Ventral and incisional hernias remain a common problem in general surgical practice, particularly after midline laparotomy. The European Hernia Society guidelines emphasize that incisional hernia is not a trivial late wound event, because it affects symptoms, recurrence risk, healthcare use, and the complexity of any later abdominal operation.[1] Standardized description of primary and incisional abdominal wall hernias is important because defect size, location, and previous surgical history strongly influence operative planning and outcome comparison across studies.[2] For large midline defects, simple bridging repair is rarely a satisfactory functional solution. Contemporary laparoscopic ventral hernia repair aims to reduce wound morbidity and improve recovery, but the principle of durable repair still depends on adequate mesh overlap, safe fixation, and restoration of abdominal wall mechanics wherever feasible.[3] Component separation, first described as an anatomic method for mobilizing abdominal wall myofascial units, changed the surgical thinking around large defects: the target became medial advancement of viable abdominal wall tissue, not merely covering a hole with prosthetic material.[4] The endoscopically assisted modification was later developed to limit the wide skin-flap dissection of open anterior component separation and preserve perforators, while still obtaining myofascial release for midline approximation.[5] Comparative work has suggested that endoscopic component separation can achieve similar reconstructive goals with less major wound morbidity and shorter hospital stay than the open approach in selected complex abdominal wall repairs.[6] Functional recovery is now increasingly recognized as an outcome in itself. Criss and colleagues showed that abdominal wall reconstruction restoring the linea alba could improve core physiology and quality of life, giving objective support to what many patients report after successful repair.[7] The relationship between hernia size and muscle performance is clinically meaningful. In giant ventral hernia, larger defect area has been linked to weaker abdominal wall strength, supporting the idea that abdominal wall repair should be judged by function as well as recurrence.[8] Patient-reported outcomes have therefore become important in hernia studies. The EuraHS platform and its quality-of-life instrument helped standardize symptom, pain, and restriction assessment in abdominal wall hernia practice.[9] Indian experience with endoscopic component separation and laparoscopic intraperitoneal mesh repair has also reported favourable postoperative and functional outcomes in large midline ventral hernia, but region-specific prospective evidence remains limited.[10] The present study was undertaken to assess change in abdominal wall muscle function at 6 months after endoscopic component separation technique with laparoscopic mesh hernioplasty in a tertiary care setting in Tamil Nadu.

Study design and setting This prospective observational study was conducted in the Department of General Surgery, Government Medical College and Hospital, Kallakurichi, Tamil Nadu, India. Patients were recruited from January to May 2022 and were followed for the 6-month postoperative assessment. Study population The study included 60 patients with large midline ventral hernia who underwent repair using endoscopic component separation technique and laparoscopic mesh hernioplasty. Both primary ventral and incisional hernias were included. Patients were evaluated clinically before surgery and again at 6 months after the procedure. Study variables and outcome measures The recorded variables included age, gender, body mass index, hernia type, defect width, defect area, operative time, mesh size, intraoperative events, preoperative core strength, 6-month postoperative core strength, percentage change in muscle function, preoperative EHPQ score, 6-month postoperative EHPQ score, length of hospital stay, time to return to normal activity, seroma, chronic pain, and recurrence. Core strength was measured in Newton-metres (Nm). EHPQ score was used as a hernia-related patient-reported outcome measure, where a lower postoperative score reflected clinical improvement. The primary outcome was change in abdominal wall muscle function at 6 months. Secondary outcomes included change in EHPQ score, perioperative morbidity, length of stay, return to activity, and recurrence during follow-up. Surgical approach All patients underwent endoscopic component separation followed by laparoscopic mesh hernioplasty. Mesh size was selected according to defect dimensions and intraoperative judgement. Operative time and intraoperative complications were recorded at the time of surgery, while postoperative events were assessed during admission and follow-up. Ethical considerations The ethics approval was obtained prior to this study. Patient confidentiality was maintained throughout the study process. Statistical analysis Continuous variables were summarized as mean ± standard deviation, with range or median where useful. Categorical variables were expressed as frequency and percentage. Paired t-test was used for preoperative and postoperative comparison of core strength and EHPQ score. Independent t-test was used for comparison between incisional and primary ventral hernia groups. Fisher exact test was applied for categorical subgroup comparisons when cell counts were small. Pearson correlation was used to explore associations between selected continuous variables. A p-value <0.05 was considered statistically significant.

