The Perfect Plane: A Systematic Review of Mesh Location and Outcomes, Update 2018

The principal approach to abdominal wall reconstruction requires implantation of mesh to decrease ventral hernia recurrence. This study compared current surgical outcomes and complications by location of anatomic mesh placement following ventral hernia repair with onlay, interposition, retromuscular, or underlay mesh reconstruction.

A systematic search of the PubMed database published from 2013 to 2018 was performed to identify patients who underwent abdominal wall reconstruction using either biologic or prosthetic mesh for ventral hernia repair. Demographic information and outcomes were obtained from each study.

Fifty-one articles met inclusion criteria, resulting in 6,227 patients who underwent mesh repair of a ventral hernia. Mesh position included onlay in 7.6% of patients, interposition in 13.2%, retromuscular in 35.9%, and underlay placement in 43.4%. Prosthetic mesh was used in 68.5% of repairs and biological mesh in 31.5%. The mean patient age was 53.1 years (range, 18-95 years), and mean BMI was 29.1 kg/m(2) (range, 15-70.9 kg/m(2)). The mean follow-up was 37.5 ± 2.3 months. The overall mean recurrence rate was 8.3%, with retromuscular (5.8%) and underlay (10.9%) mesh placement trending toward less recurrence than onlay (12.9%) and interposition (21.6%) mesh placement (P = 0.023). Inferior recurrence rates were identified in the onlay and interposition placement of biologic mesh (28.6% and 29.1%, respectively), and analysis of open approaches yielded significant differences with onlay and interposition repairs having the highest hernia recurrence rates (10.9% and 25.4%, respectively). Laparoscopic interposition mesh location showed highest recurrence (10%) as compared with retromuscular (0.1%) and underlay (4.2%) (P = 0.041).

Mesh reinforcement of a ventral hernia repair continues to be safe and efficacious, and the anatomic location of mesh implantation appears to influence outcomes. Retromuscular or underlay mesh repair is associated with a lower recurrence rate.