Introduction: Mesh reinforcement is the standard of care for primary ventral hernia repair, yet the optimal anatomical position for mesh placement remains controversial. Common techniques include onlay, preperitoneal, retromuscular, and intraperitoneal onlay mesh (IPOM) placement.
Introduction:
Mesh reinforcement is the standard of care for primary ventral hernia repair, yet the optimal anatomical position for mesh placement remains controversial. Common techniques include onlay, preperitoneal, retromuscular, and intraperitoneal onlay mesh (IPOM) placement. While each approach has theoretical advantages, comparative real-world evidence regarding long-term recurrence and bowel obstruction remains limited. This large nationwide Danish cohort study evaluated the impact of mesh positioning on clinically relevant postoperative outcomes.
Problem Statement:
Surgeons must balance recurrence prevention against procedure-related complications when selecting mesh placement techniques. However, robust population-level data comparing recurrence and bowel obstruction risks across different mesh positions are scarce, making evidence-based selection challenging.
Summary:
This nationwide registry-based cohort study included 17,832 adults who underwent elective primary umbilical or epigastric ventral hernia repair with mesh reinforcement between 2014 and 2025. Patients were categorized according to mesh position: onlay (8,764 patients), retromuscular (1,239), preperitoneal (4,292), and IPOM (3,537). Outcomes were assessed using national healthcare databases with long-term follow-up.
Compared with onlay mesh placement, both retromuscular and IPOM techniques were associated with significantly higher risks of reoperation for hernia recurrence. Retromuscular placement increased recurrence risk by 63%, while IPOM increased risk by 38%. In contrast, preperitoneal mesh placement demonstrated recurrence outcomes comparable to onlay repair.
Bowel obstruction risk also differed substantially according to mesh location. Retromuscular placement doubled the risk of bowel obstruction, whereas IPOM was associated with more than a threefold increase compared with onlay mesh placement. Preperitoneal repair again showed no significant increase in bowel obstruction risk.
These findings challenge the traditional perception that retromuscular mesh placement consistently provides superior long-term outcomes. The authors suggest that factors such as mesh-related adhesions, tissue plane characteristics, and technical variability may contribute to the observed differences.
Clinically, the study supports onlay and preperitoneal mesh placement as favorable options for primary ventral hernia repair when considering both recurrence and bowel obstruction risks. Preperitoneal repair may be particularly attractive because it combines low recurrence rates with a low risk of bowel obstruction.
Overall, this large real-world analysis suggests that onlay and preperitoneal mesh placement provide the most favorable balance between durability and safety, whereas retromuscular and IPOM techniques may carry higher risks of recurrence and postoperative bowel obstruction requiring reoperation.
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