World J Surg

DOI 10.1007/s00268-015-3252-9

SCIENTIFIC REVIEW

Mesh Location in Open Ventral Hernia Repair: A Systematic

Review and Network Meta-analysis
Julie L. Holihan1 Duyen H. Nguyen1 Mylan T. Nguyen1 Jiandi Mo1

Lillian S. Kao1 Mike K. Liang1

Societe Internationale de Chirurgie 2015

Abstract There is no consensus on the ideal location for mesh placement in open ventral hernia repair (OVHR).
We aim to identify the mesh location associated with the lowest rate of recurrence following OVHR using a
systematic review and meta-analysis. A search was performed for studies comparing at least two of four locations for
mesh placement during OVHR (onlay, inlay, sublay, and underlay). Outcomes assessed were hernia recurrence and
surgical site infection (SSI). Pairwise meta-analysis was performed to compare all direct treatment of mesh locations.
A multiple treatment meta-analysis was performed to compare all mesh locations in the Bayesian framework.
Sensitivity analyses were planned for the following: studies with a low risk of bias, incisional hernias, by hernia size,
and by mesh type (synthetic or biologic). Twenty-one studies were identified (n = 5,891). Sublay placement of mesh
was associated with the lowest risk for recurrence [OR 0.218 (95 % CI 0.060.47)] and was the best of the four
treatment modalities assessed [Prob (best) = 94.2 %]. Sublay was also associated with the lowest risk for SSI [OR
0.449 (95 % CI 0.121.16)] and was the best of the 4 treatment modalities assessed [Prob (best) = 77.3 %]. When
only assessing studies at low risk of bias, of incisional hernias, and using synthetic mesh, the probability that sublay
had the lowest rate of recurrence and SSI was high. Sublay mesh location has lower complication rates than other
mesh locations. While additional randomized controlled trials are needed to validate these findings, this network
meta-analysis suggests the probability of sublay being the best location for mesh placement is high.

Introduction

Repair of ventral hernias with mesh as opposed to suture

& Julie L. Holihan
Julie.L.Holihan@uth.tmc.edu; holihanj@gmail.com has substantially improved long-term outcomes and is
accepted as the standard of care [13]. However, many
Duyen H. Nguyen
Dhnguyen.06@gmail.com studies demonstrate an increased risk for wound compli-
cations with mesh placement including infections, seromas,
Mylan T. Nguyen
Mylan.thi.nguyen@gmail.com and mesh erosions [3, 4]. The risks of these complications
are affected by where the mesh is placed. For example,
Jiandi Mo
Mojiandi@gmail.com mesh exposed to intra-abdominal contents potentially
increases the risks of adhesions, bowel obstruction, and
Lillian S. Kao
Lillian.S.Kao@uth.tmc.edu fistula formation [5, 6]. While repair of ventral hernias with
mesh is considered routine, there is no consensus on the
Mike K. Liang
Mike.Liang@uth.tmc.edu best location to place the mesh.
For laparoscopic ventral hernia repair, the mesh is rou-
1
Department of General Surgery, University of Texas Health tinely placed in the intra-peritoneal position. However, for
Science Center, 6431 Fannin St, Houston, TX 77030, USA

