International Journal of Surgery 37 (2017) 65e70

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International Journal of Surgery

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Original research

Open retromuscular mesh repair versus onlay technique of incisional

hernia: A randomized controlled trial
Zaza Demetrashvili a, b, *, Irakli Pipia b, c, David Loladze b, Tamar Metreveli a,
Eka Ekaladze d, George Kenchadze b, Kakhi Khutsishvili b
a
Department of Surgery, Tbilisi State Medical University, 33, Vazha-Pshavela ave, 0177, Tbilisi, Georgia
b
Department of Surgery, Kipshidze Central University Hospital, 29, Vazha-Pshavela ave, 0160, Tbilisi, Georgia
c
Institute Medical Research, Ilia State University, Tbilisi, Georgia
d
Department of Biochemistry, Tbilisi State Medical University, 33, Vazha-Pshavela ave, 0177, Tbilisi, Georgia

h i g h l i g h t s

No difference in frequency of hernia recurrence between the retromuscular and onlay methods.

The retromuscular method associated with less wound complications than in onlay method.

Previous point makes retromuscular method more preferential than onlay method.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The aim of this prospective randomized clinical study was to compare and analyze the
Received 30 August 2016 results of two methods of treatment of incisional hernia: open retromuscular mesh repair and onlay
Received in revised form technique.
3 December 2016
Methods: 180 patients who underwent open elective surgery for middle primary incisional hernia were
Accepted 5 December 2016
Available online 9 December 2016
randomized into two groups. The retomuscular mesh repair was used in the first group and the onlay
technique e in the second group. Several preoperative and intraoperative factors, also wound compli-
cations (wound infection, hematoma, seroma) and hernia recurrence rate were determined and
Keywords:
Incisional hernia
compared between the groups.
Retromuscular mesh repair Results: The operative time was significantly longer in the retromuscular group compared with the onlay
Onlay technique group (P < 0.001). In the retromuscular group 17 (22.1%) wound complications were observed, in the
Wound complications onlay groupe39 (50.0%) wound complications. The difference was statistically significance (P < 0.001).
Recurrence Seroma was the most frequent postoperative wound complication, ranging from 16.9% to 41.0% among
the groups, respectively (P ¼ 0.0013). No significantly difference has been found between groups by
wound infection and hematoma. 2 (2.6%) case of hernia recurrence was marked in retromuscular group
and 4 (5.1%) case of hernia recurrence e in onlay group. But there was no statistically significantly dif-
ference between the two groups.
Conclusion: Our research shows no significant difference in frequency of hernia recurrence between
retromuscular mesh repair and onlay technique for treatment of incisional hernia. The usage of the
retromuscular mesh repair is associated with significantly less wound complications than onlay tech-
nique. That can be considered as an advantage of retromuscular method, which makes it more prefer-
ential than onlay method.
© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
* Corresponding author. Department of Surgery, Tbilisi State Medical University,
Georgia.
The treatment of incisional hernia tends to be one of major is-
E-mail addresses: zdemetr@yahoo.com (Z. Demetrashvili), iraklipipia@yahoo.
com (I. Pipia), davit2311@gmail.com (D. Loladze), t7metreveli@gmail.com sues of abdominal surgery. The incidence of incisional hernia after
(T. Metreveli), ekaekaladze@yahoo.com (E. Ekaladze), gugaken@yahoo.com laparotomies ranges between 11% and 20% [1e3]. Each year,
(G. Kenchadze), kadoc72@Yahoo.com (K. Khutsishvili).