Patient and hernia profile A total of 60 patients underwent repair for large midline ventral hernia. The mean age was 51.43 ± 13.25 years, and the mean BMI was 31.05 ± 4.88 kg/m2. Female patients constituted 36 (60.00%), while males constituted 24 (40.00%). Incisional hernia was more common than primary ventral hernia, occurring in 39 (65.00%) and 21 (35.00%) patients, respectively. The distribution of hernia type is shown in Figure 1, and the baseline clinical profile is summarized in Table 1. Donut chart displays proportions among the 60 operated patients Table 1. Baseline demographic and hernia profile (n=60). Variable Value Additional detail Age (years) 51.43 ± 13.25 Range: 28-74 Gender: Female 36 (60.00%) Gender: Male 24 (40.00%) BMI (kg/m2) 31.05 ± 4.88 Range: 22.00-42.10 BMI category: Normal 6 (10.00%) WHO adult BMI category BMI category: Overweight 19 (31.67%) WHO adult BMI category BMI category: Obese 35 (58.33%) WHO adult BMI category Hernia type: Incisional 39 (65.00%) Hernia type: Primary ventral 21 (35.00%) Defect width (cm) 13.88 ± 2.28 Range: 10.10-17.80 Defect area (cm2) 298.72 ± 100.18 Range: 140.60-541.30 Values are presented as mean ± SD or n (%). Operative profile Mean operative time was 207.90 ± 32.32 minutes. A 20x25 cm mesh was used in 30 (50.00%) patients, 25x30 cm mesh in 19 (31.67%), and 30x30 cm mesh in 11 (18.33%). Minor bleeding was the only recorded intraoperative complication and occurred in 3 (5.00%) patients. Mesh size distribution is presented in Figure 5. Pie chart shows the mesh sizes selected according to intraoperative requirement. Change in abdominal wall muscle function and EHPQ score Abdominal wall core strength increased from 42.76 ± 8.58 Nm preoperatively to 69.72 ± 11.59 Nm at 6 months, giving an absolute mean gain of 26.96 ± 6.42 Nm. The paired difference was statistically significant (p<0.001). The mean percentage change in muscle function was 65.06 ± 18.66%. This functional improvement is displayed in Figure 3 and Table 2. Bars represent mean values; whiskers show standard deviation. EHPQ score decreased from 58.83 ± 9.24 before surgery to 30.27 ± 10.08 at 6 months. The mean score reduction was 28.57 ± 5.83 points and was statistically significant (p<0.001). Figure 4 shows the improvement in patient-reported score, while Table 2 presents the paired comparison. Lower postoperative value reflects improvement in hernia-related symptoms and functional restriction. Table 2. Preoperative and 6-month postoperative functional outcomes. Outcome Preoperative 6-month postoperative Mean change p-value Core strength (Nm) 42.76 ± 8.58 69.72 ± 11.59 +26.96 ± 6.42 <0.001 EHPQ score 58.83 ± 9.24 30.27 ± 10.08 -28.57 ± 5.83 <0.001 Change in muscle function (%) NA 65.06 ± 18.66 NA NA Paired t-test was used for preoperative versus postoperative comparison. Postoperative recovery and complications The mean length of hospital stay was 6.32 ± 1.58 days. Patients returned to normal activity after a mean duration of 4.27 ± 1.06 weeks. Seroma and chronic pain were each observed in 5 (8.33%) patients. No recurrence was documented during the 6-month follow-up. The postoperative event profile is shown in Figure 5 and summarized in Table 3. Bar labels indicate the number and percentage of patients with each event. Table 3. Postoperative recovery and complication profile. Outcome Value Comment Length of hospital stay (days) 6.32 ± 1.58 Range: 4-9 Return to normal activity (weeks) 4.27 ± 1.06 Range: 3-6 Intraoperative minor bleeding 3 (5.00%) No major intraoperative event recorded Seroma 5 (8.33%) Chronic pain 5 (8.33%) Recurrence at 6 months 0 (0.00%) No recurrence documented Values are presented as mean ± SD or n (%). Subgroup and correlation analysis Primary ventral hernias had a larger mean defect width than incisional hernias (14.79 ± 2.46 cm versus 13.39 ± 2.05 cm, p=0.033). Other functional and postoperative outcomes did not show statistically significant differences by hernia type. Preoperative core strength showed a moderate inverse correlation with percentage gain in muscle function (r=-0.544, p<0.001), suggesting larger percentage gains among those who began with weaker core strength. Defect area did not correlate significantly with operative time (r=0.098, p=0.456) or percentage improvement in muscle function (r=-0.146, p=0.267). Table 4 presents the hernia-type subgroup analysis. Table 4. Comparison of incisional and primary ventral hernia groups. Variable Incisional (n=39) Primary ventral (n=21) p-value Defect width (cm) 13.39 ± 2.05 14.79 ± 2.46 0.033 Defect area (cm2) 279.86 ± 90.96 333.73 ± 109.12 0.062 Operative time (minutes) 205.87 ± 32.86 211.67 ± 31.73 0.509 Change in muscle function (%) 66.87 ± 18.77 61.70 ± 18.43 0.309 Postoperative EHPQ score 31.64 ± 10.80 27.71 ± 8.23 0.121 Seroma 4 (10.26%) 1 (4.76%) 0.649 Chronic pain 5 (12.82%) 0 (0.00%) 0.152 Recurrence 0 (0.00%) 0 (0.00%) NA Continuous variables were compared using independent t-test; categorical variables were compared usin Fisher exact test.

