|Year : 2020 | Volume
| Issue : 2 | Page : 180-186
Onlay vs retrorectus mesh placement for uncomplicated ventral hernia repair
Hamed A Elbadawy, Hazem A Badr, Mohamed O Mohamed, Eslam E Elkhateeb
Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||12-Feb-2020|
|Date of Decision||24-Feb-2020|
|Date of Acceptance||26-Feb-2020|
|Date of Web Publication||29-Jun-2020|
MBBCh Eslam E Elkhateeb
Postal Code : 11865
Source of Support: None, Conflict of Interest: None
Background Ventral hernia such as paraumbilical and epigastric hernias are among the most common surgical problems as well as the most common surgical operations performed worldwide. The two operative techniques most frequently used in the case of ventral hernia are the onlay and sublay repairs. However, it remains unclear which technique of repair is superior.
Objective The aim was to compare between two techniques of mesh placement in uncomplicated ventral hernias, onlay (mesh on external oblique) vs sublay (mesh in the retromuscular space). The patients included were evaluated for operating time, postoperative seroma formation, wound infection, drain duration, and postoperative hospital stay.
Patients and methods Fifty adult patients with uncomplicated ventral hernia were included in this study and were managed at the Al-Azhar University Hospitals. The patients were divided randomly into two groups according to the surgical technique used for the repair, without any specific criteria used in selection for any technique as follows: Group A underwent onlay mesh repair and group B had sublay mesh repair.
Results The mean operative time in patients treated with onlay mesh repair was 84.537±12.472 min (75–90) and in patients treated with sublay mesh repair was 93.438±15.536 min (80–100). As regards the drainage time, the mean total time in days was 7.532±2.472 days in onlay repair while in sublay group it was 4.153±1.251 days. Seroma formation after suction drain removal was observed in 12% patients in group A and in 4% in group B. Purulent wound infection was observed in 16 and 4% patients in group A and group B, respectively, and treated with dressing and proper antibiotic according to culture tests.
Conclusion Sublay (retromuscular) mesh repair is a good alternative to onlay mesh repairs, and the authors suggest carrying out more trials on the retromuscular mesh repair technique to include a bigger number of cases and a longer period of follow-up.
Keywords: onlay, Retrorectus, sublay, ventral hernia
|How to cite this article:|
Elbadawy HA, Badr HA, Mohamed MO, Elkhateeb EE. Onlay vs retrorectus mesh placement for uncomplicated ventral hernia repair. Sci J Al-Azhar Med Fac Girls 2020;4:180-6
|How to cite this URL:|
Elbadawy HA, Badr HA, Mohamed MO, Elkhateeb EE. Onlay vs retrorectus mesh placement for uncomplicated ventral hernia repair. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 11];4:180-6. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/180/288268
| Introduction|| |
Hernia is a protrusion of abdominal viscera through a defect in the abdominal wall. Successful repair of abdominal hernias requires thorough knowledge of anatomy of anterior abdominal wall and all its layers. Ventral abdominal hernia includes all the hernias occurring through the anterior abdominal wall excluding groin hernias (incisional, epigastric, paraumbilical, umbilical, and hypogastric hernias) .
Ventral hernia such as paraumbilical and epigastric hernias are among the most common surgical problems as well as the most common surgical operations performed worldwide .
The history of prosthetic repair in abdominal wall hernias began in 1844 by the use of silver wire coils placed on the floor of the groin to incite an inflammatory fibrosis augmenting the repair .
Many prosthetic materials have been tried in hernia repair, but the two most common in current use are polypropylene mesh and expanded poly tetra flouroethylene .
Ventral hernia repair varies from primary closure only, primary closure with relaxing incisions, primary closure with onlay mesh reinforcement, onlay mesh placement only, inlay mesh placement to intraperitoneal mesh placement .
The two operative techniques most frequently used in the case of ventral hernia are the onlay and sublay repair. However, it remains unclear which technique is superior .
