Is primary repair with synthetic mesh, via open or laparoscopic approach, superior to primary tissue repair alone for ventral hernia repair?

From the Guidelines

A primary repair with synthetic mesh in either open or laparoscopic fashion is superior to primary tissue repair alone for a ventral hernia, as it significantly reduces recurrence rates and provides additional structural support to the abdominal wall. This recommendation is based on the most recent and highest quality evidence, including a prospective randomized trial by Abdel-Baki et al. 1 that compared mesh repair to tissue repair in 42 cases with acute para-umbilical hernia, showing no recurrences in the mesh repair group versus 19% in the tissue repair group. Additionally, a 6-year study by Abd Ellatif et al. 1 included 115 patients who underwent acutely incarcerated abdominal wall hernia repair with mesh, resulting in low rates of wound infection (4.3%) and recurrence (4.3%). The use of synthetic mesh in hernia repair has been shown to have advantages, including low rates of long-term complications and reduction of recurrence 1.

The mesh provides additional structural support that distributes tension across the abdominal wall rather than concentrating it at the suture line. Common synthetic meshes include polypropylene, polyester, and expanded polytetrafluoroethylene (ePTFE), with selection depending on hernia size, location, and patient factors. The mesh is typically secured with sutures, tacks, or a combination of both. While mesh repair is superior for most ventral hernias, there are exceptions where tissue repair might be considered, such as in contaminated fields, very small defects (<1-2 cm), or patients with specific contraindications to mesh. Potential complications of mesh repair include seroma formation, infection, chronic pain, and mesh erosion, though these risks are generally outweighed by the benefit of reduced recurrence for most patients.

In cases of emergency hernia repair in a clean-contaminated surgical field (CDC wound class II), emergent prosthetic repair with a synthetic mesh can be performed without an increase in 30-day wound-related morbidity and is associated with a significant lower risk of recurrence 1. This suggests that the benefits of mesh repair can be extended to more complex cases, further supporting the use of synthetic mesh in ventral hernia repair.

Key points to consider when deciding on a repair method include:

• Hernia size and location
• Patient factors, such as comorbidities and previous surgeries
• The presence of contamination or infection
• The potential for bowel resection or other concurrent procedures
• The patient's overall health and ability to tolerate surgery.

Overall, the use of synthetic mesh in ventral hernia repair has been shown to be a safe and effective method for reducing recurrence rates and improving patient outcomes 1.

From the Research

Comparison of Mesh Types in Ventral Hernia Repair

• The use of synthetic mesh in ventral hernia repair has been compared to biologic mesh in several studies 2, 3.
• A study published in 2021 found that biologic mesh had a higher percentage of major complications, surgical site infections, and wound dehiscence compared to synthetic mesh 2.
• A systematic review and meta-analysis published in 2023 found that biologic mesh resulted in increased hernia recurrences and surgical site infections compared to synthetic mesh 3.

Laparoscopic Ventral Hernia Repair

• A study published in 2012 found that primary laparoscopic repair along with mesh placement was effective in selected cases, with a low rate of recurrence compared to conventional laparoscopic repair with mesh alone 4.
• The study suggested that primary repair with synthetic mesh in a laparoscopic fashion may be superior to primary tissue repair alone for ventral hernia repair.

Synthetic Mesh vs Suture Repair

• A systematic review and meta-analysis published in 2014 found that mesh repair had a small reduction in recurrence rates compared to suture repair, but an increased risk of seroma and surgical site infection 5.
• The study suggested that synthetic mesh may be superior to suture repair for primary ventral hernias, but further high-quality studies are necessary to determine the best approach.

Characteristics and Indications of Mesh Materials

• A review published in 2012 described the characteristics, indications, and infection profile of synthetic, composite, and biologic mesh materials 6.
• The review found that synthetic mesh is suitable for extra-peritoneal placement in uncomplicated, clean ventral hernia repair, while biologic mesh may be appropriate for contaminated fields or special situations.