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Fig. 1 Mesh location. a onlay repair, b inlay repair, c sublay repair,
d underlay; Key blue mesh red muscle black fascia gray hernia sac
open surgery, there are numerous options for mesh place-
ment (Fig. 1). Onlay repair places the mesh on the anterior
fascia, which typically involves dissection of flaps and
primary closure of the fascia below the mesh. Inlay repair
places the mesh in the hernia defect and secures the mesh
circumferentially to the edges of the fascia. Sublay repair
refers to retro-rectus or preperitoneal mesh placement. It is
also commonly referred to as a Rives-Stoppa or retro-
muscular repair. Finally, underlay repair is when mesh is
placed in the intra-peritoneal position and secured to the
anterior abdominal wall.
Each mesh location has its theoretical risks and benefits.
With onlay repair, skin flaps must be created, which
increases the risk of wound complications and mesh
infection [7]. However, onlay repair is technically easy to
perform. In addition, for large complex hernias, this space
is often already dissected with excision of the hernia sac or
with myo-fascial release (i.e., anterior component separa-
tion). Inlay repair is technically easy. However, not only is
the mesh often exposed to the intra-peritoneal contents, it is
also vulnerable to superficial wound complications. Lack
of overlap precludes mesh-tissue integration and theoreti-
cally increases the risk of recurrence. Sublay repair is often
considered more challenging and complex to perform.
Dissection of this plane can risk damaging the muscle,
blood supply, and nerves to the rectus abdominus. In
addition, this mesh location may not be appropriate for off-
midline defects. However, this space potentially protects
the mesh from both superficial wound complications and
intra-peritoneal contents. In addition, it also allows for
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World J Surg
load-bearing tissue in-growth from two directions. Under-
lay repair or intra-peritoneal repair was popularized with
the advent of laparoscopy. Placing mesh in this location
can be technically cumbersome requiring sutures to be
placed closely to prevent intra-abdominal contents from
sliding between the mesh and anterior abdominal wall.
However, while protected from superficial wound compli-
cations, the mesh is exposed to intra-peritoneal contents.
Meshes placed in this location must have an anti-adhesive
barrier or anti-adhesive properties on the peritoneal side [6,
813].
In this study, we conducted a systematic review and
performed a multiple treatment meta-analysis to identify
the best location for mesh placement with open ventral
hernia repair. We hypothesized that in open ventral hernia
repair, sublay mesh placement has the lowest recurrence
rate as compared to inlay, onlay, or underlay placement.
Methods
Search strategy
This systematic review and meta-analysis was registered
with PROSPERO, registration number CRD42015019722.
In accordance with preferred reporting items for systematic
reviews and meta-analyses (PRISMA), a search of
PubMed, Cochrane Central Register of Controlled Trials,
and Embase was performed to identify the articles for this
review [14]. Clinicaltrials.gov was also searched for
ongoing trials. The search included publications from
January 1990 through April 2015. The search strategies
were (ventral or incisional) AND hernia AND (onlay OR
inlay OR retrorectus OR retro-rectus OR retromuscular OR
retro-muscular OR preperitoneal OR Rives Stoppa OR
sublay OR underlay OR intraperitoneal OR intra-peritoneal
OR IPOM). Reference lists of selected articles were
reviewed for additional articles. Only the most recent
report from overlapping data was included. Studies were
included if they were human-related and comparative
studies evaluating two or more mesh locations in open
ventral hernia repair. Systematic reviews, meta-analyses,
letters, pediatric studies, laparoscopic repairs, techniques
manuscripts, and non-ventral hernia repairs (i.e., inguinal,
hiatal, etc.) were excluded. Non-comparative studies and
reports of less than 10 cases were also excluded.
Evaluation of articles
The methodological index of nonrandomized studies
(MINORS) was used to evaluate methodological quality
and potential bias of the articles selected for this review
[15]. The first eight of the twelve items evaluated non-
World J Surg
comparative and comparative studies. The last four items
applied only to comparative studies. Items were scored on
a 3-point scale of 0 (not reported), 1 (reported but inade-
quate), or 2 (reported and adequate). The global ideal score
is 24 for comparative studies. Two independent reviewers
scored the articles based on the criteria listed by the
assessment. Any disagreement or discrepancies were
resolved by consensus among the authors. Only studies
with MINORS C10 were included in the final analysis
[16].
Primary and secondary outcomes
The primary outcome measure was recurrence rate of
ventral hernia repairs. Secondary outcome was surgical site
infection (SSI).
Data extraction
The selected articles were reviewed and the primary and
secondary outcome data were extracted. Two reviewers
independently extracted the data. Study designs, number of
patients, patients age, patients BMI, percent of incisional
hernias included, mesh location, mesh type, mesh overlap,
mesh fixation method, and follow-up period were recorded.
Outcome measures recorded were recurrence, SSI, mesh
infection, and mesh explantation.
Statistical analysis
Pairwise meta-analysis was performed to compare all
direct treatment of mesh locations using fixed-effects and
random-effects models. A multiple treatment meta-analysis