The incidence of postoperative wound infection and wound-related complications due to mesh repair aimed at continuing research into the optimal method of treatment of these hernias ,.
| Patients and methods|| |
The study was carried out in the General Surgery Department, Al-Azhar University Hospitals from January 2019 to July 2019. It was applied on 50 adult patients who had uncomplicated ventral hernia either de novo or recurrent. The study is approved by the Ethics Committee of Faculty of Medicine, Al-Azhar University for Girls, Egypt. The patients were divided into two groups:
- Group A: onlay mesh over the external oblique (25 cases).
- Group B: sublay mesh preperitoneally (25 cases).
All patients with ventral hernia, including paraumbilical, epigastric, and incisional, except with very large defects, between 20 and 65 years of age without sex discrimination were included.
Patients with inflamed, obstructed, or strangulated ventral hernias. Very large ventral hernia defects that need special considerations before surgical interference.
These data were collected at the time of admission, for example, the name, age, sex, address, and phone number. Preoperative counseling was done. Fully informed written consent was taken. The clinical features and their duration, time of initial operation, and the interval between the first surgery and appearance of incisional hernia were obtained from the patients and recorded in the data in cases of incisional hernia. Preoperative assessment included evaluation of patients for general anesthesia and routine laboratory tests, including complete blood count, kidney functions tests, liver function tests, prothrombin time, international normalized ratio, electrolytes, blood group, chest radiography, ECG, echocardiography, and respiratory function tests if needed.
The patients were divided randomly by the use of closed envelope method into two groups according to the surgical technique used for the treatment of uncomplicated ventral hernia as follows:
- Group A (onlay mesh repair): 25 patients were operated by placing the mesh above the anterior rectus sheath and the external oblique muscle.
- Group B (sublay ‘reteromuscular’ mesh repair): 25 patients were operated by placing the mesh in the retromuscular space.
- Onlay mesh repair: the onlay repair was done under general anaesthesia with skin incision over the bulge or the defect. Using a blunt dissection, both the rectus sheath and the defect containing the hernia contents were identified. The site of opening the sacs was close to their necks. The contents were evaluated and adhesions were divided, and the reducibility of the contents was achieved. Adhesions to organs were dissected with great caution by blunt and sharp dissection without any aggressive bleeding. Once the contents were freed, they were examined to identify any accidental undetected injuries. Excessive, adherent, and/or unhealthy omentum was removed by transfixation excision ligature, in a piecemeal manner. With nonabsorbable sutures, the defect was closed. A proline mesh of adequate size was placed on the rectus sheath and fixed with stitches. Hemostasis was secured and wound was closed over a suction drain.
- Sublay mesh repair: the principles of the preperitoneal or sublay mesh repair included two main steps; mesh placement deep into the rectus muscles and mesh extension well beyond the hernia defect. After the sac is dissected and delineated, the defect is opened and the preperitoneal plane is created between the posterior rectus sheath and the rectus muscle for placement of the mesh. The posterior rectus sheath along with the peritoneum is closed with zero Prolene suture. A Prolene mesh tailored to the size is placed in the already created plane behind the rectus. The mesh is secured with few interrupted 2/0 polypropylene sutures. A suction drain is placed over the mesh. The anterior rectus sheath is closed continuously. Another drain is placed in the subcutaneous plane and the skin closed. Drains were removed when drainage was less than 20 ml in 24 h.
| Results|| |
There was no statistical difference between both groups regarding their demographic data such as age and sex as shown in [Figure 1] and [Figure 2].
|Figure 2 Application of the mesh over the rectus sheath and fixation with stitches.|
Click here to view
The mean duration of surgery in patients treated with onlay mesh repair was 84.537±12.472 (75–90) min and in patients treated with sublay mesh repair was 93.438±15.536 (80–100) min.
