When transversus abdominis release (TAR) is not enough during the repair of large midline incisional hernias: the double peritoneal flap to the rescue.

Transversus abdominis release (TAR) is becoming an increasingly popular approach to incisional hernia repair. As the technique has been applied to more complex hernias, it appears insufficient for repairing large defects due to the impossibility to achieve a tension-free reapproximation of the peritoneum and/or the linea alba, then a bridged repair with interposed omentum, reabsorbable or coated prosthesis frequently leaving the mesh in contact with the subcutaneous space, has been proposed. To overcome these setbacks, we have developed the double peritoneal flap-TAR (DPF-TAR) technique, which entails placement of a retromuscular mesh completely isolated from either peritoneal cavity and subcutaneous space by joining both peritoneal sac halves into a double-bridged design. Of 19 patients, 17 (89%) were available for the study. Median transverse diameter of the hernia was 13,3 cm (10-17), and 10 (53%) cases had a complete failure of the linea alba. Five (26%) patients developed a surgical site occurrence (SSO). With a median follow-up of 11 (4-28) months, one (5,8%) recurrence and four (23,5%) wound bulging were diagnosed. We suggest that DPF-TAR approach can provide an effective repair using native tissues to isolate the retromuscular mesh, with acceptable failure and SSOs rates. By avoiding the need for a steep learning curve, this method may constitute a handy complement to the surgeon's armory for difficult reconstructions of the abdominal wall.