was adapted from the guidelines developed by the Inter-
national Society for Pharmacoeconomics and outcomes
research task force to compare the four different locations
for mesh placement in open ventral hernia repair [17, 18].
Unlike a traditional meta-analysis which only considers
studies with direct comparisons, a multiple treatment meta-
analysis, or network meta-analysis, considers studies with
multiple competing treatments and combines direct and
indirect evidence to determine the most effective treatment
[17]. A network of treatment was created to map the
relationship between available studies. Heterogeneity was
assessed using a MantelHaenszel method that provided
pooled odds ratios and associated confidence intervals for
both fixed effect and random effect. It also produces test
statistics for heterogeneity utilizing the Higgins I2, and
reports the results as a p value. For a p value \0.05
(I2 [ 50 %) significant statistical heterogeneity exists and
the results of the random-effects model reported; otherwise
the results fixed-effects model was reported [17, 18]. A
multiple treatment meta-analysis was performed using
onlay as the reference treatment to compare all mesh
locations by estimating the fixed-effects and random-ef-
fects models in the Bayesian framework. The Bayesian
approach estimates the odds ratio and the 95 % credible
interval and the probability that each location is the best
using Markov chain Monte Carlo technique [18, 19]. The
credible interval is the Bayesian probability interval that is
similar in use to a frequentist confidence interval; however
the credible interval also incorporates information from the
prior distribution into the estimate while the confidence
intervals are solely based on the data. Model fit was
assessed by the deviance information criterion and was
used to select whether to use the fixed-effects or random-
effects model within the Bayesian framework [20].
Inconsistency of the network, also known as incoherence,
was assessed for each model and demonstrated that the
indirect evidence was not inconsistent with the direct evi-
dence on the same treatment comparisons beyond chance
[17, 18]. Statistical analysis was performed within the
statistical software R version 2.15.0 [20].
Sensitivity analysis
Sensitivity analysis were determined prior to analyses and
utilized as a second assessment of heterogeneity. The fol-
lowing sensitivity analyses were planned: studies with a
low likelihood of bias based upon MINORS score ([17),
studies of incisional hernias only, based on size (large
median defect size C 100 cm2 or width C 10 cm; med-
ium: median size between 36 and 100 cm2 or width
between 6 and 10 cm; and small: median defect
size B 36 cm2 or width B 6 cm), and studies reporting the
use of only synthetic mesh and use of only biological mesh
were evaluated separately [16, 21].
Results
The search resulted in a total of 957 titles and abstracts
(Fig. 2). After de-duplication, 472 titles and abstracts were
reviewed. An additional 431 articles were excluded for
reasons including pediatric only or non-human studies,
reviews, meta-analyses, letters, non-ventral hernia related,
studies not related to open ventral hernia repair, non-
comparative, and case reports of fewer than 10 patients.
After screening, 41 full-text articles were reviewed and 19
articles were excluded. A total of 21 articles were subjected
to MINORS for assessment and included in the systematic
review. The studies included randomized controlled trials
(n = 3), retrospective chart reviews (n = 13), and
prospective cohort studies (n = 5) (Tables 1, 2).
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Fig. 2 Search flow-chart
Quality of and heterogeneity between the studies
The median (range) MINORS score was 15 (1021). The
studies suffered the greatest weakness in criteria: (5)
unbiased assessment of study endpoint, (8) calculation of
sample size, (7) loss to follow-up of less than 5 %, (6)
follow-up period appropriate to the aim of the study, (11)
baseline equivalence of groups, and (12) adequate statis-
tical analysis. The three randomized studies had the highest
minor scores (Table 2) [2224]. Of the remaining studies,
there were 13 retrospective chart reviews and 5 prospective
observational studies of variable quality.
While the studies evaluated patients of similar age and
BMI and treated patients with similar amounts of mesh
overlap and mesh fixation, there was heterogeneity in the
type of hernia included (incisional vs. primary), the type of
mesh used (synthetic vs. biologic), as well as hernia defect
size (Table 1). Recurrence reporting was based upon
clinical exam in most studies. Follow-up duration ranged
from mean 560 months (Table 1). There was sufficient
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clinical homogeneity between studies to perform a quan-
titative synthesis of results.
Pooled results and analysis
Twenty-one studies reported on recurrence rates for ventral
hernia repair (Fig. 3). The pooled recurrence rate (range n)
was 16.5 % (036 %, 1267) for onlay, 30.2 % (080.0 %,
159) for inlay, 7.0 % (048.0 %, 1719) for sublay, and
14.7 % (056.0 %, 2746) for underlay. Ten studies repor-
ted on SSI. The pooled SSI rate (range n) was 16.9 %
(033.0 %, 302) for onlay, 31.3 % (8.737.1 %, 112) for
inlay, 3.7 % (021.0 %, 702) for sublay, and 16.7 %
(034.3 %, 402) for underlay.
Onlay mesh placement
Seventeen of 21 studies included onlay mesh placement. In
pairwise meta-analysis, onlay was associated with higher
odds for recurrence and SSI compared to sublay and
 Table 1 Characteristics of mesh repairs
Author Year Age BMI (kg/m2) F/Ua (months) Size of defect Incisional, Mesh type Mesh overlap Mesh fixation
n (%)
World J Surg

