Ascension Via Christi Hernia Center

In fact, it is also a topic of debate between hernia surgeons. There are many common misunderstandings and misconceptions that are perpetuated by medical dogma, popular media, and concern regarding litigation. Little information exists that allows the non-surgeon to help understand the evidence regarding mesh and its use in particular patients and situations. The paragraphs below are designed to assist the lay public in understanding why between 70-82% of hernia repairs performed in the United States each year use some type of mesh (42).

Is mesh necessary to prevent the hernia from coming back?

A common complication that can occur with any type of hernia repair is recurrence. This means that the repair has failed and the hernia has come back requiring another more complex and costly operation to fix it (42). The likelihood of a successful hernia repair decreases with the number of repairs that have been performed previously (43, 44).

As surgeons we want to do everything that is reasonable and safe to try to achieve durable and long-lasting repair, one that does not come back, or recur. Mesh is an important tool used to help achieve this goal.

Generally speaking, there are two ways to fix a hernia:

• Primary Repair: Abdominal wall tissue layers are sewn back together with stitches. This is also referred to as a “tissue-based repair”. No additional re-enforcement of mesh is provided where the hole is sewn closed.
• Mesh Repair: This repair involves using mesh in one of two ways:
  • Bridging Mesh: If the hole cannot be sewn shut, then mesh is used to “bridge the gap” between abdominal wall tissues. This is also known as an “interposition" and this technique is generally associated with recurrence rates higher than other techniques using mesh.
  • Re-enforcing Mesh: The hole is sewn shut and mesh is used to provide additional re-enforcement to this closure. The mesh serves as a durable re-enforcing layer above or below the patient’s abdominal wall tissue that has been repaired. Medical literature now clearly indicates that this technique is the most desirable in achieving the lowest possible recurrence rates (45, 46, 47).

Several studies have been performed that compared the results of tissue-based repairs, just sewing the hole closed, versus the use of mesh. One well known type of tissue-based primary repair, known as the “Mayo” repair, was found to have a 5-year recurrence rate of 54% (51). In another study, this repair had a 37% risk of recurrence in an 10 year followup (111). Further, if the hernia was greater than 12 cm the recurrence rate was 78% (48).

In two landmark studies published in 2000 and 2004, respectively, mesh placement clearly reduced the number of recurrent hernias. For example, at 3 years the hernia recurrence rate after initial repair was 43% for non-mesh repairs and 24% for repairs where mesh was used (49). At ten years, this same group of patients had a recurrence rate after initial repair of 63% for tissue-based repairs compared to 32% when mesh was used (50). So, the risk of the hernias recurring was halved if mesh was used in the hernia repair.

Keep in mind, these studies are now 14 years old and significant improvements have been made in regard to the general understanding and techniques of hernia repair. For instance, the studies noted above used mesh as an interposition repair to bridge a gap (49). It was not used to reenforce a layer of tissue closed above or below it, something surgeons now know is absolutely essential to achieve the best long-term results (45). Patients that have a bridged repair have hernias that come back nine times more quickly and nine times more often (45). We now know that sewing the layers of the abdominal wall closed and then reenforcing this repair with mesh greatly reduces the risk of hernia recurrence (42, 45, 46, 47). This technique has been noted to decrease hernia recurrence rates to 8-14.6% at 5 years (45, 46, 113).

So, the importance of sewing the layers of the abdominal wall back together, what surgeons refer to as “fascial reapproximation”, is of paramount importance. In our practice the only time we bridge a hernia repair when the hernia cannot be or should not be closed at that moment.

In our practice mesh is used in most circumstances. One circumstance when mesh usually is not employed is the case of a hernia that is less than half an inch. However, exceptions to this are common based on a patient’s individual risk factors. Another circumstance where mesh may not be used is in the case of a complex hernia and an infected abdominal wall where a later and more complex operation will be required.

As will be explained below, there are several important decisions that factor into whether or not mesh is used, what type of mesh is used, and where it is placed in the abdominal wall. However, there is little doubt among hernia surgeons that mesh has revolutionized both simple and complex hernia repair, that it is necessary to achieve the lowest possible rate of hernia recurrence, and that it is here to stay (46).

What are the risks of mesh placement?

Based on the medical literature, the risk of a mesh-related complication between three and five years after it is placed is 4.5-5.6% (52, 53, 54, 113).

