The use of prophylactic mesh is proposed to reinforce laparotomy wound closure, in susceptible IH patients, even in vascular and bariatric surgery or other abdominal procedures [7]. This strategy has its value but its effect is purely topical or local [8]. The results show the greater protection afforded to the scar, substantially reducing the incidence of IH, with no increase of local events, although some papers in the literature are controversial as to the number of cases of seroma and chronic pain associated with mesh use [9–12].

In spite of these advantages, there is always the possibility that these patients can develop fistulas and/or chronic surgical site infection and that the presence of a mesh, already incorporated in the wall tissues may create an obstacle to future laparotomies, as happens for trauma or cancer.

Unfortunately, we don’t know the intimate mechanism by which the hernia is triggered, in a given location, from one or more metabolic alterations, on a systemic level, nor which of these events start and/or perpetuate other ones [6]. It must be considered, though, that hernia etiology is a multifactorial affection, where different causes are involved, metabolic factors (genetic), environmental/behavioral (smoking, obesity), anatomical (dysmorphism), and also of technical/iatrogenic origin (inadequate closure of abdominal wounds, surgical site infection). The contribution of these factors to a greater or lesser extent could explain the occurrence of these defects, which sometimes assume catastrophic proportions.

It seems inevitable to consider the abdominal wall as a multisystem organ. Its contractile prerogative, thanks to the striated musculoaponeurotic contour, interspersed with periods of relaxation, promote changes in intra-abdominal pressure (IAP) . This alternating pressure modifies both the form and content of viscera and peritoneal cavity structures, optimizing the performance of each organ that is located there, as well as the whole abdomen. Digestive, urogenital, cardiovascular, and respiratory systems gain efficiency, wherein the abdominal wall has a supporting role, but also the stability, splanchnic protection, and trunk movements, specific attributes of its locomotor interface. The latter, associated with cutaneous vitality, establishes and maintains body contouring, whose aesthetic consequences cannot be underestimated. Therefore, as in any organ, it is essential that the integrity of its neurovascular contingent is preserved, to perform all these functions completely.

The surgeon will be required, depending on destruction degree and structural wall remaining, to not only do the simplest repair, but a complete restoration of the entire abdominal continent, in view of the complexity achieved by hernia disease. In this sense, all valuable reachable measures with the objective of re-establishing contents and continent must be done as a way to recover anatomical and physiological balance of the abdominal wall. Recovering its structure, partially or completely, is the only way to regain functional capacity to the wall.

Regardless of the success in getting the coveted parietal “dynamic support,” the availability of prostheses of all kinds and sizes, is essential to meet the needs of each case. However, it is imperative that the surgeon always adhere to the “restorative principle ,” because any prostheses used for the repair of the abdominal wall seek only to restore the lack of continuity, offering a holding and fibrosis-inducing barrier, not new muscle fibers. There is no cell regeneration in these tissues, just scar. Even without this scaffold, the homeostatic forces of the body will try to do this (fibrosis) to fill the defect. The hernia sac, with its dense and mesothelial connective structure, is proof of this great effort, even though insufficient. Neither the mesh nor the hernia sac provides active support to the wall. Only the musculoaponeurotic component well vascularized and innervated is capable of doing that.

Therefore, the most effective way to correct these lesions is to restore the continuity of this contractile belt surgically, often by combining techniques and prostheses [13]. On the degree of complexity achieved by hernia disease, in some circumstances, it must also subtract the herniated content (visceral and omentum resections). Working from the surface to the depth, the idea is to reconstitute all affected layers, considering relaxing incisions (discharge) and muscle advancing techniques. Even if it is possible to cover the parietal defect completely, reinforcement of the wall with the use of prostheses could be chosen, in a superficial position (onlay) or preferably deep (sublay or underlay) to decrease the chance of hernia recurrence [14].

Moreover, it is also important that the surgeon promote an acceptable cosmetic result, removing unsightly scars and associating dermolipectomy in patients with “fat apron abdomen”. This procedure is, moreover, strategic and aims to create a suitable route of access to the musculoaponeurotic layer, so the anatomy can be contemplated in its full magnitude where the defect is even without primary aesthetic purpose. Similarly, resection of such large excesses of skin and subcutaneous fat will reduce the effect of the traction exerted on the suture lines and the mesh, when placed in a preaponeurotic position (onlay). In this regard, the collaboration of a plastic surgeon is extremely useful because the tactics and aesthetic prerogatives may be associated in the same surgical procedure and are shared by all.