What is the name of the technique for repairing a midline incisional hernia with a 5 cm defect by suturing a mesh into the defect?

Mesh Placement Techniques for Midline Incisional Hernia Repair

The sublay technique is the recommended approach for repairing a midline incisional hernia with a 5 cm defect by suturing mesh into the defect, as it offers superior outcomes with lower recurrence rates compared to other techniques.

Understanding Mesh Placement Techniques

When repairing midline incisional hernias, several mesh placement techniques can be employed:

• Onlay: Mesh is placed on top of the anterior rectus sheath/fascia (superficial to the fascial defect) 1
• Sublay (Retromuscular): Mesh is placed in the retromuscular space, between the rectus muscle and posterior rectus sheath 1, 2
• Inlay: Mesh is sutured directly to the edges of the fascial defect, essentially "bridging" the gap 3
• Underlay (Intraperitoneal): Mesh is placed beneath the peritoneum, inside the abdominal cavity 3

Evidence Supporting Sublay Technique

The sublay (retromuscular) technique offers several advantages:

• Lower recurrence rates (12%) compared to inlay (44%) and onlay (23%) techniques 3
• Fewer postoperative complications compared to onlay placement 3, 4
• Reduced risk of seroma formation and surgical site infections 4
• Shorter hospital stays compared to other techniques 4
• Better long-term outcomes with high patient satisfaction 5, 2

Technical Considerations for 5 cm Defect

For a midline incisional hernia with a 5 cm defect:

• Primary fascial closure may be challenging but should be attempted when possible 1
• When primary closure is not feasible, mesh reinforcement is essential 1
• For defects >3 cm, mesh reinforcement significantly reduces recurrence rates 1, 6
• The sublay technique provides better mesh incorporation and reduces the risk of mesh exposure 5, 2

Mesh Selection

• Non-absorbable synthetic mesh is recommended for clean surgical fields 1
• In contaminated fields, biological or absorbable synthetic mesh may be considered 1
• Monofilament meshes may have advantages over multifilament options 1

Common Pitfalls and Caveats

• Inadequate mesh overlap beyond the hernia defect increases recurrence risk 1
• Improper mesh fixation can lead to migration or displacement 1
• Tension-free repair is essential to prevent recurrence 1
• Mesh infection, while rare (0.8% in one large study), significantly increases recurrence risk 2
• Seroma formation is more common with onlay technique compared to sublay 3, 4

Algorithmic Approach to Mesh Placement Selection

1. Assess defect size and patient factors:

   • For defects <3 cm without contamination: Consider primary repair 1
   • For defects >3 cm or recurrent hernias: Use mesh reinforcement 1, 6

2. Evaluate surgical field contamination:

   • Clean field (CDC Class I): Use synthetic non-absorbable mesh in sublay position 1
   • Contaminated field (CDC Class II-IV): Consider biological mesh or alternative techniques 1

3. Select optimal mesh position based on defect characteristics:

   • For 5 cm midline defect: Sublay (retromuscular) placement is optimal 3, 2, 4
   • If retromuscular dissection is technically challenging: Consider alternative techniques 5