Page 57 - Read Online

Alimi et al. Plast Aesthet Res 2020;7:5 I http://dx.doi.org/10.20517/2347-9264.2019.39 Page 3 of 9
[6]
The inlay (or interposition) technique, as defined by Parker et al. , is characterized by an approach that
places the mesh within the hernia/fascial defect with the mesh fixated to the edges of the neck of the hernia.
By definition, the inlay placement of mesh requires a bridging mesh regardless of where the mesh is fixated.
If the fascial defect closure is not achieved, this is also considered an interposition mesh. This approach can
be completed open, as well as via a minimally invasive approach.

The sublay-retromuscular technique describes mesh placed posterior to the rectus muscle and anterior to
the posterior rectus sheath. This plane continues below the arcuate line as the plane between the rectus
[6]
abdominis muscle and the transversalis fascia . This approach was originally described by Rives and
Stoppa, and is characterized by opening the rectus sheath and defining the retrorectus plane posterior
to the rectus abdominis muscle. The unique characteristics of this repair include the placement of mesh
in the well vascularized retrorectus plane. The opening of this plane allows for the medialization and
restoration of the linea alba, which results in offloading of tension on the suture line. The posterior fascia
is approximated and the mesh is placed anteriorly in the plane between the rectus abdominis muscle
[3]
and the posterior rectus fascia . While this was previously exclusively an open approach as originally
described, the sublay-retromuscular approach is now being increasingly performed via a minimally
invasive approach. These approaches include combined endoscopic/open procedures as described by
[7]
Schwarz et al. in the endoscopic mini/less open sublay repair. Additionally, this sublay-retromuscular
approach has now been extensively described as the extended totally extraperitoneal repair, and can be
[8]
[9]
performed both laparoscopically and robotically . Belyansky et al. reported on this novel approach
in 2018 and its advantages, including extraperitoneal suture closure of defects, wide mesh coverage in
the sublay-retromuscular position with the use of minimal fixation, and an anecdotal appreciation for
decreased pain associated with the repair. The sublay-preperitoneal technique describes mesh placement
in the plane behind all of the abdominal wall muscles in front of the peritoneum. This technique is more
[10]
often performed on the robotic platform, given its technical challenge in a laparoscopic approach . The
sublay-intraperitoneal technique describes mesh placement behind the abdominal wall muscles including
[11]
the parietal peritoneum . If done in an open fashion, the mesh is secured posteriorly to the posterior
rectus sheath and the parietal peritoneum of the anterior abdominal. In a minimally invasive approach,
both laparoscopically and robotically, the hernia sac is identified and its contents reduced. Although the
fascial defect is more often closed in the robotic approach, the defect can also be closed in the laparoscopic
[12]
approach . Regardless of defect closure, the mesh is then secured in place underlying fascia [13,14] .

ADVANTAGES AND CURRENT DATA
The topic of mesh selection has been an ongoing debate in the surgical community and will not serve
as the focus of this review. However, regardless of mesh selection, the optimal location remains up for
debate. Mesh implantation has been reported with both prosthetic and biologic varieties; however, multiple
factors such as hospital contracts, surgeon experience, and cost drive the decision for mesh selection [13,14] .
[15]
In Sosin et al.’s 2018 meta-analysis of ventral hernia repairs, 6227 patients undergoing ventral hernia
repair with mesh were aggregated in a total of 51 studies. The overall recurrence rate for all comers was
8.9% regardless of location of mesh. Notably, there was a statistically significant difference in recurrent rates
that was dependent on the location of mesh. The lowest recurrence rate in this meta-analysis was in mesh
placed in the sublay-retromuscular plane, with a 5.8% hernia recurrence rate (P = 0.023). Recurrence rates
[16]
in the sublay-intraperitoneal and sublay-preperitoneal (summarily referenced as underlay in Sosin et al.’s
metanalysis) mesh placement were 10.9% and 12.9%, respectively. The highest hernia recurrence rate of
[8,9]
21.6% was observed in patients who underwent an inlay mesh placement . Additionally, on repeated
meta-analysis performed by Holihan et al. [16,17] , the sublay-retromuscular repair demonstrated a lower risk
of recurrence and surgical site infection, when compared to onlay, inlay, and sublay-intraperitoneal or
sublay-preperitoneal mesh approaches (range: OR: 0.45-0.79). The sublay-retromuscular repair was given a
moderate recommendation of being the best approach when considering recurrence rate and surgical site