What is the preferred mesh placement in primary ventral hernia repair? An international survey of 442 surgeons

The practice of primary ventral hernia repair varies not only internationally but also across different centers within the same country [1‐4]. It is a common surgical procedure that can be performed with or without the use of mesh [5‐7]. Mesh may be placed by open, laparoscopic, or robot-assisted approaches, but with variations of which anatomical layers it is positioned [7‐9]. Accessing and placing mesh in different anatomical planes can lead to varying complications, including pain, foreign body sensation, and impacts on overall quality of life [10, 11]. These issues may arise from fascial dissection or a reaction to the mesh itself [10]. A range of factors might guide surgeons’ decisions regarding mesh placement, such as available published evidence, personal experience with specific cases, and patient characteristics such as sex, age, and medical and surgical history. Additionally, the nature of the hernia, whether the case is elective or emergency, along with its size and location, can play a critical role [12]. Organizational factors, such as the level of local expertise, available resources, and cost considerations, also impact these decisions, as intraperitoneal onlay mesh (IPOM) placement often requires more costly meshes due to their compositions, such as anti-adhesive coatings [13]. Furthermore, current guidelines suggest preperitoneal or retromuscular placement albeit based on low quality evidence [14].

Previous surveys have explored surgeons’ perspectives on indications, contraindications, and techniques for ventral hernia repair [1, 2, 4, 15‐17]. However, most of these studies focused on complex or incisional hernias or did not specifically address mesh placement and patient-reported outcomes. As a result, there remains a gap in understanding surgeons’ considerations regarding mesh placement in primary ventral hernia repair. To our knowledge, no studies have examined the specific factors surgeons consider, such as defect sizes, when selecting the anatomical plane for mesh placement in primary ventral hernia repairs.

Therefore, this study investigated surgeon preferences and considerations when selecting anatomical layers for mesh placement in elective primary ventral hernia repair. A secondary objective was to identify patient characteristics influencing the selection of mesh location.

A total of 442 responses were recorded, of which 21 were incomplete (5%) (Table 1). Approximately one in eight respondents were female, and the median age of participating surgeons was 48 years. Nearly all respondents were specialist surgeons (96%), with more than half having graduated as medical doctors over 20 years ago. Most participants resided in Asia (n = 264, 60%), followed by Europe (n = 114, 26%), North America (n = 56, 13%), and other regions (n = 8, 2%) (Fig. 1). Four out of five surgeons reported having performed at least 100 primary ventral hernia repairs, and nearly half had completed more than 500 repairs. Most surgeons had experience with all mesh placement techniques except for inlay repair, which was the technique with the least reported experience. When considering patient characteristics that influence mesh placement decisions, hernia defect size was most frequently selected (n = 412, 93%), followed by surgical history (n = 399, 90%) and obesity (n = 352, 80%). Other factors included age (n = 224, 51%), medication use (n = 179, 41%), diabetes (n = 175, 40%), smoking (n = 153, 35%), sex (n = 95, 22%), and alcohol misuse (n = 76, 17%). Additionally, through open comments, some surgeons mentioned inflammatory bowel disease (IBD), cost considerations, rectus diastasis, and cardiopulmonary diseases as factors influencing their decisions.

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Regarding surgical approach, robot-assisted procedures were increasingly preferred as hernia defect width increased (Table 2). For defects < 1 cm, most surgeons preferred an open approach, followed by laparoscopic approach. For defects ≥ 1 to ≤ 4 cm, laparoscopic repair was the preferred method. In cases of larger defects > 4 to 9 cm, laparoscopic, open, and robotic approaches were preferred with a more balanced distribution.

Surgeons’ beliefs of the mesh placement least likely to result in complications varied by hernia defect width (Table 3). For defects < 1 cm, the surgeons most frequently believed that preperitoneal placement carried the lowest overall risk (35–45%), followed by retromuscular (17–29%) and IPOM (12–27%). However, for recurrence and chronic pain specifically, onlay was believed by many surgeons to be more favorable than both retromuscular and IPOM. For defects ≥ 1 to ≤ 4 cm, retromuscular placement was most commonly believed to be the safest option (36–42%), followed by preperitoneal (29–40%) and IPOM (13–24%). In larger hernia defects (> 4 to 9 cm), retromuscular placement was clearly favored, with 50–75% of surgeons believing the mesh plane to be associated with the lowest complication risk, while preperitoneal was selected by 11–28% of surgeons. Across all hernia defect widths and complication categories, inlay placement was consistently considered the least favorable, with very few surgeons believing it to carry the lowest risk. Two out of three surgeons considered IPOM as a clinical concern for bowel adhesion and obstruction (Fig. 2a), while preperitoneal placement was also considered to carry a risk, though by much fewer surgeons. Additionally, more than half of surgeons considered IPOM a clinical concern for fistula formation (Fig. 2b). Surgeons’ beliefs of which repair technique would yield the best overall outcome also varied by hernia defect width (Table 4). For defects < 1 cm, the most commonly selected placements were preperitoneal repair and suture-only repair without mesh, followed by onlay repair. For defects ≥ 1 to ≤ 4 cm, preperitoneal and retromuscular repairs were equally believed to have the best outcome, followed by IPOM. For larger defects measuring > 4 to 9 cm, retromuscular repair was overwhelmingly favored, with 68% of surgeons believing this placement to be the best.

