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Nessel et al. Mini-invasive Surg 2023;7:21 Mini-invasive Surgery
DOI: 10.20517/2574-1225.2023.21

Review Open Access

Biomechanical principles of a permanently durable

abdominal wall reconstruction: current status and
potential future development

1
2
3
Regine Nessel , Carolin Lesch , Matthias Vollmer , Friedrich Kallinowsk 2
1
General, Visceral and Pediatric Surgery, SLK Klinikum Am Gesundbrunnen, Heilbronn D-74078, Germany.
2
Department of Surgery, University Hospital of Heidelberg, Heidelberg D-69120, Germany.
3
Department of Biomechanics, Technische Universität Hamburg-Harburg, Hamburg121073, Germany.
Correspondence to: Prof. Friedrich Kallinowsk. Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld
420, Heidelberg D-69120, Germany. E-mail: friedrich.kallinowski@med.uni-heidelberg.de
How to cite this article: Nessel R, Lesch C, Vollmer M, Kallinowsk F. Biomechanical principles of a permanently durable
abdominal wall reconstruction: current status and potential future development. Mini-invasive Surg 2023;7:21.
https://dx.doi.org/10.20517/2574-1225.2023.21
Received: 17 Mar 2023 First Decision: 2 Jun 2023 Revised: 7 Jun 2023 Accepted: 9 Jun 2023 Published: 25 Jun 2023

Academic Editor: Giulio Belli Copy Editor: Lin He Production Editor: Lin He

Abstract
The article reviews the biomechanical principles of durable abdominal wall reconstructions. The aim is to provide
insights and conclusions for future research in this area. Incisional hernia repair implies the creation of a compound
made of tissue, textile, and fixation elements. A pulse load bench test for incisional hernia repair has been available
since 2014, and its influences are evaluated in three different versions of the test stand. Based on these evaluations,
a biomechanical concept for long-term durable reconstructions was determined. To apply the concept to individual
patients, computed tomography of the abdomen at rest and during the Valsalva maneuver was used. A load limit
can be given for every patient based on the hernia defect area (CRIP- critical resistance to impacts related to
pressure). By considering the mesh to defect area ratio, the retention strength of a planned reconstruction can be
calculated (GRIP-gained resistance to impacts related to pressure). The gripping coefficients for tissues vary
significantly, up to 18 fold. About half of the patients have overall tissue distensions up to 350% or more, with
potential high regional variations. The surface retention forces for hernia meshes and for different sutures, tacks,
and adhesives span a wide range of 14fold. Suturing a defect strengthens the reconstruction up to 3fold.
Furthermore, recalculating data taken from multicentric randomized studies on primary sutures reveals that
improved GRIP values are associated with reduced rates of incisional hernia. Repairing consecutive incisional
hernias according to the GRIP concept results in no recurrence and low pain levels after one year. A future policy
for market access of repair materials should include cyclic load bench testing. Moreover, a tailored approach to

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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