Open Mesh Repair for Ventral Hernias ? Onlay or Preperitoneal: Analysis of a Young Surgeon's Dilemma

Background Ventral hernias are protrusions of an abdominal viscus or a part of the viscus through an opening in the anterior abdominal wall other than the groin. Most of these patients undergo conventional open mesh repair by pre peritoneal or onlay reinforcement using a prosthetic mesh. Even though technically more difficult, preperitoneal mesh placement has been considered superior to onlay mesh. However, onlay mesh placement is considered an easier and faster option, especially in a severely scarred abdominal wall. Methods All patients with ventral hernias who underwent open mesh repair by onlay or preperitoneal prosthetic (polypropylene) mesh over a period of 18 months at a tertiary care teaching hospital were included in the study. Choice of mesh placement was based on the surgeons decision at the time of surgery. They were observed for early complications like seroma formation and infection, and late complications like chronic pain and recurrence. Results 103 out of 121 patients who underwent open surgery for ventral hernias were available for follow up at the end of two years.52 patients had undergone onlay mesh repair and 51 had undergone preperitoneal repair.44 were male and 59 were female, with age ranging from 24 to 83 years. The defects ranged from 2.5 cm to 8 cm in maximal diameter. In contrast to 13 out of 51 patients of onlay repair, only 4 out of 52 patients of preperitoneal repair had at least one of the complications studied (p value = 0.031) However, there was no statistically significant difference in the incidence of long term complications of recurrence and chronic pain between the onlay and preperitoneal mesh groups. Conclusion Though onlay mesh repair has higher overall complication rates compared to preperitoneal repair, the long term outcomes are not significantly different. Whenever possible, preperitoneal mesh repair should be carried out for ventral hernias. However, onlay repair being technically easier, can be considered as a safe and appropriate option in case of technical difficulty in dissecting safe and sufficient preperitoneal space in scarred abdominal walls or when surgical expertise to do the same is not available.