http://dx.doi.org/10.1016/j.ijsu.2016.12.008
1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
66 Z. Demetrashvili et al. / International Journal of Surgery 37 (2017) 65e70
approximately 200,000 incisional hernia repairs are performed in
the United States alone [3,4].
Conventional suture repair techniques are associated with a
high rate of recurrence ranging from 12% to 54% [5e7]. Due to this,
the treatment of choice for incisional hernias should be mesh
repair, which is characterized by lower rate of hernia recurrence
[5e8]. Mesh repair can be proceeded by both, open and laparo-
scopic methods. By the usage of a mesh the most widely spread
open methods are: sublay retromuscular repair and onlay repair
[8e12]. Nowadays no consensus has been reached as to which
technique is preferable. The anatomic position of the mesh place-
ment has an impact on tissue reaction, tissue incorporation, and
tensile strength of the abdominal wall. The above mentioned fac-
tors are important during hernia recurrence and postsurgery
complications development [10,13,14].
The aim of this prospective randomized clinical trial was to
compare and analyze the results of two methods of treatment of
incisional hernia: open retromuscular mesh repair and onlay
technique.
2. Methods
From January 2007 to April 2014 patients over 18 years of age
who underwent elective surgery for middle primary incisional
hernia via open mesh technique were enrolled in this study. The
patients were operated at the surgery department of Kipshidze
Central University Hospital. The inclusion criteria were a midline
primary incisional hernia requiring operative treatment and pa-
tient's approval to participate in the study. The exclusion criteria
were recurrent incisional hernia, strangulated hernia, a patient's
preference for either operative technique, or a patient's refusal to
participate in the study. The patients were assigned to one of the
groups: the Retromuscular mesh group or the Onlay group. The
randomization (by simple random sampling) of patients to each of
the two groups described above was done before the surgical
intervention. The assignment of patients to the specific groups was
performed by the clinical manager not involved in the surgical
procedures. The study participants were blinded regarding the type
of surgical technique. All operations were performed by two skilled
general surgeons. All operations were performed under the general
anesthesia. All patients received a single dose of intravenous anti-
biotics (1.5 g cefuroxime) 15 min before operation. For all surgical
interventions (in both groups) monofilament polypropylene mesh
with a weight of 82 g/cm2 and pore size 1.0 mm (Prolene, Ethicon,
Somerville, New Jersey) was used.
Several preoperative factors were studied, which included sex,
age, body mass index, occupation, tobacco use, risk groups by
American Society of Anesthesiologists (ASA) and comorbidities.
Patients with ASA groups 4 and 5 were excluded from the study.
Among the intraoperative factors, the following were evaluated:
duration of the operation and the size of the hernia. The duration of
the operation was evaluated as skin-to-skin time.
Among the postoperative data, the following were studied:
postoperative days at the ward (hospital stay) and complications.
The latter divided into two groups: early (wound) and late com-
plications. The early complications included wound infection, he-
matoma, and seroma. The late complication included the hernia
recurrence.
After discharge from the hospital, all patients were examined
after 1 week, 15 days, 1, and 3 months at the outpatient department.
Also, these patients were examined more than 1, 2, and 3 years after
the operation date. The total follow-up time was calculated based
on the last visit to the outpatient clinic. The Follow-up for the
retromuscular group was 2e7.1 years (4.3 ± 1.2 years), whereas for
onlay group it was 2.1e6.7 years (4.6 ± 1.0 years).
The study was registered on researchregistry.com (UIN: 1584).
2.1. Surgical techniques
The old midline incisional scar was excised over the complete
length. After identifying the hernia sac it was carefully separated
from the surrounding tissues and opened. Approximately 2e3 cm
from the edges of fascial defect hernia sac would be cut, so that to
keep as much peritoneum as possible to be able to close the
abdominal cavity without problems. The abdominal content was
checked, and adhesiolysis was performed.
We used the Rives-Stoppa retromuscular technique for first
group [15,16]. The rectus sheath was opened on the both sides of
wound. Dissection of the retromuscular space was performed in all
directions. This dissection was stopped when an overlap of at least
5e6 cm in all directions was reached. The peritoneum and posterior
fascia was closed with slowly absorbable continuous suture. An
appropriate sized mesh was placed over the closed posterior fascia,
in the space between the posterior fascia and the rectus muscle and
fixed with some 2-0 polypropylene sutures (Fig. 1). One or two
suction drains were placed above the mesh. The anterior fascia was
closed using slowly absorbable continuous 2-0 suture. When the
anterior fascia closing was connected with tension we use anterior
component separation technique [17]. Additional subcutaneous
drain was placed if indicated. Skin margins were freshened and
closed (Fig. 2). Drains were removed on the third postoperative day
or when the secretion was less than 30ml/24 h.
For onlay technique, after closing the hernia defect with non-
absorbable polypropylene continuous 2-0 suture, the mesh of
appropriate size was placed over the anterior fascia. The mesh fixed
with some 2-0 polypropylene sutures (Fig. 3). The mesh covered
the anterior fascia 5 cm from the hernia defect borders in all di-
rections. Subcutaneous suction drains were placed in all patients.
Skin margins were freshened and closed (Fig. 4).
2.2. Statistical methods
The sample size calculation was performed for the following
parameters: confidence level 95%, power 80%, case/control ratio 1:1
and risk ratio 2.0 using OpenEpi v.3.01 software. The minimum
number of subjects in each of case and control groups was esti-
mated to equal to 67. The total minimal number of subjects in both
groups was equal to 134. We have included 180 subjects for simple
randomization which corresponded to approximately 25% rate of
loss to follow-up. Finally data for 77 subjects from retromuscular
mesh group and 78 subjects from onlay group have been analysed.
Descriptive statistics methods were used to characterize each
variable. Comparison of continuous variables was performed by
independent samples t-test or the Mann-Whitney U test according
to the normality of the variables. Categorical variables were eval-
uated by two tailed Chi-square test or Fisher's exact test where
appropriate. The threshold for statistical significance was set to
P < 0.05. The statistical tests were performed by IBM SPSS Statistics
v 20.0(IBM Corporation, Armonk, New York).
3. Results
From January 2007 to April 2014, 234 patients underwent open
incisional hernia repair. Among these patients, 180 were random-
ized in two groups equally (90 patients in each group). All of these
patients underwent the allocated operations. Information about 25
patients was lost during the time observation: among theme14
patients were not coming for examination, 7 patients died during
observation period (the causes of death were all non-hernia sur-
gery related), in 3 patients developed stroke, and in 1 patient
 Z. Demetrashvili et al. / International Journal of Surgery 37 (2017) 65e70 67

