Immunosuppression-free Nonvascularized Rectus Fascia Allotransplantation for Complex Hernia Repair

Background: Complex abdominal wall herniations present major reconstructive challenges, particularly in patients with contaminated fields or previous failed repairs. Synthetic meshes carry substantial infection risk, whereas biological meshes are expensive and exhibit inconsistent long-term strength, leaving many patients without dependable options. This study investigates the feasibility, safety, and immunologic profile of nonvascularized rectus fascia allotransplantation (NVRF-alloTx) for abdominal wall reconstruction in immunocompetent individuals. Methods: We conducted a prospective single-center case series of 3 immunocompetent patients who underwent elective NVRF-alloTx between 2024 and 2025 at a tertiary academic hospital. Candidates had complex or contaminated defects that were unsuitable for synthetic or biologic mesh repair. Primary outcomes were durable abdominal wall closure, graft-related complications, and immunologic responses measured by donor-specific antibody screening. Secondary assessments included radiologic evaluation, biomechanical testing, histologic integration, and chimerism analysis in 1 patient whose graft was explanted postmortem. Results: All patients achieved successful abdominal wall closure without hernia recurrence or graft failure during follow-up. Two developed de novo class I or II anti-HLA donor-specific antibodies. One patient died from unrelated cardiac disease 2 mo postoperatively; graft analysis demonstrated robust fibrovascular integration, limited T-cell infiltration, and biomechanical properties comparable to native fascia. Conclusion: This early clinical experience demonstrates that NVRF-alloTx without immunosuppression can provide durable, mechanically stable abdominal wall reconstruction in high-risk immunocompetent patients. Despite measurable alloimmune sensitization, graft function remained intact. NVRF may represent a viable alternative in contaminated settings where traditional mesh-based strategies are contraindicated. Further study is needed to confirm long-term outcomes.