The present study showed a clear improvement in abdominal wall muscle function after endoscopic component separation with laparoscopic mesh hernioplasty. Mean core strength increased by nearly 26.96 Nm at 6 months, and the percentage improvement averaged 65.06%. This is clinically relevant because patients with large midline ventral hernia often describe difficulty in rising from bed, standing for long periods, lifting domestic loads, coughing effectively, or returning to manual work. In a district-level government hospital setting, these seemingly ordinary activities matter as much as a radiological or operative endpoint. The result supports the older reconstructive principle that large midline hernias require restoration of abdominal wall continuity rather than passive coverage alone. De Vries Reilingh and colleagues reported the role of component separation in large abdominal wall hernias that could not be closed primarily, which remains a key conceptual basis for the procedure even today.[11] The functional improvement in this study also fits well with modern hernia guidelines, where patient selection, adequate mesh reinforcement, and careful technique are considered central to reducing morbidity after laparoscopic ventral and incisional hernia repair.[12] One interesting finding was the absence of recurrence at 6 months. This is encouraging, but should be interpreted cautiously. Six months is adequate for short-term wound and early functional assessment, not for final judgment of repair durability. Hernia recurrence often becomes evident later, especially in obese patients, patients with chronic cough or constipation, and patients returning early to heavy physical labour. Seroma occurred in 8.33% of patients and chronic pain in 8.33%. These rates are acceptable for a cohort with large defects, and the low event frequency may reflect the minimally invasive nature of the procedure and avoidance of extensive skin-flap dissection. Jensen and colleagues found that endoscopic component separation produces fewer wound complications than open component separation in comparative evidence.[13] The EHPQ score showed a marked fall from baseline at 6 months. Whether measured through EHPQ, EuraHS-QoL, or other hernia-specific instruments, the direction is important: patients felt and functioned better. Recent prospective work on abdominal wall reconstruction has also emphasized that quality of life and abdominal wall function improve together, rather than behaving as unrelated outcomes.[14] Preoperative core strength showed a moderate inverse relationship with percentage improvement. Put plainly, patients with weaker initial abdominal wall function had more room to improve. This does not mean that weaker patients always do better. It means percentage change can look larger when the starting point is low. Future studies should therefore report both absolute and percentage gains. Hernia type had limited influence on functional recovery in this cohort. Primary ventral hernias had a slightly larger mean defect width than incisional hernias, but the difference did not translate into higher morbidity or poorer postoperative function. This matters in Indian practice, where patients often present late after years of swelling, after previous laparotomy, or after repeated abdominal strain related to labour, childcare, chronic cough, or constipation. The role of component separation is often discussed as an anatomic release, but it is also a functional reconstruction. Heller and colleagues described the myofascial basis of component separation, explaining why medial advancement of abdominal wall units can help restore a more physiologic abdominal wall.[15] The endoscopic approach attempts to preserve the benefit of release while reducing wound morbidity. Meta-analytic evidence comparing endoscopic and open component separation has also reported lower postoperative wound complication rates with the minimally invasive approach, though the literature remains heterogeneous.[16] This study has limitations. It was a single-centre study with 60 patients, and there was no comparison arm treated with open component separation or laparoscopic mesh repair alone. Follow-up was limited to 6 months, so late recurrence, mesh-related symptoms, delayed chronic pain, and long-term activity restoration could not be fully assessed. The study also did not stratify outcomes by diabetes, smoking, pulmonary disease, occupational load, or abdominal wall rehabilitation, all of which may influence function. Even so, the prospective nature of assessment and paired preoperative-postoperative functional comparison strengthen the practical value of the findings.

