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Page 4 of 9 Alimi et al. Plast Aesthet Res 2020;7:5 I http://dx.doi.org/10.20517/2347-9264.2019.39
[16]
infections . When evaluating mesh location specific to synthetic versus biologic mesh placement, these
distinctions did not remain. Specifically, in all patients who underwent synthetic mesh placement, mesh
[16]
location was not a statistically significant predictor for recurrence rates (P = 0.95) .
[15]
When evaluating overall complication rates, Sosin et al.’s review highlights similar overall complication
rates observed in ventral hernia repairs, which ranged from 32.6% to 39.1%, regardless of mesh location
with no statistically significant difference (P = 0.738). While the onlay approach is generally considered
the least technically challenging approach to mesh placement, it has fallen out of favor due to the reported
[18]
increased wound and mesh infection complications with approximately 7.6% of hernia repairs as of
2018 being performed in this plane. This is compared to greater than 65% of meshes being placed in the
sublay-intraperitoneal, preperitoneal plane, or retromuscular plane in their pooled analysis of reported
[15]
ventral hernia repairs . The mean infection rate in the onlay subgroup was 14%. The mean hematoma/
seroma complication rate was found to be 17.4%, the highest amongst the four subgroups. However, the
differences amongst complications in different mesh planes was not significant. The onlay approach’s largest
disadvantage is the mesh’s direct contact with the environment during revision of the wound, which can
[19]
lead to the subsequent wound complications observed in these studies .
The inlay technique, which requires a bridging mesh, is performed when the fascial defect cannot be
closed. Laparoscopic repair was the dominant approach for this mesh placement accounting for 72.6% vs.
27.4% for open repairs. Infection rates in this approach was 12% and mean hematoma/seroma rate was
12.2%, which did not significantly differ among the four techniques. Hernia recurrence was the highest in
this subgroup, with a 21.6% hernia recurrence rate. The sublay-retromuscular approach to mesh placement
can be achieved both via an open surgical approach or through minimally invasive techniques. The open
[15]
approach remains the dominant surgical approach in Sosin et al.’s analysis, with 94% accounting for an
open repair. The mean infection rate was 10.4% and mean hematoma/seroma rate was 11%. This subgroup
had the lowest rate of hernia recurrence, at only 5.8% (P = 0.023). The closure of the rectus muscles over
prosthetic mesh in a well vascularized plane has proven to result in decreased wound infection rates. The
sublay-intraperitoneal technique was achieved both laparoscopically (63%) and through an open surgical
[15]
technique (37%). The mean infection rate in this group was the highest in Sosin et al.’s analysis, at 17.7%.
This compares to only 10.2% in the sublay-retromuscular cohort; however, in this analysis, these were not
found to be statistically significant. Mean hematoma/seroma rate was recorded as 11.5%. Hernia recurrence
[15]
in this group was 10.9%, the second lowest rate based on anatomic mesh placement . These data are
[16]
summarized in Table 1. These data corroborate previously reported outcomes by Holihan et al. , who found
the lowest odds of developing a surgical site infection in those with a sublay-retromuscular approach
(OR: 0.449; 95%CI: 0.12-1.16) when compared to onlay mesh placement. The sublay-intraperitoneal or
sublay-preperitoneal was almost double the odds (OR: 0.878; 95%CI: 0.29-1.99). Notably, infection rates
are significantly different when evaluating open versus laparoscopic approach. This is demonstrated in
[10]
Table 2. In Gokcal et al.’s single institution comparison of robotic preperitoneal and intraperitoneal ventral
hernia repair, perioperative outcomes at three months were similar. Extremely short-term outcomes at three
weeks demonstrated higher surgical site occurrences in the intraperitoneal cohort when compared to the
preperitoneal cohort (14% vs. 5.3%, P = 0.042).

MESH SELECTION
Mesh selection is a multifaceted dilemma based on what is familiar to the surgeon, what is available to
the surgeon based on institutional contracts and cost, and the approach to repair selected. However, at
the core of selection are the properties of the mesh and these in general fall into two categories: biologic
and synthetic. Similar to the lack of strong consensus on the optimal location for mesh placement, there
remains lack of strong consensus on what type of mesh to use. While there is general consensus on the