Objective To investigate the influencing factors for safe abdominal wall recons-truction in giant ventral hernia based on imaging and clinical features.

Methods The retrospective case‑control study was conducted. The imaging and clinical data of 369 patients with giant ventral hernia who were admitted to Beijing Chaoyang Hospital of Capital Medical University from January 2017 to December 2023 were collected. There were 182 males and 187 females, aged (63±14)years. Among 369 patients, 311 cases underwent safe abdominal wall reconstruction and 58 underwent high‑risk abdominal wall reconstruction. Observation indicators: (1) clinical and imaging characteris-tics; (2) analysis of influencing factors for safe abdominal wall reconstruction in giant ventral hernia. Comparison of measurement data with normal distribution between groups was conducted using the t test. Comparison of measurement data with skewed distribution between groups was conducted using the Mann‑Whitney U test. Comparison of count data between groups was conducted using the chi‑square test. Comparison of ordinal data between groups was conducted using the nonparametic rank sum test. Logistic regression, Lasso regression, and random forest analyses were used for influencing factors analysis.

Results (1) Clinical and imaging characteristics. There were significant differences between patients with safe and high‑risk abdominal wall reconstruction in presence of a definite secondary abdominal cavity, maximum axial diameter of the defect, maximum transverse diameter of the defect, abdominal wall defect area, component separation index (CSI), abdominal wall opening angle, ratio of CSI, muscle grayscale at the defect, hernia sac volume, hernia sac‑abdominal cavity volume ratio, and defect long‑axis‑to‑abdominal cavity ratio (P<0.05). (2) Analysis of influencing factors for safe abdominal wall reconstruction in giant ventral hernia. Results of Logistic regression analysis showed that presence of a definite secondary abdominal cavity, maximum axial diameter of the defect, maximum transverse diameter of the defect, abdominal wall defect area, CSI, abdominal wall opening angle, ratio of CSI, muscle grayscale at the defect (inner‑superior or right), hernia sac volume, hernia sac‑abdominal cavity volume ratio, and defect long‑axis‑to‑abdominal cavity ratio were factors associated with safe abdominal wall reconstruction in giant ventral hernia odds ratio (OR)=3.955, 1.189, 1.395, 1.127, 2.006, 1.042, 1.095, 0.881, 1.102, 1.109, 1.601, 95% confidence interval (CI) as 2.179-7.178, 1.113-1.271, 1.267-1.537, 1.090-1.166, 1.651-2.437, 1.014-1.071, 1.066-1.125, 0.798-0.972, 1.057-1.148, 1.067-1.153, 1.343-1.909. The top 3 factors for discriminative performance were abdominal wall CSI, ratio of CSI, maximum transverse diameter of the defect and the abdominal wall defect area, with area under the curve of 0.794, 0.777, 0.772, and 0.772, respectively. Results of Lasso regression analysis showed that body mass index, smoking, chronic obstructive pulmonary disease, American Society of Anesthesiologists classification, presence of a definite secondary abdominal cavity, abdominal wall defect area, abdominal wall opening angle, abdominal wall CSI, muscle grayscale at the defect (inner‑superior or right), and hernia sac‑to‑abdominal cavity volume ratio were associated factors with safe abdominal wall reconstruction in giant ventral hernia (coefficients as -0.002, 0.003, 0.007, 0.014, 0.021, 0.077, 0.023, 0.059, -0.010, 0.037). Results of random forest analysis showed the abdominal wall CSI, maximum transverse diameter of the defect, abdominal wall defect area, ratio of defectr opening angle, maximum axial long diameter of the defect, hernia sac‑to‑abdominal cavity volume ratio, abdominal wall opening angle, defect long-axis-to-abdominal cavity ratio, muscle grayscale at the defect (inner-superior or right), and body mass index as associated factors with safe abdominal wall reconstruction in giant ventral hernia (importance score=0.092, 0.089, 0.079, 0.056, 0.051, 0.047, 0.045, 0.039, 0.038, 0.035).

Conclusion Abdominal wall CSI, abdominal wall defect area, abdominal wall opening angle, muscle grayscale at the defect (inner‑superior or right), and hernia sac‑to‑abdominal cavity volume ratio are factors associated with safe abdominal wall reconstruction in giant ventral hernia.