BACKGROUND: Loss of domain (LOD) in complex ventral hernia (CVH) poses a major surgical challenge due to volumetric imbalance between the hernia sac and abdominal cavity, risking intra-abdominal hypertension and abdominal compartment syndrome. Management strategies remain heterogeneous.

MATERIALS AND METHODS: This narrative review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews framework. A systematic search of PubMed, Embase, and Scopus identified studies published up to January 2026 using terms including “loss of domain,” “complex ventral hernia,” “Tanaka index,” “Sabbagh ratio,” “CT volumetry,” “botulinum toxin,” “progressive pneumoperitoneum,” “component separation,” “Fasciotens,” and “robotic abdominal wall reconstruction.” Two authors independently screened the titles and abstracts. The included studies comprised consensus statements, systematic reviews, meta-analyses, and cohort studies with ≥ 20 patients. Case reports, editorials, and non-English studies were excluded. Findings were synthesized descriptively.

RESULTS: Computed tomography volumetry is the diagnostic gold standard for quantifying LOD. A Tanaka index > 25% and Sabbagh ratio > 20% identify patients at high risk for tensioned closure. Prehabilitation—including smoking cessation, glycemic control, and weight optimization—reduces surgical site morbidity. Botulinum toxin A (BTA) increases lateral abdominal wall compliance by approximately 4 cm per side, while progressive preoperative pneumoperitoneum (PPP) expands the abdominal cavity volume by up to 53%. Combined BTA and PPP achieve high primary fascial closure rates in massive defects. Transversus abdominis release provides durable retromuscular reconstruction with lower recurrence than anterior component separation. Emerging adjuncts such as Fasciotens and prolonged CO₂ insufflation offer additional muscle lengthening of up to 25%.

CONCLUSION: CVH with LOD requires objective volumetric assessment and a tailored, algorithm-based approach integrating prehabilitation, domain-expanding techniques, and neurovascular-preserving reconstruction to improve the outcomes and reduce recurrence.

BACKGROUND: Abdominal wall hernias represent a significant and growing surgical burden globally. Modifiable risk factors including obesity, type 2 diabetes mellitus, smoking, and chronic respiratory disease offer meaningful targets for prevention-oriented interventions. Population-level epidemiological analyses characterizing hernia burden and associated risk factors in Saudi Arabia remain absent from the literature.

OBJECTIVES: This study aims to characterize the temporal trends in abdominal wall hernia repair procedures, describe the prevalence and distribution of modifiable risk factors among hernia patients, and assess geographic and urban–rural variations in hernia burden and surgical outcomes across Saudi Arabia.

METHODS: This cross-sectional descriptive study analyzed secondary data from the Saudi Ministry of Health Annual Statistical Yearbooks (2016–2023), the Saudi Health Interview Survey 2018, and World Health Organization (WHO) Global Burden of Disease estimates. Hernia repair procedures were categorized by the type, surgical approach, and administrative region. Modifiable risk factors were analyzed among hernia patients compared to the general adult population. Descriptive statistics and comparative analyses were performed. Reporting followed Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

RESULTS: Annual hernia repair procedures increased from 38,200 in 2016 to 45,500 in 2023 (rate: 107–130 per 100,000 population), representing a 19.1% increase. Inguinal hernias constituted 67.9% of all repairs, followed by incisional/ventral hernias (19.1%) and umbilical hernias (9.0%). The male-to-female ratio for inguinal hernia was 7.8:1. The obesity prevalence among hernia patients (41.3%) significantly exceeded that among the general adult population (34.2%). Type 2 diabetes mellitus (28.4% vs. 17.8%), current smoking (19.2% vs. 13.1%), and chronic obstructive pulmonary disease (13.7% vs. 7.9%) were all significantly more prevalent in hernia patients. Laparoscopic repair increased from 27.8% to 52.4% for inguinal hernia over the study period, with substantially lower surgical site infection rates compared to open repair (1.4% vs. 3.8%). Northern border regions demonstrated the lowest procedure rates and highest complication rates nationally.

CONCLUSIONS: Abdominal wall hernia repair procedures are increasing in Saudi Arabia alongside the rising prevalence of modifiable risk factors, particularly obesity and type 2 diabetes mellitus. Preventive strategies targeting obesity reduction, glycemic optimization, and smoking cessation, combined with equitable expansion of laparoscopic repair capacity, represent priority interventions to reduce hernia burden and surgical complications.

BACKGROUND: Obesity is a well-recognized risk factor for incisional hernia formation and is associated with increased postoperative morbidity after abdominal wall reconstruction. However, the influence of obesity severity on short- and long-term outcomes following elective incisional hernia repair remains inadequately defined.

MATERIALS AND METHODS: This prospective observational study included 101 obese patients (body mass index [BMI] ≥ 30 kg/m²) undergoing elective incisional hernia repair over 18 months. Perioperative, postoperative, and long-term outcomes were evaluated, and multivariable logistic regression was performed to identify independent predictors of surgical site infection and hernia recurrence.