Fig. 1. Open retromuscular mesh repair: A. Closing the posterior fascia with a running suture; B. Placement of the mesh on the posterior fascia.

Fig. 2. Schematic drawing of open retromuscular mesh repair.

Fig. 3. Onlay technique: placement of the mesh on the anterior fascia.

68 Z. Demetrashvili et al. / International Journal of Surgery 37 (2017) 65e70

Fig. 4. Schematic drawing of Onlay technique.

developed myocardial infarction. Subsequently 77 patients from
retromuscular group and 78efrom onlay group were consecutively
examined during follow-up. The data of this investigation was
analyzed in this article (Fig. 5). Primary outcome includes operation
time, hospital stay and wound complications (wound infection,
hematoma, seroma), secondary outcome includes hernia
recurrence.
Both groups were similar by preoperative (sex, age, body mass
index, tobacco use, American Society of Anesthesiologists risk
groups, comorbidities, and occupation) factors. No statistically
significant differences were found between the groups by these
factors (Table 1).
The difference was not indicated between groups according of
size of hernia. The operative time was significantly longer in the
retromuscular group compared with the onlay group (P < 0.001)
(Table 2).
Regarding the postoperative data, no statistical significant dif-
ference has been found between groups by postoperative time
spent at the ward (hospital stay). In the retromuscular group 17
(22.1%) wound complications were observed, in the onlay group -
39(50.0%) wound complications. The difference was statistically
significance (P < 0.001). Seroma was the most frequent post-
operative wound complication, ranging from 16.9% to 41.0% among
the groups, respectively (P ¼ 0.0013). No significantly difference
has been found between groups by wound infection and hema-
toma. 2(2.6%) case of hernia recurrence was marked in retro-
muscular group and 4(5.1%) case of hernia recurrence e in onlay
group. But there was no statistically significantly difference