Afifi et al. 2005 Onlay: 52.8 8.8 30 (median) [10 cm diameter 41 (100) Synthetic C4 cm Onlay: suture underlay:
Underlay: suture, staplers
52.15 10.59
Weber et al. 2010 - 60 [5 cm2 - synthetic C5 cm sutures
Venclauskas 2010 Onlay: Onlay: 30.5 12 Onlay: 114.5 90.9 107 (100) synthetic 5 cm sutures
et al. 56.9 11.5 Sublay: 28 Sublay: 110 83.8
Sublay: 53 11.6
Helgstrand et al. 2013 60 (4969 IQR) - 21 (1035) (median, IQR) 7 cm (median) 593 (18) - 5 cm sutures, tacks, glue, clips
Hope et al. 2012 60 (2489) [mean - 13 - 49 (84) Synthetic, - -
(range)] biological
Kumar et al. 2012 - - 60 - - - - -
Li et al. 2012 Onlay: 57.6 1.1 Onlay: Onlay: 77(1143) Onlay: 56.4 9.4 cm2 92 (69) - - -
Underlay: 32.3 0.69 Underlay: 39 (2140) Underlay: 50.3 12.9
59.4 1.2 Underlay: (median, range) cm2
31.2 0.72
Rosen et al. 2012 Sublay: Sublay: 12 Sublay: 49 (100) Biological 35 cm Sutures
58.6 13.5 30.8 5.7 279.6 163.1 cm2
Underlay: Underlay: Underlay:
58.2 13.4 31.1 4.8 183.2 125 cm2
Forte et al. 2011 62 (3484 range) - 12 - 246 (100) Synthetic C5 cm Sutures
Prasad et al. 2011 Sublay: Sublay: Sublay: 22.7 13.4 Sublay: 30.8 24.4 195 (70) Synthetic, Suture, tacks
51.1 11.1 30.2 3.0 Underlay: 22.5 11.9 cm2 biological
Underlay: Underlay: Underlay: 29.9 22.0
49.2 11.4 30.9 2.6 cm2
Scheuerlein 2011 Onlay & Sublay: - 20 [435] (median, range) Onlay & sublay: 57 29 (100) Synthetic Onlay & Onlay & sublay: sutures
et al. 57 (3314) cm2 sublay: C 3 cm Underlay: sutures ? clips
Underlay: 59 Underlay: 37 (3158) Underlay: C5 cm
cm2
Diaz et al. 2009 52.2 (15.2) 30.7 (9.6 SD) 10.3 201 cm2 208 (100) Biological 35 cm -
[1787]
Lin et al. 2009 55 (2384) 35.26 5 C25 cm2 140 (100) Biological - -
Abdollahi et al. 2010 52 (285) - 98 (48174) - 354 (100) Synthetic - -
Berrevoet et al. 2010 Sublay: 54.8 Sublay: 28.2 Sublay: 48.8[4256] Sublay: 2.6 cm2 0 Synthetic Sublay: C 3 cm sutures
Underlay: 48.1 Underlay: 29.4 Underlay: 31[2442] Underlay: 2.3 cm2 Underlay: C 2.5 cm
[median, range]
Gleysteen et al. 2009 Onlay: 57 (mean) Onlay: 66[1204] Onlay: 10 (3-30) cm Onlay: 29 Synthetic Sutures
Sublay: 55 Sublay: 62[3-116] Sublay: 9(3-20) cm (39)
[median, range] Sublay: 15
(30)