The length of hospital stays in our study in patients treated with onlay technique was 3.652±1.832 days and in patients treated with sublay was 2.03±1.153 days ([Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15]).
|Figure 4 Preperitoneal plane between the posterior rectus sheath and rectus muscle.|
Click here to view
|Figure 8 Anterior rectus sheath is closed then a drain is inserted over it.|
Click here to view
|Figure 11 Distribution of patients regarding the duration of surgery in minutes.|
Click here to view
|Figure 12 Distribution of patients regarding the duration of hospital stay in days.|
Click here to view
Drain was removed in patients treated with onlay mesh repair after a period of time that ranged from 5 to 9 (7.532±2.472) days, While in patients treated with retromuscular mesh repair, the drain was removed after a period of time that ranged from 2 to 6 (4.153±1.251) days.
Seroma formation after suction drain removal was observed: three (12%) patients in the onlay technique necessitated frequent aspiration under antiseptic techniques until complete evacuation of the formed seroma while in the sublay technique only one patient developed seroma diagnosed by the aid of ultrasonographic imaging and was treated conservatively.
Purulent wound infection was observed in four patients and in one patient in group A and group B, respectively, and were treated with dressing and were given proper antibiotics according to culture tests.
| Discussion|| |
Ventral hernia either de novo or recurrent is a common surgical problem and refers to fascial defect of the anterolateral parietal abdominal wall fascia and muscles, through which intermittent or continuous protrusion of intra-abdominal or preperitoneal contents occurs .
Repair of ventral hernia is an ongoing challenge in surgical practice and a wide spectrum of surgical techniques have been developed ranging from direct suture techniques to the use of various types of mesh to close the defect and strengthen the musculofascial tissues to avoid recurrence .
In this study, there was no statistical significance regarding age, gender, and type of ventral hernia between the two studied groups.
The mean duration of surgery in patients treated with onlay mesh repair was 84.537±12.472 (75–90) min and the duration of surgery in patients treated with sublay mesh repair was 93.438 ±15.536 (80–100) min.
In the study conducted by Gordara et al. , the mean time for surgery in the onlay group was 49.35±8.29 min (30–90 min) compared with 63.15±15 min (36–96 min) in the sublay group. The study by Saber et al.  found that the mean operative time for onlay repair was 67.09±13.19 min (range: 45–90 min), whereas for sublay it was 93.26±24.94 min (range: 60–140 min).
In our study, the mean operative time was longer in the sublay group than in the onlay group owing to the time consumed to create the preperitoneal tunnel. Our data agree with other reported studies.
The length of hospital stays in our study in patients treated with the onlay technique was 3.652±1.832 days and in patients treated with the sublay was 2.035±1.153 days, whereas in a study by Godara et al.  the mean duration of hospital stay was 6.8±1.50 days in the sublay group and 4.6±1.30 days in the onlay group.
Moreover, Voeller and Mangiante  reported a mean hospital stay of ∼5.8 days in the sublay group and 4.5 days in the onlay group.
Drain was removed in patients treated with onlay mesh repair after a period of time that ranged from 5 to 9 days (7.532±2.472 days) which is slightly higher than that reported by Godara et al.  of which the period of drainage ranged from 2 to 7 days and slightly higher than that reported by Bauer et al.  of which the mean duration of drainage was 5 days, while in patients treated with retromuscular mesh repair, the drain was removed after a period of time that ranged from 2 to 6 days (4.153±1.251 days), which is comparable to that reported by Kohler et al.  of which the period of drainage ranged from 2 to 5 days (2±0.8 days), but lower than that reported by Hameed et al.  of which the period of drainage ranged from 3 to 8 days with the average period being 4–6 days.
Seroma is one of the most common complications following open technique and is particularly likely to occur when large skin flaps are developed during the surgical procedure. Although small seromas frequently resolve within 6–8 weeks without sequelae, a large symptomatic or persistent seroma occasionally requires multiple aspirations with subsequent increased risk for secondary infection . This study showed postoperative seroma formation in the onlay technique in three (12%) patients and in the sublay technique in one (4%) only patient.
Seroma formation is a common complication after the repair of abdominal wall hernia. Other studies have reported that the rate of seroma formation in the sublay repair is much less than the onlay repair ).
