July 15, 2026
Small ventral and inguinal hernias are common and can be straightforward to repair. But when a hernia is recurrent or uniquely located, or it involves a significant portion of the intestines outside the abdominal wall, it needs special expertise.
Mayo Clinic in Rochester, Minnesota, is home to fellowship-trained hernia surgeons who perform a high volume of complex hernia repairs. Their experience allows them to push the boundaries of what's possible with hernia repair and which people they can help.
What makes a hernia complex?
Recurrence is the most common factor that increases hernia complexity. Most of the complex hernia surgeries performed at Mayo Clinic are reoperative, says Charlotte Horne, M.D., a metabolic and abdominal wall reconstructive surgeon.
Other factors affecting hernia complexity include:
- Infection of the mesh used in a prior repair.
- Involvement of an ostomy.
- Large size (greater than 10 cm).
- Location in the flank, back or diaphragm or near bony structures.
- Occurrence after removal of abdominal tissue for reconstruction.
- Patient risk factors, such as high BMI and smoking.
Planning complex hernia surgery to ensure a strong repair
Because each patient and hernia is different, complex hernia repair requires detailed planning to determine how to proceed through the surgery and address difficult areas. CT scans and past surgical notes help guide the planning process.
"If a hernia occurs at the site of a previous surgery, such as after a prostatectomy, it's important to understand how that procedure affected the abdominal wall," Dr. Horne says. "For repeat hernias, we try to determine the cause of the failure so we can prevent a future recurrence."
Advanced techniques in complex hernia repair and abdominal wall reconstruction
Abdominal wall reconstruction using mesh is a key part of complex hernia surgery. Depending on the situation, many types of synthetic mesh are available, including different weights and permanent and absorbable varieties.
"One benefit of completing a hernia fellowship is learning about the different mesh types and when to use them," says Dr. Horne. "Our team has also spent time with manufacturers to understand how mesh products are made and the science behind them."
Patients are often concerned about mesh due to reports in the media. Poor outcomes in the past were primarily caused by mesh negatively interacting with the bowel. Today, surgeons use various tissue planes in the abdominal wall to allow for a wide overlap of hernia defects, including those next to bony landmarks. This approach reduces mesh-related complications by minimizing the need for mesh fixation and eliminating the interface between mesh and bowel.
"We use minimally invasive robotic surgery whenever possible. Sometimes that includes doing most of the procedure robotically, then using open surgery for the skin and soft tissue work."
Surgeons use advanced techniques in complex hernia repair and abdominal wall reconstruction, including:
- OnabotulinumtoxinA injections. These injections into the oblique abdominal muscles before ventral hernia surgery lengthen the muscles. A 2021 publication in the British Journal of Surgery demonstrated the benefits of onabotulinumtoxinA injections, including increased intra-abdominal compliance and volume. This extra space and compliance make the closure of larger hernia defects easier, minimizing recurrence.
- Component separation. Separating the muscle and tissue layers of the abdominal wall creates a plane that extends from the back muscles to the central tendon of the diaphragm and down to the pubis. This large plane facilitates adequate margins of mesh around the hernia and allows for mesh placement in off-midline areas and over bony structures.
- Transversus abdominis release. A type of component separation, this procedure involves dividing the transversus abdominis muscle and fascia along their lengths to create a large extraperitoneal space for mesh. The surgeon then places a large piece of mesh outside the visceral cavity to overlap the hernia defect. This release also helps minimize the tension on the hernia closure.
Minimally invasive robotic surgery for complex hernia repair
At Mayo Clinic, surgeons use open and robotic surgery for complex hernia repair. The procedure for tissue separation and mesh placement is similar; however, robotic surgery requires only six small incisions.
The main indications for open surgery include a very large hernia and multiple previous repairs with mesh. When a hernia reaches 15 to 18 cm, the insufflation needed to operate makes it challenging to close the hernia defect well. Open surgery is also a better option if a patient needs scar revision, excess skin removal or soft tissue repair.
"We use minimally invasive robotic surgery whenever possible. Sometimes, that includes doing most of the procedure robotically, then using open surgery for the skin and soft tissue work," Dr. Horne says.
Minimally invasive techniques make surgery safe for people with high BMIs
When it comes to BMI, people with complex hernia disease are often told they must lose weight before surgery, which can be challenging.
Dr. Horne has served as chair of the practice advisory committee of the American Hernia Society, which issues recommendations for preoperative optimization for hernia repair. According to the committee's 2023 recommendations, a BMI above 45 to 50 is considered prohibitive for elective ventral and abdominal hernia repair, but many surgeons use lower thresholds.
"We like patients to be healthy and invested in their care, but we also try to meet them where they are," says Dr. Horne. "We can often minimize the morbidity associated with hernia repairs for people with high BMIs if we use minimally invasive techniques."
Streamlining patient care
Mayo Clinic surgeons see the full spectrum of hernia disease and have fine-tuned their approach to minimize complications. They also work to make traveling to Rochester for hernia repair more convenient with coordinated appointments and virtual visits.
Most out-of-town patients spend two weeks in the Rochester area after surgery to ensure a smooth recovery. Longer term, the team follows up with all patients at four weeks and at one and two years. They then check in via phone annually.
Setting the goalpost for patient outcomes
The primary objective of hernia repair is to help patients feel and function better in their daily lives. Because every patient starts in a different place, the benefits of surgery are individualized and guided by each person's goals.
"We educate patients about the risks and expected results and let them choose what a good outcome looks like to them," says Dr. Horne. "For those living with pain or deformity or who have been denied hernia repair because of their weight, surgery provides highly valued relief."
For more information
Horne CM, et al. Understanding the benefits of botulinum toxin A: retrospective analysis of the Abdominal Core Health Quality Collaborative. British Journal of Surgery. 2021;108:112.
Refer a patient to Mayo Clinic.