Mesh Location in Open Ventral Hernia Repair: A Systematic Review and Network Meta‐analysis

Abstract

There is no consensus on the ideal location for mesh placement in open ventral hernia repair (OVHR). We aim to identify the mesh location associated with the lowest rate of recurrence following OVHR using a systematic review and meta-analysis. A search was performed for studies comparing at least two of four locations for mesh placement during OVHR (onlay, inlay, sublay, and underlay). Outcomes assessed were hernia recurrence and surgical site infection (SSI). Pairwise meta-analysis was performed to compare all direct treatment of mesh locations. A multiple treatment meta-analysis was performed to compare all mesh locations in the Bayesian framework. Sensitivity analyses were planned for the following: studies with a low risk of bias, incisional hernias, by hernia size, and by mesh type (synthetic or biologic). Twenty-one studies were identified (n = 5,891). Sublay placement of mesh was associated with the lowest risk for recurrence [OR 0.218 (95% CI 0.06-0.47)] and was the best of the four treatment modalities assessed [Prob (best) = 94.2%]. Sublay was also associated with the lowest risk for SSI [OR 0.449 (95% CI 0.12-1.16)] and was the best of the 4 treatment modalities assessed [Prob (best) = 77.3%]. When only assessing studies at low risk of bias, of incisional hernias, and using synthetic mesh, the probability that sublay had the lowest rate of recurrence and SSI was high. Sublay mesh location has lower complication rates than other mesh locations. While additional randomized controlled trials are needed to validate these findings, this network meta-analysis suggests the probability of sublay being the best location for mesh placement is high.

Randomized prospective comparison of long-term results of onlay and sublay mesh repair techniques for incisional hernia

“…However, in a cohort study, Gleysteen (17) reported that onlay and sublay mesh repair techniques have similar wound complication rates (16% and 12%, respectively). In a recent meta-analysis, sublay mesh repair was reported as having the least wound infection rate than onlay, inlay, and underlay mesh placement [Odds Ratio: 0.449 (95% CI, 0.12-1.16)] (19). In the present study, the mean operation time was shorter in the onlay group and the mean complication rate was lower in the sublay group.…”

Management of Incisional Hernias at a Tertiary Centre

“…It is most likely due to a selection bias. Anecdotal evidence from this centre suggests increasing use of the sublay technique in line with recent evidence [18], particularly among surgeons doing relatively higher numbers.…”

Tension Free Onlay Ventral Hernia Repair by Polypropylene Mesh- A Newer Approach

“…While repair of ventral hernias with mesh is considered routine, there is no consensus on the best location to place the mesh. [10][11][12] When considering the best location for mesh placement, a number of features are important to consider. First, mesh tissue integration may reduce long-term recurrence with theoretically improved rates with greater mesh-tissue overlap.…”

“…Sublay repair allows for tissue integration from two loadbearing tissues from both sides-Posterior rectus sheath and the anterior myofascial complex. [10][11][12] In addition, sublay mesh placement protects the mesh from exposure from superficial wound complications, intra-abdominal adhesions and contamination. Creation of DE vascularising skin flaps is avoided.…”