RESULTS: Among the 101 patients with obesity, 48 (47.5%) had Grade I, 30 (29.7%) had Grade II, and 23 (22.8%) had Grade III obesity. Increasing obesity severity was significantly associated with higher rates of surgical site infection (6.3% vs. 16.7% vs. 34.8%; P = 0.006), wound dehiscence (2.1% vs. 6.7% vs. 21.7%; P = 0.009), chronic postoperative pain (4.2% vs. 13.3% vs. 26.1%; P = 0.018), and hernia recurrence (4.2% vs. 10.0% vs. 26.1%; P = 0.014). Grade III obesity remained independently associated with recurrence after adjustment for mesh-to-defect ratio (mesh:defect area ratio) and other clinical covariates. A progressively lower mesh-to-defect ratio with increasing obesity grade was independently associated with recurrence, emphasizing the importance of adequate mesh reinforcement in obese patients.

CONCLUSIONS: Increasing BMI was associated with greater wound morbidity, prolonged hospitalization, and higher recurrence after incisional hernia repair. Maintaining an adequate mesh-to-defect ratio may reduce recurrence, particularly in severe obesity, while laparoscopic repair demonstrated favorable perioperative outcomes.

BACKGROUND: Inguinal hernia repair is a common elective surgical procedure. With the increasing burden of noncommunicable diseases, many patients undergoing hernia surgery have chronic illnesses that may influence perioperative stability and recovery. Evidence regarding perioperative events in this group remains limited, especially in resource-constrained settings.

MATERIALS AND METHODS: This hospital-based prospective observational cohort study included 65 adult patients undergoing elective inguinal hernia surgery in a tertiary-care hospital. Patients were categorized into two groups based on the presence or absence of chronic diseases. Demographic, clinical, surgical, and anesthetic details were collected prospectively using a structured questionnaire. Perioperative events, including intraoperative complications and immediate postoperative outcomes, were recorded using predefined clinical criteria and analyzed using descriptive statistics and multivariable logistic regression.

RESULTS: Patients with chronic diseases showed a trend toward a higher frequency of intraoperative events, including bleeding, anesthesia-related events, hemodynamic instability, and cardiopulmonary events; however, most individual comparisons were not statistically significant. The presence of any chronic disease showed increased odds of intraoperative complications, but this association did not reach statistical significance (adjusted odds ratio: 2.62; 95% confidence interval: 0.94–7.32; P = 0.06). Patients with chronic illnesses had a significantly longer postoperative hospital stay.

CONCLUSION: Preexisting chronic diseases may be associated with a higher frequency of perioperative events and prolonged postoperative hospital stay among patients undergoing elective inguinal hernia repair. However, these findings should be interpreted cautiously due to the limited sample size and nonsignificant results for most individual outcomes. Careful preoperative assessment, optimization of comorbidities, and close intraoperative monitoring may improve perioperative care.

Bochdalek hernia is a congenital posterolateral diaphragmatic defect that typically presents during the neonatal period with severe respiratory compromise. Adult presentation is rare and often manifests with vague respiratory or gastrointestinal symptoms, making diagnosis challenging and frequently delayed. A 65-year-old female presented with progressively worsening shortness of breath and severe orthopnea for 20 days. She also reported a longstanding history of mild exertional dyspnea over 4–5 years. There was no history of thoracoabdominal trauma or prior surgery. Chest radiography demonstrated abnormal soft tissue shadows within the left hemithorax. Contrast-enhanced computed tomography of the thorax and abdomen confirmed a 5 cm × 5 cm left posterolateral diaphragmatic defect with multivisceral herniation including the stomach, spleen with splenic artery, omentum, transverse colon, and upper pole of the left kidney, consistent with an adult left-sided Bochdalek hernia. The patient underwent exploratory laparotomy through an L-shaped incision. The herniated abdominal viscera were carefully reduced into the abdominal cavity, and the diaphragmatic defect was repaired primarily using nonabsorbable sutures. The postoperative course was uneventful. The patient experienced immediate improvement in respiratory symptoms with complete resolution of orthopnea and was discharged in stable condition without complications. Adult Bochdalek hernia should be considered in elderly patients presenting with unexplained respiratory symptoms, even in the absence of a history of trauma. Cross-sectional imaging plays a crucial role in diagnosis and operative planning. Early surgical repair is essential to prevent life-threatening complications such as strangulation and visceral ischemia.

Primary scrotal lipomas of giant proportions are exceptionally rare and frequently present as an irreducible inguinoscrotal hernia leading to misdiagnosis. These lesions are often identified incidentally during surgical exploration, as in our case, posing a diagnostic dilemma. Diagnostic ambiguity associated with these swellings often results in inadequate preoperative evaluation, thereby presenting unforeseen challenges during surgery. Although scrotal exploration remains the definitive treatment, comprehensive preoperative assessment is crucial to avoid intraoperative surprises and to help the clinician provide better surgical planning and outcomes. Here, we report a case of a giant primary scrotal lipoma arising from the spermatic cord in a 47-year-old male, presenting as a painless, progressively enlarging, nontransilluminant scrotal swelling. The lesion was initially misdiagnosed as an irreducible inguinoscrotal hernia on ultrasound, highlighting the importance of adequate preoperative evaluation. In addition, we would like to emphasize the consideration of such a rare entity as the differential diagnosis of giant scrotal swellings.