Excluding hernia recurrence, mesh complications occur in two major ways. The first of these involves mesh becoming infected and the second involves mesh interacting with other structures in the body, like the intestines.

Mesh Infection

To quote a recent review article from the Journal of Plastic and Reconstructive Surgery, “…the concern for performing a hernia repair with synthetic mesh stems from the fear that placement of a synthetic mesh in a contaminated field will result in a chronic mesh infection” (25).

While mesh infection may not be the most feared complication in hernia surgery, it certainly is something that surgeons are extremely concerned about and have studied extensively.

Because wound infections can and do lead to mesh infections, a great deal of time is spent prior to surgery making the patient as healthy as possible before an operation, a process referred to as optimization. To review information presented in the Optimization Section, obesity, smoking, diabetes, and prior infections all significantly increase the risk of wound infection.

Studies of hernia specific risks for developing a wound infection suggest that if patients have had a previous mesh infection or even if they simply have a recurrent hernia, they are at increased risk for developing a wound infection, which can lead to a mesh infection (44, 55, 56).

In 2010, a group of hernia surgeons came up with a classification system to try to predict the likelihood of a patient developing a wound infection based on some of these patient characteristics. This group, referred to as the Ventral Hernia Working Group, developed a system with 4 classes that noted increasing levels of risk for wound infection (47). For instance, the lowest risk class for development of a wound infection is a class 1, a healthy patient with no risk factors (47). Risk of infection increases through the four classes to its highest level, class 4, where a patient has a known active mesh infection (47).

This classification system has been studied to determine its predictive value. A group of 299 patients studied confirmed that risk for infection after a hernia repair increased as expected from class 1 ( 14%) to class 4 (49%) (57). One conclusion from this paper recommended streamlining the system from four classes of risk to three and this is the system that most surgeons use today.

So, if your surgeon tells you that your hernia is a “class 3” then you know that you have about a 38% risk of developing a wound infection after your surgery (57). This classification system matters because it will likely lead to other decisions being made in regard to the type of mesh used in your repair and where the mesh is placed in your abdominal wall. Sometimes, another operation will be necessary; and is referred to as a staged-repair. These decisions are discussed below.

Mesh infection is usually manifested by pain and a non-healing or draining wound and may not become manifest for a year or more after surgery (54, 58, 59). Once a mesh infection is diagnosed, management can be complicated. For many years, removing the mesh and starting over at a later time was thought to be the correct course of action (60).

In one study involving 619,751 hernia repairs mesh removal, a complex procedure referred to as explanation, was performed 438 times (58). This equates to about 1 mesh removal per 1000 patients, but this is felt to be a low number and other studies have suggested rates of 5-7% (52, 54).

However, salvaging the mesh is possible in some cases and it may be possible to treat the infection and the infected mesh with antibiotics and drainage (60, 61, 62, 68). Sometimes the mesh and infected tissue needs to be partially cut away in a procedure referred to as a debridement (60, 62).

These are not easy decisions and there is no textbook answer to management of infected mesh. Some important factors to be considered include the health of the patient, the severity of the infection, how the mesh was placed, where the mesh was placed, and what type of mesh was used. For instance, a wide-pore polypropylene mesh can usually be cleared of bacteria, but an infected mesh made with a material called PTFE nearly always needs to be removed (62).

In this practice, we have used multiple strategies to manage mesh and wound infections. Without a doubt, though, the best strategy is prevention of wound infection.

Intra-Abdominal Adhesions and Fistulas

The medical word for scar tissue is adhesion. Anytime a person has an operation in their abdomen they form adhesions and this process in the human is complex and not well understood (63). This is true for all types of abdominal surgery, not just hernia surgery.

Generally speaking, the presence of adhesions make the next abdominal surgery, whether it is to repair a hernia or to remove the gallbladder, more complicated (64). This is because things in the abdomen that are not supposed to be stuck together become that way as a result of the first surgery. This effect is additive and the more surgeries a person has had in their abdomen the more complex and disorganized it will be. The typical recurrent hernia patient in our practice has had, on average, between 5 and 8 abdominal operations.

The problem with this increased complexity is that separating the tissues that are stuck together, called adhesiolysis, increases the risk of damaging the same structures that are stuck together. When a surgeon damages a piece of intestine, say, puts a hole in it, this is called an enterotomy. This is a bad problem that can lead to death if not recognized and treated aggressively. Also, this is why surgeons have developed techniques for repairing hernias using minimally invasive techniques and never entering the abdominal cavity, thus avoiding or decreasing the risk of bowel injury.

