if feasible.
• There is no major concern that reduction and closure will cause abdominal compartment physiology.

• Fascia is severely scarred, friable, infected, or cannot safely hold sutures.
• There is extreme loss of domain with marked abdominal-cavity undercapacity.
• Closure remains high tension after traction.
• There is inability to monitor or manage respiratory/intra-abdominal pressure effects.

Choose TAR when

• Standard retromuscular repair cannot provide low-tension midline closure.
• Defect is usually large, commonly over 10 cm, recurrent, or associated with substantial lateral retraction.
• Wide mesh overlap is needed in a retromuscular/pretransversalis plane.
• Fasciotens or BTA is insufficient, unavailable, or inappropriate.
• The operation is being undertaken by a surgeon experienced in TAR.

• Active infection or uncontrolled contamination, unless the operative strategy specifically addresses it.
• Severe obesity, smoking, poorly controlled diabetes, malnutrition, or limited pulmonary reserve.
• Prior posterior component separation/TAR may make planes difficult and increases planning complexity.

Choose BTA when

• Repair is elective, allowing 2-4 weeks before surgery.
• Defect width is generally over 10 cm, or there is loss of domain / marked lateral muscle shortening.
• CT suggests difficult medialization but a chance of primary fascial closure after muscle relaxation.
• The goal is to reduce closure tension and possibly limit the need for TAR.
• It can be paired with progressive preoperative pneumoperitoneum in selected severe loss-of-domain cases.

• Urgent surgery is required.
• There is hypersensitivity to the product or infection at the injection site.
• Significant neuromuscular-junction disorder is present.
• The patient has poor respiratory reserve, substantial baseline ventilatory weakness, or aspiration risk.
• The surgical team has no standardized injection, anesthesia, and follow-up protocol.

A practical decision pathway

1. Defect less than about 8 cm, no loss of domain:
   Standard retromuscular repair with primary closure may be feasible. Advanced adjuncts are often unnecessary.
2. Defect 8-10 cm or more, but no major loss of domain:
   Plan retromuscular mesh repair. Consider Fasciotens intraoperatively if closure is tight. Use TAR only if safe closure remains impossible.
3. Defect over 10 cm, retracted lateral muscles, elective repair:
   Consider preoperative BTA, then reassess during surgery. Fasciotens can be added if residual tension persists. TAR remains available if closure is still not safe.
4. Loss of domain, especially Tanaka ratio over 20-25%:
   Optimize patient, consider BTA with or without progressive pneumoperitoneum, and plan the reconstruction in a specialist center. TAR may be required. Fasciotens can assist but should not be expected to overcome severe domain loss alone.
5. Very wide/recurrent defect or failure of BTA/traction to obtain low-tension closure:
   TAR with retromuscular/pretransversalis mesh is usually the more reliable reconstructive solution.