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underlay but lower odds compared to inlay (Table 3). On

multiple treatment meta-analysis, onlay was one of the

sutures ? staplers
worst mesh placement options with a very low probability

Underlay: suture
(\0.001) of being the best treatment (Table 4).

Sublay: sutures

Onlay: staples
Mesh fixation

Inlay: sutures
Underlay:
Inlay mesh placement

Sutures

Of the 21 studies, six reported on inlay. In pairwise meta-

analysis, inlay was associated with higher odds for recur-
rence and SSI than onlay, sublay, and underlay (Table 3).
Mesh overlap

On multiple treatment meta-analysis, inlay had higher odds

for recurrence compared to onlay [3.946 (0.48713.256)]
35 cm

68 cm
C2 cm

(Table 4). Inlay also had a higher odds for SSI compared to

onlay [1.113 (0.0883.833)] (Table 3). Inlay was one of the

worst mesh placement options with a very low probability
Mesh type

Synthetic

Synthetic

Synthetic

Synthetic

(\0.001) of being the best treatment (Table 4).

Sublay mesh placement

Sublay: 32
Incisional,

Underlay:
296 (100)

36 (72)

Fourteen of the 21 studies reported on sublay. In pairwise

95 (100)

53 (100)

50 (100)
(64)
n (%)

meta-analysis, sublay was associated with lower risk of

recurrence and SSI compared to onlay, inlay, and underlay
(Table 3). On multiple treatment meta-analysis, sublay had
Underlay: 93.96 cm2

a lower risk for recurrence [0.218 (0.0610.465)] and SSI

Sublay: 55.88 cm2

[10 cm diameter
[3 cm diameter

[5 cm diameter

[0.449 (0.1181.155)] compared to onlay (Table 4). Sublay

Size of defect

was ranked the best mesh placement option with a high

probability of being the best treatment. Sublay had a
94.2 % probability of having the lowest odds of recurrence

and 77.3 % probability of having the lowest odds for SSI.

Underlay mesh placement

Underlay: 19.6

Underlay: 33.9
F/Ua (months)

Fifteen of the 21 studies included underlay. In pairwise

672 (range)
Sublay: 21.9

Onlay: 19.4
Inlay: 33.2

meta-analysis, underlay was associated with lower risk for

recurrence and SSI than onlay and inlay but had higher risk
compared to sublay (Table 3). On multiple treatment meta-

analysis, underlay had a lower risk for recurrence [0.59

BMI (kg/m2)

(0.0691.504)] and SSI [0.878 (0.2911.985)] compared to

onlay (Table 4). While underlay had the second highest
probability of being the best treatment, it remained a dis-
29

tant second. The probability of underlay having the lowest

odds of recurrence was only 5.8 % and for SSI was 11.4 %.
reported as mean unless otherwise stated
55.25 (3083)

60.4 (2894)

57.8 (3379)
61 (2294)

Sensitivity analysis
Age

Sensitivity analysis was performed for studies at low risk

of bias (MINORS \ 17), studies of only incisional hernias,

2006
2009

2006

2004

2004
Year

and studies using only synthetic mesh. For all of these, the
Table 1 continued

probability that sublay repair was associated with the

Israelsson et al.
Lomanto et al.
Demetrashvili

lowest risk of recurrence and SSI remained high (Table 5).

Kingsnorth
Reilingh

Onlay, inlay, and underlay remained very unlikely to have

de Vries
et al.

et al.

et al.
Author

the best outcomes. It was not feasible to perform a sensi-

tivity analysis of ventral hernia repairs stratified by hernia
a

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 Table 2 Study characteristics and outcomes
Author Year Study type MINORS N Mesh locations Recurrence N (%) SSI N (%) Mesh infection N (%) Mesh explantation N (%)

Afifi et al. 2005 PRCT 20 41 Onlay (22) Onlay: 6 (27.3) Onlay: 1 (4.5) Onlay: 1 (4.5)
World J Surg

