Trends in mesh placement in elective ventral hernia repair: an 18-year nationwide register-based study

Mesh reinforcement is generally recommended in ventral hernia repair. This study examined temporal trends in mesh placement in elective ventral hernia repair over the past 18 years to better understand changes in clinical practice, with a secondary focus on trends in surgical approach.

This study utilized prospectively collected data from the Danish Ventral Hernia Database, covering the period from its inception in 2007 to 2024 in Denmark. Primary and incisional hernias with defect widths < 10 cm were included in the analysis.

A total of 62,963 operations were included, with primary hernias accounting for 76% of cases. Mesh repair has increased over time, particularly for primary ventral hernias, rising from 820 cases (40.9%) in 2007 to 2,300 cases (80.6%) in 2024. Until around 2018, intraperitoneal onlay mesh (IPOM) placement was the most common repair technique for hernia defects > 1 cm. Its use then declined significantly and was surpassed by onlay for defects measuring ≤ 4 cm, followed by preperitoneal and retromuscular mesh placements. For defects > 4 cm, retromuscular placement became dominant (72% for incisional hernias in 2024; 54% for primary hernias). By 2024, the use of IPOM had become minimal across all defect sizes. Over the study period, laparoscopic repairs decreased, while open and robotic approaches increased.

Mesh placement has changed over time, and in the beginning of the 2010s, IPOM was the most commonly used placement, but its use declined and was replaced by extraperitoneal placements, with onlay preferred for small- and medium-sized defects and retromuscular for large defects. By 2024, the use of IPOM had become minimal. These shifts have not followed current evidence and may therefore reflect evolving surgeon preference. Stronger evidence is needed to guide best practices and improve patient outcomes.