The postoperative wound infection occurred in the onlay group in four (16%) patients and in the sublay group in one (4%) patient, which is lower than occurred with the onlay group. Another study reported that infection occurred in 11.6% of cases in the onlay group, and in 3% in the sublay group which is less than our study . Godara et al.  reported 22.5% of the cases in the only group who developed wound infection and 4% of cases in the sublay group, which is higher than reported by Kohler et al.  which reported that 2.5% of cases in the onlay group had wound infection.In our study, we reported a lower incidence of wound infection in the sublay group patients when compared with the onlay group.
The implantation of prosthetic mesh remains the most efficient method for dealing with any ventral hernia especially the sublay technique as it has several advantages, and one of the most important is not transmitting the infection from subcutaneous tissues to the mesh, as it lies deep in the preperitoneal space .
| Conclusion|| |
Sublay (retromuscular) mesh repair is found to be a good alternative to onlay mesh repairs. This study advocates this method of ventral hernia repair as it is applicable to all sites of ventral hernia. The mesh is mostly hidden and is anchored behind the rectus sheath. The complication rate is low with less drainage time, reduced seroma formation and wound infection. We suggest carrying out more trials on the retromuscular mesh repair technique to include a bigger number of cases and a longer period of follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ali Q, Murad F, Awan TA, Khan A, Malik AZ. Onlay vs sublay technique of repairing ventral abdominal hernia. J Rawalpindi Med Coll
Malik AM. Laparoscopic vs open repair of para-umbilical hernia. Is it a good alternative?. J Pak Med Assoc
Phelps AM. A new operation for hernia. New York Med J
Murphy JL, Freeman JB, Dionne PG. Comparison between Marlex and Gor-tex to repair abdominal wall defects in rats. Can J Surg
Millikan KW. Incisional hernia repair. Surg Clin N Am
Timmermans L, de Goede B, van Dijk SM, Kleinrensink GJ, Jeekel J, Lange JF. Meta-analysis of sublay vs onlay mesh repair in incisional hernia surgery. Am J Surg
Gray SH, Hawn MT, Itani Kamal MF. Surgical progress in inguinal and ventral incisional hernia repair. Surg Clin N Am
Forbes SS, Eskicioglu C, McLeod RS, Oakrainec A. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg
Ahmed M, Niaz A, Hussain A, Saeeduddin A. Polypropylene mesh repair of incisional hernia. JCPS
Ibrahim AH, El-Gammal AS, Mohamed Heikal MM. Comparative study between ‘onlay’ and ‘sublay’ hernioplasty in the treatment of uncomplicated ventral hernia. Menoufia Med J
Godara R, Garg P, Raj H, Singla SL. Comparative evaluation of ‘sublay’ vs ‘onlay’ mesh plasty in ventral hernias. Internet J Surg
Saber A, Emad KB. Onlay vs sublay mesh repair for ventral hernia. J Surf
Voeller GR, Mangiante EC. Laparoscopic Repair of Ventral − Incisional Hernias
. Nyhus LM, Condon RE (editors). 5th ed. Philadelphia, PA: JB Lippincott Co. 2000. 534–540
Bauer JJ, Harris MT, Kreel I, Gelerent IM. Twelve years experience with polypropylene in repair of abdominal wall defect. Mt Sinai J Med
Hameed F, Ahmed B, Ahmed A, Dab RH, Dilawaiz XX. Incisional hernia repair by preperitoneal (sublay) mesh implantation. APMC
Haytham MA, Hur K, Hirter A, Kim LT, Thomas A, Berger DH. Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome. Am J Surg
Robert J, Fitzgibbons A, Samuel C, editors. Abdominal wall hernias. In: Greenfield’s Surgery Scientific Principles and Practice
. 5th ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins 2011. 1159–1198
El-Santawy HMG, El-Sisy AAE-A, El-Gammal AS, El-Kased AF, Mahmol H. Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia. Med J
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]