Endoscopic component separation technique combined with laparoscopic mesh hernioplasty was associated with significant improvement in abdominal wall core strength and EHPQ score at 6 months among patients with large midline ventral hernia. The procedure showed low short-term morbidity, with seroma and chronic pain each occurring in 8.33% of patients and no recurrence documented during early follow-up. The findings support the functional value of reconstructive midline restoration in selected patients, while longer and comparative follow-up is required to confirm durability and recurrence outcomes. Source of Funding Nil. Conflict of Interest None declared.

1. Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, et al. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg. 2023;110(12):1732-1768. doi:10.1093/bjs/znad284. 2. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407-414. doi:10.1007/s10029-009-0518-x. 3. Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli R, et al. SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc. 2016;30(8):3163-3183. doi:10.1007/s00464-016-5072-x. 4. Ramirez OM, Ruas E, Dellon AL. Components separation method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86(3):519-526. doi:10.1097/00006534-199009000-00023. 5. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE. Endoscopically assisted components separation for closure of abdominal wall defects. Plast Reconstr Surg. 2000;105(2):720-729; quiz 730. 6. Harth KC, Rosen MJ. Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg. 2010;199(3):342-346; discussion 346-347. 7. Criss CN, Petro CC, Krpata DM, Seafler CM, Lai N, Fiutem J, et al. Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery. 2014;156(1):176-182. doi:10.1016/j.surg.2014.04.010. 8. Strigard K, Clay L, Stark B, Gunnarsson U, Falk P. Giant ventral hernia-relationship between abdominal wall muscle strength and hernia area. BMC Surg. 2016;16:50. doi:10.1186/s12893-016-0166-x. 9. Muysoms F, Campanelli G, Champault GG, DeBeaux AC, Dietz UA, Jeekel J, et al. EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair. Hernia. 2012;16(3):239-250. doi:10.1007/s10029-012-0912-7. 10. Losu PU, Lal R, Gupta AK, Chaudhary P. Assessment of quality of life using EuraHS-QoL score and postoperative outcome measures following endoscopic video-assisted component separation with laparoscopic intraperitoneal onlay mesh repair in large midline ventral hernia repair. Int J Abdom Wall Hernia Surg. 2023;6(4):215-221. doi:10.4103/ijawhs.ijawhs_9_23. 11. de Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van Nieuwenhoven EJ, et al. Components separation technique for the repair of large abdominal wall hernias. J Am Coll Surg. 2003;196(1):32-37. doi:10.1016/S1072-7515(02)01478-3. 12. Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society): Part A. Surg Endosc. 2019;33(10):3069-3139. doi:10.1007/s00464-019-06907-7. 13. Jensen KK, Henriksen NA, Jorgensen LN. Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and meta-analysis. Surg Endosc. 2014;28(11):3046-3052. doi:10.1007/s00464-014-3599-2. 14. Toma M, Oprea V, Molnar C, et al. Quality of life and abdominal wall functionality after abdominal wall reconstruction: a prospective single center follow-up study. Hernia. 2024;28(6):2223-2234. doi:10.1007/s10029-024-03143-4. 15. Heller L, McNichols CH, Ramirez OM. Component separations. Semin Plast Surg. 2012;26(1):25-28. doi:10.1055/s-0032-1302462. 16. Switzer NJ, Dykstra MA, Gill RS, Lim S, Lester E, de Gara C, et al. Endoscopic versus open component separation: systematic review and meta-analysis. Surg Endosc. 2015;29(4):787-795. doi:10.1007/s00464-014-3741-1