As stated earlier, hernia repairs are often performed in patients who have had previous abdominal surgery and have adhesions in their abdominal cavity. The risk of a bowel injury during these cases is about 2-4%, but if a bowel injury does occur then the patient is at greater risk for wound infection, mesh infection, need for reoperation, and death (65, 66).

Another well-known and feared complication that is associated with increased complexity from dividing scar tissue around the intestines is called a fistula. This is an abnormal communication between two organs or spaces in the body that results from injury to the bowel during the operation. In this circumstance, the intestines drain out of the skin like an unintentional colostomy (67). This is a rare complication and it can be treated but requires patience and fortitude on behalf of the patient and surgeon (67).

A common practice is to place the mesh in the abdominal cavity. This is referred to as the “underlay” position and is discussed in the section below. In this type of procedure the mesh is placed directly over the intestines. Where-ever it is placed in the body mesh creates inflammation and this process is referred to as a foreign body reaction (63, 68, 69). This process leads to adhesion formation (63, 68, 69). So, when the mesh is placed directly over the intestines scar tissue can form between the mesh and bowel. This becomes an issue when patients have a hernia recurrence or need an another operation to have a hysterectomy or a gallbladder operation, etc.

One study showed that 23.3% of hernia repairs required surgery for a variety of problems not related to the hernia repair (gallbladder, gynecologic, colon cancer) in the 7 years following their hernia surgery (70). Many surgeons today perform laparoscopic hernia repairs where mesh is placed in the underlay position. In a review of 733 laparoscopic hernia repairs, 17% of patients required an abdominal operation during the first 2.2 years after their surgery (66). Again, many of these operations had nothing to do with their hernia repair (66).

The presence of mesh in the abdominal cavity significantly increases the risk of a complication, like a bowel injury, during the second operation (66, 70). In a study of 335 patients, the presence of mesh in the abdominal cavity was associated with increased overall complications at the time of the subsequent surgery including need for bowel resections and surgical site infections (71). Also, this study revealed a 5% rate of fistula formation (71).

The type of mesh used in these cases is different among the different studies. Many meshes are designed to reduce the formation of adhesions by coating the back of the mesh with a chemical or substance designed to decrease adhesion formation. This type of mesh is referred to as a “barrier-coated mesh” and there are several types produced by different manufacturers.

The idea and the science behind these meshes are sound, however, there is a lack of a reproducible animal model in which to study them (63). It is felt that any barrier should be effective for 5-7 days after the operation (68). There are many animal studies that review how effective an anti-adhesion barrier can be in an experimental setting, however, there is precious little data that exists in regard to how well they perform in the clinical setting, in a real group of patients (73). To be sure adhesions do still form to these products when they are used (72).

There are certainly times when putting mesh in the abdominal cavity is unavoidable. However, for the reasons noted above, whenever possible attempts are made to place the mesh somewhere else in the abdominal wall and outside the abdominal cavity.

Mesh fracture and chronic fibrosis will be discussed in the sections below.

What are the different types of mesh?

Three types of mesh are commonly used to repair hernias. Each has its own profile of performance and indications for use:

Synthetic Mesh

This type of mesh is derived from petroleum products (49). They are plastic polymers that differ from each other based on how different atoms are arranged on a carbon skeleton (49). They are permanent in the sense that they are designed to be functional for the rest of the patient’s life. The three materials of note are polypropylene, polyester, and a material called PTFE (73).

Of these, polypropylene, which was first used for hernia repair in 1958, is the most widely used as it is relatively inexpensive (73). Also, polypropylene mesh appears to have higher rates of salvage and less need for complete mesh removal when exposed to bacteria (62, 74).

Many hernia surgeons feel as though we are in the midst of a paradigm shift because this mesh appears to clear infection well. In situations where there is a high risk of infection (see discussion above) conventional wisdom has long held that installing a synthetic mesh was dangerous because it could not clear the infection and a complex operation with mesh removal would be required. However, new studies suggest favorable outcomes when this mesh is placed in situations where infection is statistically likely (55, 61, 75, 76).

