Mesh Fixation to External Oblique Aponeurosis in Inguinal Hernia Repair
Mesh should be placed between the external oblique aponeurosis and internal oblique muscles (intermuscular placement) rather than fixed to the external oblique aponeurosis in inguinal hernia repair, as this provides better outcomes with lower recurrence rates. 1
Optimal Mesh Placement Technique
The placement of mesh in inguinal hernia repair is critical for successful outcomes. The evidence supports the following approach:
- Intermuscular placement: The mesh should be positioned under the external oblique aponeurosis and over the internal oblique muscles and transversalis fascia 1
- This technique is sometimes incorrectly referred to as an "onlay graft" but is more accurately described as an "intermuscular graft"
- This approach is simpler to apply and has resulted in almost no recurrences or side effects compared to other techniques
Rationale for Intermuscular Placement
The intermuscular placement offers several advantages:
- Lower recurrence rates: The intermuscular technique has demonstrated excellent outcomes with minimal recurrences 1
- Technical simplicity: This approach is easier to perform compared to the "inlay" technique (placing mesh under the transversalis fascia)
- Reduced complications: Concerns about potential "interstitial" hernias with this technique have proven unfounded 1
Special Considerations for Complex Cases
In certain situations, alternative approaches may be warranted:
- Large defects: For defects larger than 3 cm, mesh repair with adequate overlap (1.5-2.5 cm beyond defect edges) is recommended 2
- Contaminated fields: In cases of strangulated hernias with bowel necrosis or peritonitis, primary repair is recommended for small defects (<3 cm), while biological mesh may be used for larger defects 3
- Connective tissue disorders: Patients with conditions like Ehlers-Danlos syndrome or Marfan syndrome may particularly benefit from mesh reinforcement 4
Potential Complications and Management
When performing inguinal hernia repair with mesh, be aware of these potential complications:
- Wound infection: Occurs in 4-12% of cases, particularly in contaminated fields 2
- Recurrence: 5-year recurrence rates are approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 2
- Pain management: Acetaminophen is recommended as first-line treatment, avoiding NSAIDs due to bleeding risk 2
Follow-up Care
Proper post-operative care includes:
- Monitor for at least 24 hours, focusing on hemodynamic stability and surgical site complications 2
- Educate patients on signs of complications requiring immediate attention (severe constant pain, redness, nausea, vomiting, fever) 2
- Schedule appropriate follow-up to monitor for recurrence 2
The intermuscular placement of mesh between the external oblique aponeurosis and internal oblique muscles represents the optimal approach for most inguinal hernia repairs, offering simplicity, effectiveness, and low recurrence rates.