Mesh Repair Procedures for Umbilical Hernias
Prosthetic mesh repair is strongly recommended for all umbilical hernias regardless of defect size due to significantly lower recurrence rates compared to tissue repair, without increased wound infection risk. 1, 2
Types of Mesh Repair Procedures
Open Mesh Repair Techniques
- Onlay Mesh Repair: Mesh is placed on top of the fascial defect after primary closure of the hernia 3
- Sublay (Retrorectus) Mesh Repair: Mesh is placed in the extraperitoneal space behind the rectus muscle but anterior to the posterior rectus sheath, providing better force distribution 4
- Intraperitoneal Mesh Repair: Mesh is placed inside the peritoneal cavity, directly against the viscera, requiring specific mesh types to prevent adhesions 5
- Mesh Strip Technique: Novel approach using strips of polypropylene mesh as sutures, combining simplicity of suture repair with advantageous force distribution of mesh 6
- Cone Mesh Technique: For defects <3 cm, a cone of polypropylene mesh is inserted into the defect and attached with non-absorbable sutures 4
Laparoscopic Mesh Repair Techniques
- Transabdominal Preperitoneal (TAPP) Repair: Involves entering the peritoneal cavity, creating a peritoneal flap, placing mesh in the preperitoneal space, and closing the peritoneum 5
- Total Extraperitoneal (TEP) Repair: Mesh is placed in the preperitoneal space without entering the peritoneal cavity 5
- Enhanced-view Totally Extraperitoneal (eTEP) Approach: Advanced laparoscopic technique placing mesh outside the abdominal cavity while maintaining minimally invasive approach 7
- Intraperitoneal Onlay Mesh (IPOM): Mesh is placed inside the peritoneal cavity and fixed to the abdominal wall 5
Mesh Selection Based on Surgical Field Classification
Clean Surgical Field (CDC Class I)
- Synthetic Mesh: Polypropylene mesh is recommended for uncomplicated umbilical hernias with no intestinal strangulation 1, 2
- Provides lower recurrence rates (0-4.3%) compared to tissue repair (14-19%) 2, 3
Clean-Contaminated Surgical Field (CDC Class II)
- Synthetic Mesh: Can be safely used in cases with intestinal strangulation and/or bowel resection without gross enteric spillage 5
- No significant increase in 30-day wound-related morbidity compared to non-mesh repair 5
Contaminated/Dirty Surgical Field (CDC Classes III and IV)
- Primary Repair: Recommended for small defects (<3 cm) with bowel necrosis and/or gross enteric spillage 5
- Biological Mesh: Recommended when direct suture is not feasible in contaminated fields 5
- Polyglactin Mesh: Alternative when biological mesh is unavailable 5
- Open Wound Management with Delayed Repair: Another alternative when biological mesh is unavailable 5
Special Considerations
Defect Size Considerations
- Traditional teaching suggested mesh only for defects >3 cm, but current evidence supports mesh for all sizes 3, 8
- Recurrence rates are significantly higher with primary repair even for small defects 3
- Some studies suggest tissue repair may be acceptable for defects <2.3 cm, but mesh repair still shows superior outcomes 8
Laparoscopic vs. Open Approach
- Laparoscopic approach shows lower wound infection rates and shorter hospital stays 5, 1
- Laparoscopy allows for evaluation of hernia content viability and repair of occult contralateral hernias 5
- Hernioscopy (mixed laparoscopic-open technique) is effective for evaluating viability of herniated loops 5
Common Pitfalls and Caveats
- Avoid tissue repair even for small defects, as mesh significantly reduces recurrence rates 2, 3
- Be cautious with synthetic mesh in contaminated fields (CDC class III) as infection rates can be as high as 21% 5
- Absorbable prosthetic materials should be avoided as they lead to inevitable hernia recurrence due to complete dissolution 5
- In cirrhotic patients with ascites, rapid ascites removal can paradoxically cause hernia incarceration 2