Fig. 5. Study flow chart. A randomized trial of retromuscular mesh vs. onlay technique in incisional hernia repair.
 Z. Demetrashvili et al. / International Journal of Surgery 37 (2017) 65e70 69

Table 1 compare them to the results of analogs international researches.

Preoperative factors in two treatment groups. Our study has shown that operation time is significantly shorter
Characteristics Retromuscular (n ¼ 77) Onlay (n ¼ 78) P value in the onlay group than in the retromuscular group. Our data is
Sex
similar to the data from several other investigations [8,20,21],
Male 36 32 0.52 although according to Weber et al. [22] operation time using these
Female 41 46 two methods is not different.
Age (years) 59.6 (13.1) 61.2(16.7) 0.51 Wound complications is the common problem in incisional
BMI, kg/m2 29.4(4.7) 28.8(3.9) 0.39
hernia repair using mesh [7,21,23e25]. Some scientist designate
Comorbidities
Cardiovascular 10 11 0.84 development of these complications after onlay techniques more
Respiratory system 4 6 0.75 frequently compared to retromuscular method [20,25,26], other-
Diabetes 3 2 0.68 wise, other papers do not indicate the difference [22,27]. Seroma
Steroid use 2 4 0.68
and wound infection are the main problems after the mesh repair
ASA risk group
1 25 29 0.61
surgery, especially in the onlay technique group [5,7,20,23]. Ac-
2 32 37 0.52 cording to several scientific literature, seroma is more frequent
3 20 12 0.17 complication of onlay technique than in retromuscular method
Current smoker 45 38 0.26 [20,23], but Kumar et al. [27] does not show this kind of result.
Occupation
More frequent development of seroma is related to two reasons:
Light work 45 40 0.42
Physical work 32 38 1.During the operation broad dissection of subcutaneous tissue is
performed; 2. There is tight contact of foreign body (mesh) to the
ASA e American Society of Anesthesiologists; BMI e Body mass index.
Data are expressed as mean (SD) or absolute number of patients.
subcutaneous tissue [5,7,23]. Controversial hypotheses exist con-
cerning the wound infection: one group of researchers indicate on
the prevalence of infections in case of onlay method compared to
Table 2 retromuscular repair [20,25,26], but Kumar et al. [27] does not
Intraoperative factors in two treatment groups. designate the difference. Timmermans et al. [24] Metaeanalysis
Characteristics Retromuscular (n ¼ 77) Onlay (n ¼ 78) P value shows no difference in terms of seroma development comparing
retromuscular and onlay methods, at the same time, less cases of
Operation time, min 155.1(42.3) 124.5(39.7) <0.001
Hernia size (cm2) 100.4(81.8) 92.7(72.4) 0.54 wound infection are indicated in retromuscular group. High inci-
dence of wound infection after using onlay method is explained by
Data are expressed as mean (SD).
superficial localization of mesh and facilitated colonization of
bacteria in the area. Due to scientists opinion mesh position on the
between the two groups (Table 3). posterior rectus fascia would benefit from a more vascularized area
compared with the onlay position [9,10].
Our results show less number of wound complication in retro-
4. Discussion
muscular group (22,1%) compared to onlay group (50.0%)
(P < 0.001). Seroma indicator during postoperative period is the
Incisional hernia remains one of the most frequent complica-
cause of the difference. Seroma rate was higher in onlay group
tions after abdominal surgery. Hernias are associated with reduced
(P ¼ 0.0013). There was no difference in frequency of wound
quality of life and high socioeconomic costs [1e4,18]. Relevantly the
infection and hematoma between these two groups.
treatment of this disease tends to be one of the major issues of
Scientific data show the higher rate of hernia recurrence after
current surgery. Despite the fact that various surgical techniques for
suture repair compared to mesh repair [5e8]. Thereupon mesh
repair of an incisional hernia are available, the best method to
