Does Mesh Location Matter in Abdominal Wall Reconstruction? A Systematic Review of the Literature and a Summary of Recommendations

Background: Mesh implantation during abdominal wall reconstruction decreases rates of ventral hernia recurrence and has become the dominant method of repair. The authors provide a comprehensive comparison of surgical outcomes and complications by location of mesh placement following ventral hernia repair with onlay, interposition, retrorectus, or underlay mesh. Methods: A systematic search of the English literature published from 1996 to 2012 in the PubMed, MEDLINE, and Cochrane library databases was conducted to identify patients who underwent abdominal wall reconstruction using either prosthetic or biological mesh for ventral hernia repair. Demographic information was obtained from each study. Results: Sixty-two relevant articles were included with 5824 patients treated with mesh repair of a ventral hernia between 1996 and 2012. Mesh position included onlay (19.6 percent), underlay (60.7 percent), interposition (6.4 percent), and retrorectus (12.4 percent). Prosthetic mesh was used in 80 percent of repairs and biological mesh in 20 percent. The weighted mean incidences of early events were as follows: wound complications, 19 percent; wound infections, 8 percent; seroma or hematoma formation, 11 percent; and reoperation, 10 percent. The weighted mean incidences of late complications included 8 percent for hernia recurrence and 2 percent for mesh explantation. Recurrence rates were highest for onlay (17 percent) or interposition (17 percent) reinforcement. The infection rate was also highest in the interposition cohort (25 percent). Seroma rates were lowest following a retrorectus repair (4 percent). Conclusions: Mesh reinforcement of a ventral hernia repair is safe and efficacious, but the location of the reinforcement appears to influence outcomes. Underlay or retrorectus mesh placement is associated with lower recurrence rates.