ABSTRACT

There is biomechanical advantage to placing mesh in the retro-myofascial plane for repair of ventral abdominal hernias. Intra-abdominal pressure applied to the periphery of the mesh increases apposition to the abdominal wall rather than causing distraction and this translates, in general, into lower recurrence rates than after “inlay” and “onlay” mesh placement. Traditionally, retro-myofascial mesh is placed in the pre-peritoneal or retro-muscular space. Both traditional techniques require extensive dissection and placement of large sheets of mesh which can cause symptomatic impairment of abdominal wall compliance. Pre-peritoneal dissection can be particularly tedious due to pathological adherence of peritoneum to the posterior abdominal wall in longstanding primary and incisional hernias. In the technique described, mesh is tucked into the retro-myofascial plane without any dissection into pre-peritoneal, retro-muscular or peritoneal spaces. The operation is less tedious, takes less time to perform, can often be done under local anaesthesia, demands less mesh and achieves similar recurrence rates to traditional retro-myofascial mesh repairs. Sixty-one operations have been performed by the author using this technique, with a recurrence rate of 8.2% after 13 years to 3 months of follow-up (median, 3.75 years) and 9.3% if patients with less than one year of follow-up are excluded. Factors predisposing to recurrence after mesh repair of ventral hernias are numerous and complex. A fair comparison of recurrence rates between this technique and traditional retro-myofascial repairs requires a randomized controlled trial but the crude recurrence rate for this operation falls well within the range reported for traditional repairs from other studies.