Hi all,

Here’s a simple but still very important (I think!) question regarding the philosophy of mesh overlap in open ventral hernia…

I’m keen to clarify the concept of transverse diameter mesh overlap, the key point in open hernia repair

In lap ventral hernia repair it’s easy as there is a defect effectively left open and just covered with an IPOM mesh. Hence e.g. an 8x8cm defect needs to be covered with 5cm overlap in all directions i.e. at least a 13x13cm mesh

In open hernia repair the fascia defect is in the linea alba to be precise (not posterior or anterior rectus sheath). We can easily get craniocaudal overlap by dissecting retroxiphoid and retropubic into the cave of Retzius… BUT…

If we bring together the posterior elements (PRS) to ensure giant prosthetic reinforcement of the visceral sac (GPRVS) - the whole point of hernia surgery - then what about the 5cm overlap?

If the defect was e.g. 10cm but the PRS comes together, we only put mesh to the linea semilunaris on both side i.e. the natural limit of a Rives-Stoppa.

We do not go retromuscular into the TAR plane just for overlap if the PRS comes together (or at least I don’t!).

Thus when we bring the posterior layer together (and hence just do a Rives-Stoppa) the original defect may have originally been eg 8-10cm but is now closed in the posterior midline and our mesh in transverse diameter is eg 15cm, that is not 5cm overlap on all sides…

What do you all think?! Something I’ve long thought about! Do we overlap the original fascial defect, in which case we’d have to do more TARs even when the PRS comes together and a Rives-Stoppa will suffice; or just do we just cover from linea semilunaris to linea semilunaris and get craniocaudal overlap accepting that we have covered the viscera, got a nice retrorectus sublay plane for visceral protection and vascular graft and close the ARS on top…?!

Interesting to think about the basic principles!

Tell me if I’m way off!

Look forward to hearing peoples’ thoughts!

Many thanks,

John.