BACKGROUND: Abdominal wall defects, such as incisional hernias, are a common source of pain and discomfort and often require repeated surgical interventions. Traditional mesh repair techniques typically rely on fixed overlap based on defect size, without considering important biomechanical factors like muscle activity, internal pressure, and tissue elasticity. This study aims to introduce a biomechanical approach to incisional hernia repair that accounts for abdominal wall instability and to evaluate a visualisation tool designed to support surgical planning. METHODS: We developed HEDI, a tool that uses computed tomography with Valsalva manoeuvre to automatically assess hernia size, volume, and abdominal wall instability. This tool was applied in the preoperative evaluation of 31 patients undergoing incisional hernia repair. Surgeries were performed concurrently with the development of the tool, and patient outcomes were monitored over a three-year period. RESULTS: Here we show that all 31 patients remain free of pain and hernia recurrence three years after surgery. The tool provides valuable visual insights into abdominal wall dynamics, supporting surgical decision-making. However, it should be used as an adjunct rather than a standalone guide. CONCLUSIONS: This study presents a biomechanical strategy for hernia repair and introduces a visualisation tool that enhances preoperative assessment. While early results are promising, the tool's evolving nature and its role as a visual aid should be considered when interpreting outcomes. Further research is needed to validate its broader clinical utility. People with abdominal wall problems, such as hernias, often experience pain and may need repeated surgeries. Traditional repair methods do not always consider how the abdominal wall behaves under pressure. In this study, we explored an approach that uses two imaging scans, one taken at rest and another during a breathing technique that puts the abdomen under strain. Comparing these scans shows how the abdominal wall moves and stretches, helping surgeons understand its biomechanics before surgery. Using this method, 31 patients were treated, and none reported pain or hernia recurrence after three years. These results suggest that incorporating detailed visual information into surgical planning may improve outcomes and make repairs safer and more effective. eng