Loss of domain (LOD) is a recognized concept in complex ventral hernia surgery but has received limited attention in the context of diaphragmatic hernia repair. Failure to recognize this physiology may precipitate catastrophic intra-abdominal hypertension and abdominal compartment syndrome (ACS). Here, we report a case of a 21-year-old male with a long-standing left-sided diaphragmatic hernia who presented for elective surgical repair. Diagnostic laparoscopy revealed a left diaphragmatic hernia containing the stomach, transverse colon, and omentum. Notable abdominal wall rigidity noted during insufflation suggested reduced abdominal compliance and possible functional LOD. Due to technical difficulties, the procedure was converted to an open bilateral subcostal approach. Following the reduction of herniated contents, the diaphragmatic defect was repaired primarily and reinforced with prosthetic mesh. However, primary abdominal closure was not feasible because of a markedly contracted and noncompliant abdominal cavity. Temporary abdominal closure using a Bogota bag was performed. Following postoperative failure of the Bogota bag, re-exploration and negative pressure-assisted abdominal closure were attempted. The patient developed progressive bowel edema and persistent abdominal compartment physiology despite intensive care support and repeated closure attempts. The condition remained refractory to intervention, and the patient expired on postoperative day 21. This case represents an extreme form of functional LOD in diaphragmatic hernia, where reintegration of chronically displaced viscera exceeds abdominal cavity compliance. Preoperative volumetric assessment, progressive pneumoperitoneum, botulinum toxin A, and staged reconstruction may be valuable in selected cases. Recognition of LOD physiology and adoption of a physiology-based rather than purely anatomical approach may help prevent fatal ACS following diaphragmatic hernia repair.

Lumbar and flank hernias are rare, and the ideal repair approach remains debated. There have been fewer than 1500 lumbar/flank hernias reported in the literature, and cases due to traumatic injury are even rarer. In this case report, we describe a traumatic flank hernia in a patient who was pinned between two motor vehicles, an accident that resulted in avulsion of the oblique muscles from the iliac crest.. Additional traumatic injuries included bucket-handle injuries of the ileum requiring small bowel resection, and multiple orthopedic injuries. After initial small bowel resection and resuscitation, subsequent imaging demonstrated the new anastomosis herniating into an 11 cm × 6 cm flank hernia with avulsion of the oblique muscles. The hernia was repaired primarily with iliac crest bone anchors and no mesh placement. Recovery was uncomplicated, and the patient was discharged to an acute rehabilitation unit. At 12 months post-repair, there is no recurrence.

Laparoscopic inguinal hernia repair is increasingly performed because of reduced postoperative pain and faster recovery compared with open surgery. However, carbon dioxide (CO₂) insufflation may lead to specific complications, including subcutaneous emphysema (SE). A 65-year-old man underwent elective totally extraperitoneal extended view repair for right inguinal hernia. Fifty minutes after CO₂ insufflation, a progressive rise in end-tidal CO₂ reaching 60 mmHg was observed, accompanied by mild oxygen desaturation. Physical examination revealed subcutaneous crepitus extending to the patient's neck. Ventilatory adjustments were performed, and the insufflation pressure was reduced. Subcutaneous catheters were inserted into the supraclavicular region. The procedure was successfully completed. Postoperative chest radiography confirmed extensive SE without pneumothorax or pneumomediastinum. The patient remained clinically stable and was conservatively managed. Complete resolution was confirmed radiologically, and the patient was discharged on the third postoperative day. SE is an uncommon but increasingly recognized complication of extraperitoneal laparoscopic hernia repair. Vigilant intraoperative monitoring allows for early detection and appropriate management, preventing unnecessary morbidity.

Sacrococcygeal hernia is a rare complication that may occur following coccygectomy or sacrococcygeal resection. Due to its rarity, optimal management strategies remain unclear, and only a few cases have been reported in the literature. We report a case of a 70-year-old female patient who developed a large sacrococcygeal hernia following en bloc sacral coccygectomy performed for a sacral chordoma. Six months after surgery, the patient presented with a progressively enlarging posterior sacral swelling associated with constipation and difficulty in ambulation. Magnetic resonance imaging demonstrated herniation of small bowel loops and sigmoid colon through the postoperative sacral defect. The patient underwent successful repair through a posterior sacral approach using a coated titanized polypropylene mesh placed in a bridging fashion. The postoperative recovery was uneventful, and the patient was discharged on the eighth postoperative day. Sacrococcygeal hernia remains a rare surgical entity with limited evidence guiding management. This case demonstrates that posterior approach repair using coated titanized polypropylene mesh is a feasible and effective technique for managing large sacrococcygeal defects while avoiding the morbidity associated with laparotomy.