Polypropylene is manufactured with different weights. This mesh is also designed to have holes that we refer to as pores. Think of a heavy weight mesh with small pores as a tightly woven blanket. It’s heavy and if held up to the light one cannot see through it. Conversely, light weight mesh with large pores is like a crocheted blanket and one can easily see through it. A midweight mesh is mix of the two and, as you would expect, in the middle in terms of weight and porosity.

The more lightweight a polypropylene mesh is, the less the body reacts to it (73, 69). Thus, it shrinks less and is more compliant that a heavier weight mesh (70). Because of the large pore size, this lightweight mesh also grows into tissues better that other mesh with smaller pores (69). Also, larger pores may give midweight and lightweight mesh an edge in dealing with bacteria as discussed above.

Considering these facts, lightweight polypropylene mesh would seem to be the right choice for most hernia repairs (77). For some types of hernias, like inguinal hernias of the groin repaired in particular ways, this is true (78). However, one problem that has been encountered with lightweight polypropylene mesh is referred to as mesh fracture (79, 80). Essentially, the mesh simply breaks and the hernia recurs through the broken material (79, 80). In a series of 36 patients followed over a 36 month period, 19% had recurrent hernias due to mesh fracture (80). Most likely, this fracture is the result of the layers of tissue sewn together above and/or below the mesh have separated, leaving mesh as the only strength layer, something it was not designed to do (80).

If you ask ten different hernia surgeons, you are likely to get 10 different opinions as to the best type of synthetic mesh to use in a particular situation. At this time, we believe that the evidence supports the use of a midweight large pore polypropylene mesh for most standard hernia repairs in a patient with low or intermediate risk of infection.

Biologic Mesh

In patients with high risk of wound and mesh infection there has been concern about placing a synthetic mesh. Every hernia surgeon has an unpleasant tale to tell regarding mesh infection and the operation to remove it and reconstruct the abdominal wall. This problem is what biologic mesh was designed to address.

Biologic mesh is tissue that is derived from cows (bovine), pigs (porcine), and humans (81). Essentially, these tissues are harvested and processed in a proprietary fashion with each company having their unique process (81). The goal of this processing is to remove everything that the patient’s body could reject (cells, viruses, bacteria) and to provide a scaffolding on which the body can add its own cells (81).

Benefits that have been noted when using biologic mesh include increased growth of blood vessels, increased incorporation into the bodies tissues, decreased adhesion formation to the intestines, and the ability to heal if exposed in a wound infection (82, 83, 84, 85, 86). Though little evidence for the use of biologic mesh existed at the time, the Ventral Hernia Working Group (discussed above) recommended the use of biologic mesh in patients with a high risk of wound infection with the goal of decreasing the risk of mesh infection (47, 57).

However, some of the initial studies using biologic mesh called into question its utility as it was noted to have higher wound complications and rates of recurrent hernias (81, 82) of the hernia repair (83). One important aspect of this study was that in 19% of the hernias in this study, the mesh was used to bridge a gap, not as a layer of reenforcement (83). Thus, these hernias were much more likely to recur. One important point that is often missed, however, is that these patients were all at high risk for wound and mesh infection but no mesh removals were required (83).

We now know that biologic mesh has a hernia recurrence rate comparable to synthetic mesh when used to reenforce a repair (84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94). In a review of 1229 hernia repairs, biologic mesh was found to have less infectious complications and similar recurrence rates compared to synthetic mesh (84). This was also found to be the case in other large reviews of 761, 359, and 126 patients, respectively (85, 86, 887). In complex cases were complete reconstruction of the abdomen is required, similar findings were noted (88, 89, 90, 91, 92, 93, 94).

One of the benefits of biologic mesh is that infected wounds can be managed with little worry of mesh infection and need for mesh removal (86, 87, 91, 92, 93, 94, 95, 96). In some cases, a device called a wound vacuum has been attached directly to the biologic mesh and the wound has healed (91, 94, 95).

So, if biologic mesh has a rate of hernia recurrence and wound complication that are comparable to synthetic mesh in hernias at high risk for infection, why is it not used all of the time? Well, it is extremely expensive and not all biologic meshes are created equal (97). Some of these products are extensively studied and others are not. Each mesh has its own chemical arrangement and they do not all behave equally.

Again, if you ask those same 10 hernia surgeons we referenced above about when and how to use biologic mesh, you are likely to get 10 different answers.

