Background: The main principle of abdominal incisional hernia repair is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. Ideally, midline structural support is restored by midline approximation of local musculo-aponeurotic tissues. Approximation of these tissues without tension on the suture line will restore the elasticity and flexibility of the abdominal wall. However, 30% to 50% of defects larger than 6 cm recur after primary closure, because of the tension on the suture line. Insertion of an alloplastic material to decrease or eliminate tension on the suture line can reduce the incidence of recurrence to 10% or less. But inorganic prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization. With the availability of biological materials, surgeons are increasingly using these materials for effective surgical management of abdominal incisional hernia The aim of this study was to determine the feasibility and efficacy of repairing large abdominal incisional hernias by reconstructing the midline using bilateral abdominis rectus muscle sheath (ARS) relaxing incisions and a biological material onlay. Methods: Between January 2002 and December 2009, 104 patients underwent repair oflarge incisional hernias at 2 community hospitals. After replacement of hernia sac contents into the peritoneal cavity, a relaxing incision was made in the ARS bilaterally. Then the midline was closed primarily. The biological material was onlaid and sutured to the lateral edges of the relaxed ARS. Main outcome measures were postoperative complications and hernia recurrence. Results: Median age 61 years (range, 39-86) years. Body mass index was 34 (range, 23-44). Of the 104 patients, 37 had undergone I or more previous repairs. In 19 patients (18%), mesh had been used. In 14 patients the mesh had been placed as a sub lay, and in 5 patients the mesh had been placed laparoscopically. We removed the mesh in all 19 cases. Size of the defect was 195 (range, 150-420) cm 2 • Median operation time was 125 (range, 75-255) minutes. Four patients (3.8%) had a large wound hematoma that required operative drainage. Four (3.8%) patients developed skin necrosis at the edge of the wound, exposing the biological material; they were treated conservatively with dressings and oral antibiotics and discharged 9 days after surgery. Three (2.8%) developed urinary tract infection, which was treated successfully with appropriate oral antibiotics. One (0.9%) developed pneumonia postoperatively; this was successfully treated with appropriate antibiotics and the patient was discharged 10 days after surgery. Wound seroma occurred in 57 (55%) patients. In all cases, the seroma was suspected by physical examination and both confirmed and managed by fine needle aspiration, with or without sonography. The median time between surgery and diagnosis of seroma was 19 days (range, 12-42). The mean time to complete resolution was 52 days...

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