repair needs to be prevalent in incisional hernia treatment. Which
provide a durable repair of incisional hernias has not been deter-
method e retromuscular or onlay is better one considering hernia
mined. Many clinical studies consider that the mesh reinforcement
recurrence e it is the debatable question. The scientific conceptions
during incisional hernia repair has been demonstrated to improve
are heterogeneous: some of the research specify less frequency rate
long-term outcomes compared with suture repair [5,6,8,19]. Due to
of hernia recurrence after retromuscular method [21,26,28], on the
this the current treatment of choice is mesh repair. However, the
other hand, some scientists designate no difference between the
types of mesh repair, and possible locations of mesh placement
results of these two methods [20,25]. As an exception, Weber et al.
speak to the uncertainty and lack of evidence to support any one
[22] indicates that there is less frequency of hernia recurrence after
repair.
onlay method than after retromuscular method. Our data indicate
Retromuscular mesh repair and onlay repair are the most widely
no difference in frequency rate of hernia recurrence between the
spread techniques for open incisional hernia repair; both of them
retromuscular and onlay groups (2.6% vs. 5.1% respectively,
have advantages and disadvantages [8e12]. The purpose of our
P ¼ 0.68).
clinical study was to evaluate the outcomes of two surgical ap-
There are several limitations of this study. First, we excluded
proaches (retromuscular mesh repair and onlay technique) and to
emergency repairs because they are associated with poor outcomes
after incisional hernia repair and therefore should be addressed
Table 3 separately [29]. Secondly, our work does not include the data of
Surgical outcomes in two treatment groups. treatment of recurrent incisional hernias. Thirdly, as we have not
investigated postoperative pain and feeling of foreign body,
Characteristics Retromuscular (n ¼ 77) Onlay (n ¼ 78) P value
consequently, we are unable to compare retromuscular and onlay
Hospital stay (days) 5.2(2.4) 5.5(2.7) 0.47
methods according to these indicators. Considering all above
Wound complications 17(22.1) 39(50.0) <0.001
Wound infection 2(2.6) 5(6.4) 0.44 mentioned we think that large, prospective randomized research
Hematoma 2(2.6) 2 (2.6) 1.0 needs to be conducted including investigation all above-listed
Seroma 13(16.9) 32(41.0) 0.0013 factors.
Recurrence 2(2.6) 4(5.1) 0.68 In conclusion, based on our prospective study comparison be-
Data are expressed as mean (SD) or absolute number of patients (%). tween retromuscular mesh repair and onlay technique for primary
70 Z. Demetrashvili et al. / International Journal of Surgery 37 (2017) 65e70
incisional hernia, there were no significant differences indicated in
terms of development of hernia recurrence. The usage of the ret-
romuscular mesh repair is associated with significantly less wound
complications than onlay technique. That can be considered as an
advantage of retromuscular method, which makes it more prefer-
ential than onlay method.
Ethical approval
None.
Sources of funding
None.
Author contribution
Zaza Demetrashvili participated in the design and coordination
of the study, collected the data, analysed the data, carried out the
statistical analysis and wrote the manuscript. Irakli Pipia, David
Loladze, Tamar Metreveli, Eka Ekaladze, George Kenchadze and
Kakhi Khutsishvili developed the literature search, collected the
data and assisted in writing up. All authors read and approved the
final manuscript.
Conflict of interest statement
The authors declare that they have no conflict of interests.
Research registration unique identifying number (UIN)
Research registry 1584.
Guarantor
Zaza Demetrashvili.
Acknowledgments
We are thankful to Prof. George Kamkamidze for the help to
carried out the statistical analysis.
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