Our policy is to strongly consider biologic mesh in two distinct circumstances. The first is if a patient is at high risk of developing a wound or mesh infection. Our expectation here is a definitive repair that will be long-lasting. The second situation is in the form of a temporary fix. For example, if a patients has a severe infection or is too ill to tolerate a definitive reconstruction, then a bridging biologic mesh can be placed to buy time until a definitive reconstruction can be performed. This is done with the expectation that the hernia will likely come back, but the patient will be better able to tolerate the operation later on down the road.

Long-Acting Resorbable Mesh

This type of mesh is designed to offer the same benefit of biologic mesh at a lower cost (98). Essentially, these synthetic products that are designed to offer temporary reenforcement of the abdominal wall and then to melt away after a period of time (98). It is felt that these products should decrease the risk of mesh infection and need for mesh removal (98). They are also known as biodegradable mesh, bioabsorbable mesh, or biosynethetic mesh (98).

Currently, there are three of these products available for use in humans and though the technology behind these products has been available for many years, they are a relative new-comer to hernia surgery. Currently, few published studies are available regarding the use of this type of mesh in complex hernia repair. One study, referred to as the COBRA study followed complex repairs for 24 months and was noted to have a recurrence rate of about 14% (99). It is tempting to compare these results to those studies regarding biologic mesh noted above but that is a dubious endeavor. First, more is known about the importance of avoiding a bridging repair (discussed above) and the hernias in the bioabsorbable study were smaller. (98, 99). Though it is a good beginning, the COBRA study presents more questions than answers as to which type of mesh, biologic or bioabsorbable is best to use in wounds at high risk of infection (86).

Another more recent study examining bioabsorbable meshes displayed an 18 month recurrence rate in complex patients to be 9% (100). However, the predicted absorption time for the mesh that was studied was 18 months (100). It is possible that more hernia recurrences will be discovered after the mesh has completely dissolved. Other recent work compared polypropylene mesh to biosynthetic mesh in 75 patients and found that the bioabsorbable mesh had higher rates of wound complications and hospital readmissions (101).

Bioabsorbable mesh may figure prominently in the field of complex hernia repair in the future. It may also may not. We just do not have enough study and data regarding the long-term use of these products to know if they behave better, worse, or the same as the other products for which good data already exists (79). As a result, we use these products are employed in our practice sparingly and only under specific circumstances.

What does mesh position mean and why is this important?

Basic Anatomy

If one were to pass an imaginary needle from the skin to the inside of the abdominal cavity, where the intestines live, that needle would pass through 7 distinct layers of tissue as it travels further away from the skin. This is an oversimplification of the relevant surgical anatomy as additional more subtle planes of tissue exist but for the purposes of keeping it simple, this number works.

The strength layers of the abdominal wall are referred to as the fascia. When a patient has a hernia, he or she has a hole in the fascia. There are generally two layers of fascia in the abdominal wall they lay in front and behind the abdominal muscles, respectively. These muscles are referred to as the rectus muscles. These are the “six-pack” muscles. Between the layer of fascia behind the muscle and in front of the intestines is a tissue-paper thin layer of tissue referred to as the peritoneum. The peritoneum is a big sac that your intestines live in.

What is important to understand is that these layers create several different places where mesh can be installed during a hernia repair with a different set of benefits and risks for each individual layer of placement. Different choices are made in consideration for the patient’s unique anatomy, risks, medical history, and sometimes lifestyle and activity level.

Onlay

With this procedure, mesh is placed above the layer of fascia in front of the rectus muscles. In this procedure, the skin and tissue over this layer of fascia are dissected apart, this is referred to as “making a skin flap”. The hernia is closed with stitches and the mesh is placed in the pocket of tissue between the tissue and the fascia (102). Some benefits of this technique include the fact that mesh is placed outside of the abdominal cavity and that patients appear to have less pain (102). This technique is also valuable for atypical hernias where other techniques may be more difficult (102).

However, one must remember that there are blood vessels that supply the skin that pass through the space that is separated and these are nearly always compromised to some degree by this operation (103). This is an extremely important concern in patient who have had previous abdominal operations or aortic surgery (102). Patients who smoke and have this operation are at especially high risk for wound complications and need for further surgery (102). In comparing this technique to the retromuscular technique describe below, the onlay technique demonstrated higher infection and recurrence rates (104).

This mesh position also places the mesh as close as is possible to the skin and thus, a wound infection does not have far to travel to involve the mesh.

