Evolution and trends in abdominal wall defect repair: from anatomical reconstruction to functional regeneration

The repair of abdominal wall defects has undergone a technical evolution from traditional tissue suturing to modern mesh reinforcement. Its core concept has progressively shifted from mere anatomical reconstruction towards the goal of restoring abdominal wall function. This journey spans early explorations with Onlay and Inlay techniques, to the establishment of the retro-muscular plane as the gold standard, and further to the innovative integration of intraperitoneal onlay mesh (IPOM) and Sublay techniques during the laparoscopic era. IPOM became mainstream due to its advantages of smaller wounds and faster recovery, however, its inherent limitations, including adhesion risks from mesh‑viscera contact, chronic inflammatory responses, and fixation-related complications (such as stapling pain and enterocutaneous fistula), has prompted specialists to re‑evaluate its indications. With the maturation of laparoscopic retromuscular plane techniques and the rise of robot‑assisted Sublay repair, the role of IPOM in abdominal wall defect repair is facing challenges. Its future application may be progressively confined to specific cases. In recent years, the introduction of component separation techniques has expanded the boundaries of anatomical repair, while regenerative medicine‑driven biomaterials and functional meshes (e.g., stem cell‑loaded scaffolds, immunomodulatory meshes) are driving a paradigm shift towards tissue regeneration. Looking ahead, the integration of surgical robotics, three‑dimensional imaging navigation, and artificial intelligence assisted decision‑making systems will propel abdominal wall defect repair into a new era of individualized precision therapy. The ultimate goal will no longer be confined to defect closure, but will encompass the comprehensive reconstruction and repair of abdominal wall biome-chanics and the microenvironment. Therefore, the authors systematically review the historical evolution, evidence‑based medicine, and future trends of the placement hierarchy of abdominal incisional hernia meshes, aiming to provide guidance for optimizing surgical strategies and impro-ving patient prognosis.