This retrospective cohort study was conducted at the Military Medical Clinical Centre of the Southern Region in Odesa, Ukraine, between June 2022 and December 2025. The study included 79 male patients who sustained combat-related abdominal injuries and subsequently underwent elective surgical repair of ventral hernias. The minimum interval between the initial injury and the planned hernia repair was 6 months.

All patients sustained small bowel injuries, and some also had associated liver injuries without involvement of major blood vessels or bile ducts. Patients with more severe injury patterns, including major vascular or biliary tract injuries, were not included in the study.

Social habits, including smoking and alcohol consumption, were recorded at admission. No active alcohol use was reported at the time of surgery. Smoking was common in the cohort, and its prevalence was comparable between the study groups. Patients with significant comorbidities, such as diabetes mellitus, chronic cardiovascular insufficiency, chronic pulmonary disease, chronic kidney or liver disease, as well as chronic pain syndromes, were excluded in order to minimise potential confounding factors.

Demographic and clinical data, including age, body mass index (BMI), comorbidities, operative characteristics, and postoperative outcomes, were collected for all patients. Only patients with complete clinical and perioperative datasets were included in the final analysis.

Patients were divided into two groups according to the surgical approach. From September 2023 to August 2025, ventral hernia repair in this patient population was performed exclusively using open techniques. In September 2025, laparoscopic IPOM plus repair was introduced into clinical practice. The surgical team had prior experience with this technique in elective ventral hernia repair in non-trauma patients. From October 2025 to December 2025, laparoscopic repair became the standard approach and was performed exclusively in this cohort. All procedures were carried out at the same institution under standardized perioperative management protocols.

A total of 46 patients underwent open surgery, while 33 patients were treated using a laparoscopic approach. The two groups were comparable with respect to baseline clinical characteristics including age, BMI, comorbidities, and injury profile (Table 1).

In the open surgery group, retromuscular (sub-lay) repair was considered the preferred technique and was planned whenever feasible. Sub-lay repair was performed in 25 patients. However, in a substantial proportion of patients following damage control surgery, the retromuscular plane was partially or completely disrupted due to multiple laparotomies, extensive scarring, dense adhesions, or loss of the posterior rectus sheath. In such cases, safe dissection of the retromuscular space was not possible. When reconstruction of the retromuscular plane was not feasible, an on-lay mesh repair was performed. Overall, 21 patients in the open group underwent on-lay repair. The choice between sub-lay and on-lay repair was dictated by intraoperative anatomical findings rather than by surgeon preference.

In the laparoscopic group, ventral hernia repair was performed using the IPOM plus technique. Primary fascial defect closure with non-absorbable sutures was achieved in all patients prior to mesh placement, ensuring restoration of the anterior abdominal wall continuity without undue tension. Subsequently, a composite mesh was positioned intraperitoneally with sufficient overlap and secured using circumferential fixation in accordance with established IPOM plus technique standards (Figure 4).

Given the limited and unequal follow-up duration between the study groups, long-term outcomes such as hernia recurrence and chronic pain were not evaluated. The analysis therefore focused on early postoperative outcomes within the first 90 days after surgery.

Postoperative outcomes included length of hospital stay, operative time, and the incidence of postoperative complications such as seroma, haematoma, surgical site infection, and postoperative intestinal obstruction. Postoperative pain intensity was assessed using the visual analogue scale (VAS). Recovery of bowel function was evaluated as the time to first postoperative bowel movement. The need for reoperation and hospital readmission within 90 days after surgery were also recorded.

Under current treatment conditions in Ukraine, length of hospital stay reflects not only medical recovery but also institutional requirements, as discharge was permitted only after complete wound healing and suture removal, full recovery of physiological functions, and confirmation that no further medical assistance was required.

All outcome data were collected retrospectively from institutional medical records.

Statistical analysis was performed using IBM SPSS Statistics, version 27.0 (IBM Corp., Armonk, NY, USA). The distribution of continuous variables was assessed using the Shapiro–Wilk test. Continuous data are presented as mean ± standard deviation and were compared between groups using the independent samples t-test. Categorical variables are presented as counts and percentages and were analyzed using the χ² test or Fisher’s exact test, depending on the expected cell frequencies. All statistical tests were two-sided. A p-value <0.05 was considered statistically significant. No missing data were identified in the study cohort.

Operative characteristics are summarised in Table 2.

In the open surgery group, retromuscular (sub-lay) repair was successfully performed in 25 patients (54.3%). In the remaining 21 patients (45.7%), sub-lay repair was not feasible due to severe post-traumatic anatomical alterations, including disruption of the posterior rectus sheath, dense adhesions, and extensive scarring; therefore, an on-lay mesh repair was performed.

In the laparoscopic group, all patients underwent IPOM plus repair with successful primary fascial defect closure in all cases.

Extensive adhesiolysis was required in most patients in both groups, reflecting the high prevalence of severe intra-abdominal adhesions following damage control surgery. No statistically significant difference in operative time was observed between the open and laparoscopic groups (p > 0.05).