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Our findings suggest that the repair technique surgeons considered to yield the best overall outcome varied according to the width of the hernia defect. For smaller hernia defects, the suture-only and preperitoneal mesh placements where mainly believed to be the best technique. However, as the defect size increased, retromuscular mesh placement became increasingly favored, with over two-thirds of surgeons selecting it for defects > 4 cm. Additionally, laparoscopic and robot-assisted approaches were more commonly preferred as hernia defect width increased.

Our observations contrast with the results of an online case-based survey from 2017, which was conducted in the Facebook group International Hernia Collaboration (IHC). The case-based survey presented a specific patient case with a hernia defect of 5 × 6 cm. In that survey, most surgeons answered that they favored the laparoscopic IPOM approach [2]. However, several factors limit the comparability between the two studies. The case-based survey focused on one patient with an incisional hernia and a certain defect size, whereas our survey addressed primary ventral hernias in general and not exclusively one case, and there were thus three conditions that differed in risk profiles and may warrant different treatment strategies [25]. Additionally, there was a seven-year gap between the surveys, during which new guidelines for mesh placement were published [14, 26]. At the time of the case-based survey, available guidelines did not provide specific recommendations on mesh positioning [27]. Another case-based survey from 2021 reported that IPOM, retromuscular, and preperitoneal approaches were used with similar frequency among surgeons [17]. This survey also focused on one patient case with incisional hernia and only included surgeons from Canada, limiting the generalizability of its findings to a global context. In contrast, our survey provides international insights into surgeons’ current preferences, which, for most surgeons, appear to align with current recommendations from guidelines, particularly for larger hernia defects [14, 28]. In hernia defects ≤ 4 cm, however, surgeon preferences were more varied. This reflects an ongoing debate on the optimal mesh placement for elective primary ventral hernia repair, as the current guidelines on mesh placement are based on very low certainty of evidence [14, 28, 29]. Our findings suggest a shift away from IPOM as a precautionary measure to reduce the risk of bowel adhesions and obstruction, based primarily on case reports and small series [14, 30, 31]. This is reflected in surgeons’ selection of the best overall mesh placement, which indicates a trend away from IPOM compared with previous survey studies [2, 17]. Although some observational studies have examined the risks of bowel adhesions and obstruction, they often lack comparators or sufficient power to draw definitive conclusions regarding the safety of IPOM [32, 33]. As such, current trends may be shaped more by concern over complications than by strong evidence. This highlights the need for high-quality, well-powered trials so that surgical decision-making can be guided by robust data rather than prevailing practice or local preference.

In addition to hernia defect size, our findings show that surgeons also considered previous surgical history and obesity as important factors influencing the selection of mesh placement. Prior surgical history may lead to intraabdominal adhesions, which can complicate laparoscopic procedures and influence the feasibility of certain mesh planes [34]. These considerations are particularly relevant when selecting the optimal mesh placement, as they may directly impact surgical outcomes. In our study, laparoscopic approaches were commonly preferred for hernias ≥ 1 cm, potentially reflecting efforts to reduce infection risk [35]. Additionally, multiple studies have shown that obesity and smoking are associated with an increased risk of wound complications and infections following mesh repair [36, 37]. However, to our knowledge, little to no evidence exists on mesh placement depending on patient characteristics such as obesity and surgical history. Given these limitations, further research is needed to strengthen the evidence base and guide surgeons toward the safest and most effective mesh placement for patients.

Mesh placements believed to result in the best overall outcome varied by hernia defect size. For defects < 1 cm, preperitoneal and suture-only repairs were most commonly selected. For defects ≥ 1 to ≤ 4 cm, preperitoneal and retromuscular were equally favored, while for defects > 4 to 9 cm, retromuscular placement was selected by the majority of surgeons. Laparoscopic and robotic-assisted approaches were more commonly preferred with increasing defect size. Key patient characteristics influencing mesh placement decisions included hernia defect size, surgical history, and obesity. Despite clear trends in surgeon beliefs, there is very limited evidence supporting the mesh placements believed to yield the best outcomes, underscoring the need for further high-quality research.