Underlay (19) Underlay: 0 Underlay: 1 (5.3) Underlay: 0

Weber et al. 2010 PRCT 20 550 Onlay (181) Onlay: 22 (12.2)
Sublay (369) Sublay: 53 (14.4)
Venclauskas et al. 2010 PRCT 21 107 Onlay (57) Onlay: 6 (10.5)
Sublay (50) Sublay: 1 (2.0)
Helgstrand et al. 2013 Prospective 17 2798 Onlay (454) Onlay: 73 (16.1)
Sublay (323) Sublay: 39 (12.1)
Underlay (2021) Underlay: 328 (16.2)
Hope et al. 2012 Retrospective 12 58 Onlay (39) Onlay: 14 (35.9)
Inlay (10) Inlay: 8 (80.0)
Underlay (9) Underlay: 5 (55.6)
Kumar et al. 2012 Prospective 13 63 Onlay (45) Onlay: 4 (8.9) Onlay: 6 (13.3)
Underlay (18) Underlay: 1 (5.6) Underlay: 2 (11.1)
Li et al. 2012 Retrospective 14 134 Onlay (67) Onlay: 12 (17.9) Onlay: 20 (29.9) Onlay: 5 (7.5)
Underlay (67) Underlay: 7 (10.4) Underlay: 23 (34.3) Underlay: 3 (4.5)
Rosen et al. 2012 Prospective 18 49 Sublay (23) Sublay: 2 (8.7) Sublay: 5 (21.7)
Underlay (26) Underlay: 7 (26.9) Underlay: 8 (30.8)
Forte et al. 2011 Retrospective 12 246 Onlay (9) Onlay: 3 (33.3) Onlay: 3 (33.3) Onlay: 2 (22.2)
Sublay (207) Sublay: 1 (0.48) Sublay: 9 (4.3) Sublay:2 (0.9)
Underlay (30) Underlay: 0 Underlay: 0 Underlay: 0
Prasad et al. 2011 Retrospective 16 279 Sublay (68) Sublay: 2 (2.9) Sublay: 0
Underlay (211) Underlay: 7 (3.3) Underlay: 0
Scheuerlein et al. 2011 Retrospective 13 29 Onlay (10) Onlay: 7 (70.0) Onlay: 0 Onlay: 0
Sublay (4) Sublay: 0 Sublay: 0 Sublay: 0
Underlay (15) Underlay: 1 (6.7) Underlay: 0 Underlay: 0
Diaz et al. 2009 Retrospective 15 208 Onlay (28) Onlay: 4 (14.3) Onlay: 8 (28.6)
Inlay (89) Inlay: 18 (20.2) Inlay: 33 (37.1)
Underlay (91) Underlay: 17 (18.7) Underlay: 31 (34.1)
Lin et al. 2009 Retrospective 10 140 Onlay (3) Onlay: 0
Inlay (34) Inlay: 12 (35.3)
Underlay (103) Underlay: 24 (23.3)
Abdollahi et al. 2010 Retrospective 11 354 Onlay (33) Onlay: 2 (6.1) Onlay: 1 (3.0) Onlay: 1 (3.0)
Sublay (312) Sublay: 2 (0.6) Sublay: 7 (2.2) Sublay: 1 (0.3)
Underlay (9) Underlay: 0 Underlay: 0 Underlay: 0
Berrevoet et al. 2010 Prospective 19 116 Sublay (56) Sublay: 2 (3.6) Sublay: 0
Underlay (60) Underlay: 5 (8.3) Underlay: 0

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Mesh explantation N (%)

Sublay: 2 (4.0)
Underlay:0)

Mesh infection N (%)

Fig. 3 Network analysis of studies included in multiple treatments

meta-analysis. Width of line represents number of studies. Size of
node represents sample size

Underlay: 1 (2.0)
Sublay: 5 (10.0)
Onlay: 9 (12.0)

Onlay: 3 (23.1)
Sublay: 2 (4.0)

Table 3 Summary of all pairwise meta-analysis

Inlay: 2 (8.7)
Underlay: 0
SSI N (%)

Recurrence
OR 95 % CI P value Heterogeneity

P value*

Onlay (reference) vs.

Underlay: 2 (11.8)
Recurrence N (%)

Underlay: 1 (2.0)

\0.001
Onlay: 15 (20.0)

Onlay: 33 (19.3)

Inlay 2.189 1.513.17 0.734

Sublay: 5 (10.0)

Inlay: 10 (43.5)
Onlay: 3 (23.1)

Onlay: 2 (12.5)
Sublay: 2 (4.0)

Sublay: 1 (2.0)

Sublay: 9 (7.3)

Sublay: 1 (3.0)
Onlay: 3 (6.8)

Sublay 0.379 0.290.48 0.999 \0.001

Underlay 0.873 0.731.05 0.993 0.030
Inlay: 0

Inlay: 0

Inlay (reference) vs.

Sublay 0.173 0.120.26 0.999 0.649
Underlay 0.399 0.280.57 0.999 0.295
Mesh locations

Sublay (reference) vs.

