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We retrospectively reviewed a series of 14 patients who had undergone a radical resection of a soft tissue tumor in the inguinofemoral, iliopsoas, or pelvic region, which involved resection of the inguinal ligament and reconstruction with the described technique. One out of the 14 patients was excluded from the final analysis as a polyglactin mesh was used. The mesh being rapidly absorbable would inherently put the patient at an increased risk of developing an incisional hernia as compared to a polypropylene mesh and would confound the results. To maintain the homogeneity of the cohort, this patient was excluded from the final outcome analysis.

The data collected included patient demographics, oncological details like histopathology of the tumor, staging, location, and outcomes in terms of post-operative complications, local tumor recurrence, and development of an incisional hernia.

Long-term follow-up data, such as local recurrence or development of an incisional hernia, were collected either based on records from a recent outpatient visit or by telephonic enquiry.

The study was conducted in a tertiary care center in south India. Data was collected between the years 2017–2025.

Soft tissue tumors involving the inguinal region were excised en bloc with adequate oncologic margins (Figures 1–3). Superior to the inguinal ligament, the dissection was maintained in an extraperitoneal plane, and any inadvertent peritoneal breach was repaired primarily. This excision resulted in a composite defect of the lower abdominal wall with loss of the abdominal wall musculature and inguinal ligament (Figure 3).

Reconstruction of this defect was performed using a prosthetic mesh placed in the extraperitoneal space (Figure 4), configured in a hammock-like manner. Superiorly, the mesh (commonly polypropelene) was anchored to the parietal abdominal wall using transfascial sutures or tackers. Inferiorly the mesh was secured medially to Cooper’s ligament, folded downward, and its edges were anchored sequentially to the psoas, the iliacus and the anterior superior iliac spine. Laterally, the mesh was tucked and fixed to the transverse process of the vertebra, taking care to preserve the neurovascular bundle (Figures 5, 6).

The folded edge of the mesh effectively served as a reconstructed inguinal ligament. In male patients, the testicular vessels are medialized and directed into the scrotum along with vas deference or a new deep ring was created by fish-tailing the lateral end of the mesh (Figures 7, 8). Finally, the residual anterior abdominal wall musculature was closed in layers or reconstructed with flap, and skin closure was performed as appropriate.

An extraperitoneal approach was employed in the majority of patients (10 of 13) to achieve tumor access and resection. Two patients required hemipelvectomy to obtain adequate oncologic margins due to the tumors origin from the bony pelvis. In all cases, prosthetic reinforcement was performed using a mesh placed in the extraperitoneal plane.

The primary material used for reconstruction was a polypropylene mesh, applied in 11 of 13 patients. A Titanium-coated polypropylene mesh was used in two patients. In the first case requiring a titanium-coated mesh, the patient had a markedly attenuated peritoneum with multiple tears that required primary repair, prompting the use of a mesh with a more bowel-friendly interface. In the second case, extensive sub-adventitial dissection around major vessels necessitated avoiding direct mesh–vessel contact; hence, a titanium-coated mesh was chosen for its inert, biocompatible surface.

We would also like to draw the readers’ attention to one patient in whom a polyglactin (Vicryl) mesh was used because an inadvertent bladder injury contaminated the field. This patient was excluded from the study cohort to maintain homogeneity, as a polyglactin mesh is a rapidly absorbable material and its use inherently confers a higher risk of subsequent incisional hernia formation. In such situations, the authors would instead recommend the use of a poly-4-hydroxybutyrate (P4HB) mesh, which has been shown to be a relatively safe option in contaminated fields and provides long term reinforcement while maintaining acceptable outcomes [4, 5]. Unfortunately, a P4HB mesh was not available at our institution at the time this patient underwent surgery.

Mesh dimensions varied across cases and are summarized in Table 1. Primary closure of the abdominal wall defect was achieved in most patients (11 of 13), while two required rotational flap reconstruction. Vascular reconstruction was undertaken in three patients.

Wide local excision aimed at achieving R0 resection was attempted in all patients. Among these, 6 patients had at least one close margin (<0.1 cm), 2 patients had a positive margin, and 5 patients had clear (negative) margins.

Within 30 days post-surgery, 4 patients developed surgical site infections. Among these, 2 experienced complete to near complete superficial wound dehiscence. Importantly, none of the patients with wound dehiscence had exposure of the mesh or a mesh infection.

Two of these patients were managed with daily dressings, and the wounds healed by secondary intention. Two of these patients were managed with negative pressure wound therapy, of which one eventually required a split-thickness skin graft to cover the wound.

Seroma formation occurred in 2 patients. Management included conservative management with empirical antibiotic therapy in one patient and ultrasound-guided drain placement in another. Both patients improved.

The details of postoperative outcomes and treatment are summarized in the Table 2.

The average length of hospital stay was 17 days (range: 9–32 days).

There were no surgery-related mortalities and no documented cases of mesh infection.

At the time of analysis, four patients had a documented visit to the outpatient department at least a year postoperatively, and seven were contacted telephonically. Two patient were not contactable. The median follow up period was 12 months with an interquartile range of 7–24 m.

Among these patients, three had developed a local recurrence and one had developed distant metastasis with no local recurrence. Four patients had passed away during the follow-up period, including two who experienced early recurrence within 6 months of surgery.

One patient developed an incisional hernia, which was asymptomatic and picked up only on surveillance imaging.

With regard to quality of life, a formal assessment was not done, however none of the patients (those who had local recurrence were excluded from this particular assessment to avoid confounding)complained of debilitating chronic pain and were able to carry out their activities of daily living.

Patient-specific oncological outcomes are detailed in Table 3.

Despite these benefits, certain limitations must be acknowledged. The study’s small sample size and retrospective design limit the generalizability of the findings. However, larger prospective studies are inherently challenging given the rarity of these tumors. Additionally, follow-up was predominantly conducted via telephone interviews. While only one patient was diagnosed with an incisional hernia, the absence of routine clinical examinations and imaging limits definitive conclusions regarding the long-term incidence of incisional hernias.

This technique offers a simple, safe, cost-effective, and reproducible method for reconstructing the myopectineal orifice in patients undergoing radical resection of soft tissue tumors involving the inguinofemoral region, with the sacrifice of the inguinal ligament. Though, due the nature of the disease it self, local recurrence may be high, the patients quality of life may be improved by the use of this technique to avoid the development of an incisional hernia.

Further studies with longer-term clinical and radiological follow-up are warranted to validate the durability and efficacy of this approach.