In a recent cumulative review of 13 studies that placed the mesh in this area, 472 patient outcomes were reported (105). The overall infection rate was approximately 14% and hernia recurrence rates were 12.9% nearly two years after repair (105).

Interposition or Bridging

As described in other sections, this technique involves not closing the hernia and bridging it with mesh. Despite evidence that signifies the importance of sewing the defect closed and using mesh to reenforce this closure, many surgeons routinely perform bridging repairs in the form of laparoscopic hernia repair. Only recently have surgical atlases begun to describe techniques for closing the fascia during laparoscopic repairs (103).

This technique is described in more detail in the Hernia Education section. What is important to understand is that mesh is delivered into the abdominal cavity and secured to the inside of the abdomen with small absorbable rivets, referred to as tacs.

A cumulative review of 20 studies involving 821 patients, the overall infection rate was 12% and hernia recurrence rates were the highest of the evaluated mesh positions at 21.6% at 36 months after repair (105).

Retromuscular or Retrorectus

This technique involves closing both the front and back layers of fascia individually and placing a mesh in the space behind rectus muscle (102, 103). For many dedicated hernia surgeons, this repair has become the standard of care (102).

There are several benefits to this repair. First the mesh is kept out of the abdominal cavity and next to abdominal muscles that have a rich blood supply, this affords the mesh an opportunity to become incorporated quickly and thoroughly (102, 103, 106). Also, wide mesh overlap of the defect is possible (102, 103). With the maneuvers required to place the mesh in this position, the shape of the rectus muscles change and move closer to the midline, thus enhancing the ability to close a larger hernia (102, 103, 107). This operation also serves as a platform for other more complex reconstructions (102, 103,). Finally, the mesh is kept out of the abdominal cavity and serves to reenforce two layers of repaired fascia (102, 103).

Referring back to the cumulative review noted in the sections above, retromuscular repair was noted to have an average infection rate of 10.4% and a hernia recurrence rate of 5.8% at 18 months (105). The conclusion of another recent analysis involving 51 independent studies and more than 6200 patients concluded that placing the mesh in the “underlay” position is associated with a lower recurrence rate and other reviews and studies have confirmed these findings as well (52, 53, 104, 108, 111, 112).

Underlay

Mesh is said to be placed in the underlay position when it is placed in the abdominal cavity (inside the peritoneal lining) or outside the abdominal cavity but behind the layer of fascia behind the muscles (extreperitoneal or preperitoneal) (105). Preperitoneal mesh placement affords the advantage of a layer of tissue, the peritoneum, between the mesh and the intestines. While this may be some confusing anatomy, it is an important distinction if one is to consider the ramifications of mesh placement inside the abdominal cavity discussed above.

In the cumulative study that is referenced in the sections above the underlay position was noted to have a high infection rate, 17.7% and a low recurrence rate of 10.9% at 24 months (100). However, many of these procedures were performed with open surgery (37.8%) and so newer and minimally invasive techniques, such as the robotic or laparoscopic TAPP procedure (see General Questions and Hernia Education Section) (105).

Putting it all together

To paraphrase the conclusions from the review noted above, now more than ever there are more options available to the hernia surgeon in regard to technique and mesh types (105). There is also an astounding amount of data that involves different and complex problems and inherent bias on the part of the researchers and the readers (105).

Thus, it is important for each hernia surgeon to do several things. First, they need to understand their own limits of technique and abilities. The need to know their own results. This is accomplished by following patients over the longest possible period of time after their operation and why this center participates in data collection and analysis programs like the Americas Hernia Society Quality Collaborative.

Secondly, the surgeon needs to be up to date on the medical literature and available data as there is always somebody, somewhere who is taking a new look at an old problem. Such is the case with surgeons now using minimally invasive robotic techniques to perform complex operations that used to only be accomplished with large open incisions.

So, considering mesh position several priorities have evolved as to how we treat hernias.

When possible, we try to keep mesh out of the abdominal cavity and to place it in the retrorectus or preperitoneal position. We believe the data available strongly suggest the benefits of this position in regard to lower recurrence rates and overall lower complication rates.

Also, if we can achieve the goals of a good and durable repair in a minimally invasive fashion, then that is how the operation is performed. With the advanced techniques of eTEP and TAPP used on the daVinci robot system, this is often possible. These techniques are reviewed in the General Questions and Hernia Educations section.