Underlay (50)

Underlay (17)
Sublay (123)
Onlay (171)
Sublay (50)

Sublay (51)

Sublay (50)

Sublay (33)
Onlay (75)

Onlay (44)

Onlay (13)

Onlay (16)

Underlay 2.299 1.862.85 \0.001 0.506

Inlay (23)
Inlay (2)

Inlay (1)

SSI
Onlay (reference) vs.
Inlay 6.730 4.2110.75 \0.001 0.162
Sublay 0.366 0.230.59 0.999 0.243
125

296

100
95

53

50
N

Underlay 0.592 0.410.86 0.999 0.219

Inlay (reference) vs.
MINORS

Sublay 0.054 0.030.09 0.999 \0.001

19

15

14

16

17
19

Underlay 0.088 0.060.14 0.999 0.429

Sublay (reference) vs.
Retrospective

Retrospective

Retrospective

Retrospective

Retrospective

Underlay 1.618 1.022.55 0.144 0.682

Prospective
Study type

* Random-effects model reported for pairwise analysis with hetero-

geneity P value \ 0.05
2006
2009

2009

2006

2004

2004
Year

size or hernias repair only with biologic mesh only due to a

low number of direct comparisons.
de Vries Reilingh et al.
Table 2 continued

Demetrashvili et al.

Discussion
Kingsnorth et al.
Gleysteen et al.

Israelsson et al.

Lomanto et al.

In this network meta-analysis, sublay repair had the highest

Author

probability of having the lowest rate of hernia recurrence

and SSI. Underlay repair had the second highest probability

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Table 4 Multiple treatments meta-analysis

OR 95 % credible interval Probability of being the Rank
best among four treatments

Recurrencea
Onlay (reference) \0.001 3, 4
Inlay 3.946 0.4913.26 \0.001 3, 4
Sublay 0.218 0.060.47 0.942 1
Underlay 0.590 0.071.50 0.058 2
SSIb
Onlay (Reference) \0.001 4
Inlay 1.113 0.093.83 0.113 3
Sublay 0.449 0.121.16 0.773 1
Underlay 0.878 0.291.99 0.114 2
a
DIC 108.3
b
DIC 59.6

Table 5 Sensitivity analysis

Probability of being the best among four treatments
All trials Low risk of bias Synthetic mesh only Incisional hernias only

Recurrence
Onlay (reference) \0.001 0.045 0.005 \0.001
Inlay \0.001 \0.001 0.001 \0.001
Sublay 0.942 0.839 0.744 0.833
Underlay 0.058 0.116 0.25 0.167
SSI
Onlay (reference) \0.001 0.054 \0.001 0.001
Inlay \0.001 \0.001 0.106 0.019
Sublay 0.942 0.946 0.612 0.734
Underlay 0.058 \0.001 0.282 0.246

of having the lowest rate of hernia recurrence and SSI
while onlay and inlay had poor results. While there were
few high-quality studies, the results when only evaluating
studies at low risk for bias did not change. Furthermore,
these results are in line with other systematic reviews
addressing mesh location [5, 25, 26].
When considering the best location for mesh placement,
a number of features are important to consider. First, mesh-
tissue integration may reduce long-term recurrence, with
theoretically improved rates with greater mesh-tissue
overlap [27]. Second, wound complications increase the
risk of recurrence. Thus, techniques that avoid of the
development of devascularizing flaps may be preferred
[15]. Third, the ideal mesh placement should have tissue
coverage to minimize exposure to superficial SSIs as well
as intra-peritoneal contents. Last, technical ease may affect
surgeon choice of procedure as well as risks for postop-
erative complications.
Sublay repair allows for tissue integration from two
load-bearing tissues from both sides: posterior rectus
sheath and the anterior myo-fascial complex. In addition,
sublay mesh placement protects the mesh from exposure
from superficial wound complications, intra-abdominal
adhesions, and contamination. Creation of devascularizing
skin flaps is avoided. Alternatively, inlay repair does not
allow for any tissue integration, any wound complication
can potentially expose the mesh, and the mesh is exposed
to intra-abdominal contents. While onlay allows for tissue
ingrowth from two directions, the skin flaps are not load-
bearing. Mesh placed in the onlay location is vulnerable
forcing the surgeon to create devascularizing skin flaps and
leaving the mesh susceptible to superficial wound com-
plications. Underlay has the advantages of protecting the
mesh from superficial wound complications and avoiding
development of skin flaps. However, this position requires
mesh to be placed intra-abdominally which leaves the mesh

