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Lesch et al. Mini-invasive Surg 2023;7:25 https://dx.doi.org/10.20517/2574-1225.2023.31 Page 11 of 13

Figure 8. Possible behaviors and outcomes of a compound under repetitive cyclic loading.

appears, the higher the likelihood of failure. A strain-stable state of the compound needs to be achieved.
This allows a durable repair. The strain-stable condition is achieved when the compound has survived 425
impacts. If the compound is unable to establish the strain-stable condition called plastic shakedown, failure
occurs.

Preoperative CT Scans with Valsalva visualize the importance of lifelike bench test assessment. The behavior
of the abdominal wall, the hernia, and additional unstable zones are visible. According to our findings, high
intraabdominal pressures should be avoided postoperatively. It increases the failure rates significantly. The
early period seems to be the most vulnerable for deformation and failure.

DECLARATIONS
Acknowledgments
Jacob Relle, Philipp Lösel, and Vincent Heuveline developed the evaluation routine and analyzed the CT
scans as approved by the Ethics Committee of the Heidelberg University vote S-522/2020. We are grateful
for the financial support by the Heidelberger Stiftung Chirurgie (grants 2016/ 22, 2017/ 171, 2018/ 215,
2019/ 288, 2020/ 376, and 2021/ 444).

Authors’ Contributions
Performed the data analysis and wrote the article: Lesch C
Performed the experiments: Kugel F, Ludwig Y
Provided crucial thoughts and content for the discussion of tissue behavior and plastic shakedown: Uhr K
Leads the construction of the bench test as well as its maintenance: Vollmer M
Contributed important thoughts and discussions for the construction of the experiments and the paper:
Nessel R
Closely guided the execution of the experiments, designed parts of the experiments, and continuously
supervised the paper: Kallinowski F

Availability of data and materials
The raw data supporting the conclusions of this article will be made available by the authors without
reservation.