Within the open surgery group, no statistically significant differences were observed between patients undergoing sub-lay and on-lay repair with regard to operative time, length of hospital stay, postoperative pain scores, recovery of bowel function, or early postoperative complications.

The mean length of hospital stay in the open surgery group, taking institutional discharge requirements into account, was 16.89 ± 4.29 days (range, 10–25 days). In the laparoscopic group, the average duration of hospital stay was significantly shorter, amounting to 10.39 ± 4.34 days (range, 7–22 days). This difference between the groups was statistically significant (p < 0.001).

Postoperative pain intensity was assessed using the visual analogue scale (VAS) on postoperative days (POD) 1, 2, and 3. In the open surgery group, mean VAS scores were 6.41 ± 0.83 on POD 1 and 5.59 ± 1.00 on POD 2. In the laparoscopic group, postoperative pain was significantly lower during the early postoperative period, with mean VAS scores of 5.71 ± 0.91 on POD 1 and 4.97 ± 1.09 on POD 2. The differences between the groups were statistically significant on both POD 1 (p < 0.001) and POD 2 (p < 0.05).

By POD 3, pain intensity decreased substantially in both groups and became comparable, with mean VAS scores of 3.93 ± 0.68 in the open group and 3.91 ± 0.68 in the laparoscopic group (p > 0.05).

Recovery of bowel function was evaluated as the time to first postoperative bowel movement. In the open surgery group (n = 46), first postoperative bowel movement occurred on POD 2 in 16 patients (34.8%), on POD 3 in 22 patients (47.8%), and on POD 4 in 8 patients (17.4%). In the laparoscopic group (n = 33), recovery of bowel function occurred earlier. First bowel movement was observed on POD 2 in 20 patients (60.6%) and on POD 3 in 13 patients (39.4%). No patients in the laparoscopic group experienced bowel recovery later than on POD 3.

Overall, patients undergoing laparoscopic IPOM plus repair demonstrated significantly earlier recovery of bowel function compared with those treated with open surgery (p < 0.01).

Postoperative intestinal obstruction was observed in 1 patient (2.2%) in the open surgery group. The condition was managed conservatively, with resolution achieved without the need for surgical reintervention. No cases of postoperative intestinal obstruction were recorded in the laparoscopic group. The difference between the groups was not statistically significant (p > 0.05).

All patients underwent routine postoperative ultrasound examination of the anterior abdominal wall to detect seroma formation. Seromas were identified in 19 patients (41.3%) in the open surgery group and in 8 patients (24.2%) in the laparoscopic group. Although the incidence of seroma formation was lower following laparoscopic IPOM plus repair, the difference between the groups was not statistically significant (p > 0.05). In both groups, seromas were managed conservatively. Ultrasound-guided aspiration was performed when clinically indicated, and no patient required surgical intervention. In patients with clinically relevant seromas, hospital stay was prolonged until complete resolution was confirmed by follow-up ultrasound examination.

Comparison between patients with and without seroma formation revealed no significant differences in operative characteristics, including hernia defect size, extent of adhesiolysis, or number of previous laparotomies. In the open surgery group, seroma formation was not associated with mesh position (on-lay or sub-lay). In the laparoscopic group, all meshes were placed intraperitoneally according to the IPOM plus technique.

Therefore, the higher incidence of seroma formation observed after open repair is unlikely to be attributable to differences in hernia characteristics or mesh positioning. It is more likely related to the greater degree of soft tissue dissection and the creation of subcutaneous dead space inherent to open surgical techniques, particularly in patients with extensive post-traumatic scarring following damage control surgery.

No cases of surgical site infection were observed in either group during the 90-day postoperative follow-up period. Specifically, no superficial, deep, or organ space infections were diagnosed according to clinical assessment and institutional diagnostic criteria.

No non-surgical postoperative complications were observed in either group during the 90-day follow-up period. Specifically, no cases of cardiovascular events, respiratory complications, thromboembolic events, urinary tract infections, or other systemic complications were recorded.

No patients in either group required reoperation within the 90-day postoperative period. Similarly, no hospital readmissions were recorded in either the open surgery or laparoscopic IPOM plus group during follow-up.

A comparative summary of all postoperative outcomes is provided in Table 3.

This study has several important strengths. It addresses a clearly defined and underrepresented patient group - individuals with large post-traumatic ventral hernias following damage control surgery for combat-related abdominal shrapnel injuries.

All procedures were performed in a single specialised military centre using standardised perioperative protocols, ensuring consistency in surgical technique and perioperative care. The cohort was clinically homogeneous, as all patients had comparable injury mechanisms, surgical histories and defect characteristics, and the exclusion of significant comorbidities minimised potential confounding.

The comparison reflects a structured transition from open repair to laparoscopic IPOM plus within the same institution and during consecutive time periods, thereby limiting selection bias and maintaining baseline comparability between groups.