123

susceptible to organ/space infections. In addition, the mesh
must grow into peritoneum, the bodys natural anti-adhe-
sion barrier. This may explain why the recurrence rates
with this repair are higher despite the potential for
increased mesh overlap.
Sublay repair is not without its own set of challenges.
The surgical approach can be perceived as more technically
challenging than other techniques, particularly in patients
who have had prior abdominal surgeries. Patients with
previous stomas, gynecologic procedures, or ventral hernia
repairs may have a damaged posterior sheath or damaged
rectus muscle. This may leave this space difficult to
develop, limited in size, or non-existent in rare circum-
stances. In addition, risks of damaging the blood supply,
muscle, or lateral penetrating nerves pose technical con-
cerns. Furthermore, the semilunar lines limit the lateral
extent of the sublay repair and potentially limiting the
amount of mesh overlap. Off-midline incisions may not be
ideal hernias to approach with this technique. While those
new to sublay repair may find it technically daunting,
anecdotal experience has demonstrated ease in learning and
adopting this approach; however studies to evaluate the
learning curve are needed.
Given the limited data available but the enormous
clinical experience available, most surgeons no longer
consider the inlay repair appropriate for ventral hernia
repair. All studies demonstrate that inlay repair has the
highest recurrence and SSI rates. Increasingly, onlay repair
is losing favor with sublay and underlay repairs growing in
popularity. Most studies with low risk of bias indicated that
the recurrence rate of onlay repair is inferior to sublay and
underlay. Between the two studies that examined the SSI
rate of onlay repair, both studies demonstrate that onlay
repair yield inferior results compared to sublay and
underlay. This network analysis suggests that sublay repair
may have the best results with underlay repair as a distant
second best. A randomized controlled trial to compare
sublay and underlay would require a sample size (given
a = 0.05, b = 0.20) of 562 to show a difference in
recurrence (7.0 vs. 14.7 %) and 198 to show a difference in
SSI (3.7 vs. 16.7 %).
Network meta-analyses allow for utilization of a larger
amount of evidence, estimation of the relative effectiveness
among multiple interventions, and rank ordering of the
interventions [28]. In contrast to pairwise meta-analysis,
network meta-analysis can provide estimates of relative
efficacy between all interventions. For many comparisons,
the network meta-analysis may yield more reliable and
definitive results. However, there are a number of potential
limitations. Inadequate reporting of findings and inade-
quate evaluation of the required assumptions may impede
confidence in the findings and conclusions. We followed
the grading of recommendations assessment, development,
123
World J Surg
and evaluation (GRADE) Working Group guidelines to
allow readers to determine confidence in the results from
this network meta-analysis [20, 29].
This network meta-analysis is limited due to the quality
of literature that is available. The majority of literature
pertaining to mesh placement is of poor methodological
quality. In particular, we noted that blinded outcomes
assessment and improved follow-up is needed. However,
using sensitivity analysis and only assessing studies with a
low risk of bias, the results did not change. Furthermore,
there was some heterogeneity in follow-up duration
between studies, with many studies reporting follow-up as
little as 1 month. Outcomes from studies with great dif-
ferences in follow-up may not be comparable; however, the
majority of the studies had a mean follow-up of at least
1 year. Hernia size could also affect outcomes, and a
sensitivity analysis by hernia size was planned. However,
this analysis was unable to be performed due to a low
number of direct comparisons between studies with similar
sizes. In addition, other differences in repair technique may
have accounted for some of the differences in outcomes,
including mesh type and method for mesh fixation. Future
studies should compare mesh location in hernias of similar
sizes with similar repair techniques to validate these
results.
Conclusion
Sublay placement of mesh demonstrates improved out-
comes compared to onlay, inlay, and underlay repairs;
however the quality and level of data remains poor. Ran-
domized controlled trials with longer follow-up may be
warranted to validate the results of this network meta-
analysis; however, this network meta-analysis demon-
strates a high probability that sublay repair is associated
with the fewest SSIs and hernia recurrences.
Disclosures Mike K. Liang this work was supported by the Center
for Clinical and Translational Sciences, which is funded by National
Institutes of Health Clinical and Translational Award UL1 TR000371
and KL2 TR000370 from the National Center for Advancing Trans-
lational Sciences. The National Center for Research Resources or the
National Institutes of Health was not responsible for the design and
conduct of the study; collection, management, analysis, and inter-
pretation of the data; preparation, review, or approval of the manu-
script; or decision to submit the manuscript for publication.
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