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Invited Critique
August 14, 2009

Mesh-Reinforced Ventral Hernia Repair—Invited Critique

Arch Surg. 2009;144(8):745. doi:10.1001/archsurg.2009.94

This retrospective single-surgeon series of 125 patients undergoing incisional hernia repair highlights many issues for both patient and surgeon when approaching these repairs. However, the methods for determining one of the main outcome measures, hernia recurrence, are not at all described. Despite this major flaw, the series provides some data that onlay mesh repair is fraught with high rates of recurrence and with continuation of the process that led to the hernia in the first place, with subsequent hernias developing late outside of the index repair. These results should lead most surgeons to consider application of the retrorectus technique in any patient with an incisional hernia, whether the approach to the repair is open or laparoscopic. Gleysteen has described the retrorectus technique sufficiently so that surgeons can replicate it in their practices. The repair described is notable in the suturing techniques of a running suture on one side of the repair, followed by interrupted sutures on the opposite side. It is unclear how much the actual suturing technique adds to the retrorectus mesh placement, although the amount of postoperative pain might be different from a repair that uses through-and-through sutures on both sides (expecting that the transmuscular sutures are the cause of some pain). The author's first conclusion in the abstract should be viewed as opinion, as there are no data presented to support or refute the statement that “[e]xtraperitoneal mesh reinforcement avoids intestinal complications and subsequent operations to remove mesh.” Specifically, there were no fistulas in either group and no difference in complication rates. Meanwhile, the retrorectus technique described deserves further study in a prospective manner with attention to postoperative patient-centered outcomes such as pain.

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