Early postoperative outcomes were assessed comprehensively, including pain scores, recovery of bowel function, seroma formation confirmed by routine ultrasound, and 90-day reoperation and readmission rates, with no missing data. These features strengthen the reliability of the findings and support the validity of the short-term conclusions.

The main limitation of this study is the relatively short and unequal follow-up between groups, which precluded the assessment of long-term outcomes such as hernia recurrence and chronic pain. As a result, the present analysis is restricted to early postoperative results and does not allow conclusions regarding the durability of repair.

Second, the retrospective design carries an inherent risk of selection bias and limits control over potential confounding variables. Although baseline characteristics were comparable between groups, unrecognised factors may have influenced treatment allocation and outcomes. An additional limitation relates to the chronological nature of group allocation. Open repairs were performed during an earlier study period, whereas laparoscopic IPOM plus became the standard approach later. Consequently, the comparison reflects a sequential change in clinical practice rather than concurrent treatment allocation. Although perioperative management protocols remained unchanged throughout the study period, unmeasured temporal factors such as increasing institutional experience, improvements in perioperative care pathways, or changes in organisational efficiency may have influenced some outcomes, particularly length of hospital stay. Therefore, the observed differences cannot be attributed exclusively to the surgical technique.

In addition, laparoscopic IPOM plus was introduced later during the study period. Although the surgeons had prior experience with this technique in non-trauma patients, its application in patients with extensive post-traumatic adhesions and distorted abdominal wall anatomy represents a distinct technical challenge. Therefore, a learning-curve effect specific to this patient population cannot be completely excluded.

Third, this was a single-centre study conducted in a specialised military institution and included exclusively male patients with combat-related injuries. Consequently, the findings may not be fully generalisable to civilian populations or to patients with ventral hernias of non-traumatic origin.

Another limitation is that the open surgery cohort included both sub-lay and on-lay repairs. However, no significant differences in early postoperative outcomes were identified between these subgroups within the present study.

Finally, the sample size was relatively modest, which may have limited the statistical power to detect differences in less frequent complications.

Prospective multicentre studies with longer and standardised follow-up are required to confirm these findings and to determine whether the early advantages observed after laparoscopic IPOM plus repair translate into sustained long-term benefit.

Despite its limitations, this study suggests that laparoscopic IPOM plus repair may offer meaningful early benefits for patients with large ventral hernias following damage control surgery for abdominal shrapnel injuries. The observed reductions in hospital stay, early postoperative pain and time to restoration of bowel function are clinically relevant in a population characterised by extensive adhesions and distorted anatomy. The technique proved technically feasible in this demanding setting and may be considered in other centres managing similar complex post-traumatic reconstructions.

The findings must, however, be interpreted within the specific context in which the study was conducted. The cohort was treated at a single military hospital in Ukraine during wartime and consisted exclusively of male patients without major comorbidities. Institutional discharge policies also resulted in longer hospital stays than would typically be expected in other healthcare systems. In addition, the injury pattern, characterised by combat-related shrapnel trauma, multiple prior laparotomies and extensive scarring, differs substantially from that encountered in most civilian ventral hernia practice. For these reasons, caution is required when applying the present results to non-military populations, women, older patients, individuals with significant comorbidity, or routine incisional hernia repair. The findings should therefore be regarded as context-specific rather than broadly generalisable.

Nevertheless, several observations are likely to have wider relevance. These include the frequent difficulty of achieving retromuscular repair after damage control surgery, the comparable short-term outcomes of on-lay and sub-lay techniques in open reconstruction, and the feasibility of laparoscopic IPOM plus repair with fascial closure even in the presence of severe adhesions. Such considerations may be applicable to surgeons managing post-open abdomen or trauma-related hernias in other settings.

Future research should seek to confirm these findings in prospective, multicentre studies with larger sample sizes and standardised long-term follow-up. Assessment of hernia recurrence, chronic pain and quality of life will be essential to determine whether the early advantages observed translate into sustained clinical benefit. Inclusion of more diverse patient populations, including civilian trauma cases and individuals with relevant comorbidities, would further clarify the external validity of these results.

In this retrospective single-centre study of patients with large ventral hernias following damage control surgery for abdominal shrapnel injuries, laparoscopic IPOM plus repair was shown to be feasible and safe in the early postoperative period. Compared with open repair, the laparoscopic approach was associated with a shorter hospital stay, reduced early postoperative pain and more rapid recovery of bowel function, without an increase in short-term complications.

Open retromuscular repair was not consistently achievable in this post-traumatic setting because of disruption of anatomical planes and dense adhesions. When retromuscular reconstruction was not feasible, on-lay repair provided comparable short-term results within the open cohort. These findings underline the importance of tailoring the reconstructive strategy to intraoperative anatomical conditions rather than adhering rigidly to a single preferred technique.

Although the results are limited to early outcomes and reflect the experience of a specialised military centre, they suggest that laparoscopic IPOM plus may represent a valuable alternative for abdominal wall reconstruction after damage control surgery. Further prospective studies with long-term follow-up are required to determine whether the early advantages observed translate into durable clinical benefit.