World Journal of Surgery

, Volume 43, Issue 1, pp 149–158 | Cite as

Abdominal Wall Reconstruction Utilizing the Combination of Absorbable and Permanent Mesh in a Retromuscular Position: A Multicenter Prospective Study

  • Miguel Ángel García-UreñaEmail author
  • Javier López-Monclús
  • Diego Cuccurullo
  • Luis Alberto Blázquez Hernando
  • Providencia García-Pastor
  • Stefano Reggio
  • Elena Jiménez Cubedo
  • Carlos San Miguel Méndez
  • Arturo Cruz Cidoncha
  • Alvaro Robin Valle de Lersundi
Original Scientific Report with Video



Optimal mesh reinforcement for abdominal wall reconstruction (AWR) in complex hernias remains questionable. Use of biologic, absorbable and synthetic meshes has been described. The idea of using an absorbable mesh (AM) under a permanent mesh (PM) in a retromuscular position may help in these challenging situations.


Between 2011 and 2016, consecutive patients undergoing open AWR utilizing an AM as posterior layer reinforcement and configuration of a large PM were identified in a multicenter prospectively maintained database in four hospitals. Main outcomes included demographics, ventral hernia classifications, perioperative data, complications and recurrences.


A total of 169 complex incisional hernias were analyzed. Mean age was 60.9, with mean body mass index 30.7 (range: 20–46). Location of incisional hernias (IH) was: 80 midline, 59 lateral and 30 midline and lateral. 78% were grade I and II in Ventral Hernia Working Group classification. 52% of patients were discharged with no complication. There were 19% seromas, 13% hematomas, 12% surgical-site infection and 10% skin dehiscence. Only partial mesh removal was necessary in one patient. After a mean follow-up of 26 months (range 15–59), there were five (3.2%) recurrences. Reoperations on patients showed a band of fibrosis separating the peritoneum from the PM.


The combination of AM with very large PM in the same retromuscular position in AWR seems to be safe. The efficacy with recurrence rates below 4% in complex midline and lateral IH may be explained by the use of larger PMs that are extended and configured with the support of AMs. Reoperations on patients have confirmed the previous experimental reports on the use of the AM.


Compliance with ethical standards

Conflict of interest

García-Urena has received speaker fees for symposium organized by Dynamesh, Braun, and Gore. Lopez-Monclús has received speaker fees for symposium organized by Gore.

Supplementary material


3D-configuration of a large PM with the support of AM after a left TAR and right Rives in a large iliac incisional hernia (MP4 55,539 kb)


Stoppa configuration and extension of a large PM after a bilateral TAR in a complex midline incisional hernia (MP4 28,417 kb)


  1. 1.
    Bower C, Roth JS (2013) Economics of abdominal wall reconstruction. Surg Clin North Am 93:1241–1253CrossRefGoogle Scholar
  2. 2.
    Slater NJ, Montgomery A, Berrevoet F et al (2014) Criteria for definition of a complex abdominal wall hernia. Hernia 18:7–17CrossRefGoogle Scholar
  3. 3.
    Iqbal CW, Pham TH, Joseph A, Mai J, Thompson GB, Sarr MG (2007) Long-term outcome of 254 complex incisional hernia repairs using the modified Rives-Stoppa technique. World J Surg 31:2398–2404. CrossRefGoogle Scholar
  4. 4.
    Mehrabi M, Jangjoo A, Tavoosi H, Kahrom M, Kahrom H (2010) Long-term outcome of Rives-Stoppa technique in complex ventral incisional hernia repair. World J Surg 34:1696–1701. CrossRefGoogle Scholar
  5. 5.
    Carbonell AM, Cobb WS, Chen SM (2008) Posterior components separation during retromuscular hernia repair. Hernia 12:359–362CrossRefGoogle Scholar
  6. 6.
    Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 204:709–716CrossRefGoogle Scholar
  7. 7.
    Posielski NM, Yee ST, Majumder A, Orenstein SB, Prabhu AS, Novitsky YW (2015) Repair of massive ventral hernias with “quilted” mesh. Hernia 19:465–472CrossRefGoogle Scholar
  8. 8.
    Gibreel W, Sarr MG, Rosen M, Novitsky Y (2016) Technical considerations in performing posterior component separation with transverse abdominis muscle release. Hernia 20:449–459CrossRefGoogle Scholar
  9. 9.
    Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ (2015) Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia 19:285–291CrossRefGoogle Scholar
  10. 10.
    Winder JS, Behar BJ, Juza RM, Potochny J, Pauli EM (2016) Transversus abdominus release for abdominal wall reconstruction: early experience with a novel technique. J Am Coll Surg 223:271–278CrossRefGoogle Scholar
  11. 11.
    Petro CC, Como JJ, Yee S, Prabhu AS, Novitsky YW, Rosen MJ (2015) Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen. J Trauma Acute Care Surg 78:422–429CrossRefGoogle Scholar
  12. 12.
    Petro CC, Orenstein SB, Criss CN et al (2015) Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients. Am J Surg 210:334–339CrossRefGoogle Scholar
  13. 13.
    Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB (2016) Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 264:226–232CrossRefGoogle Scholar
  14. 14.
    Rosen MJ, Bauer JJ, Harmaty M et al (2017) Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the COBRA study. Ann Surg 265:205–211CrossRefGoogle Scholar
  15. 15.
    Liu L, Petro C, Majumder A, Fayezizadeh M, Anderson J, Novitsky YW (2016) The use of Vicryl mesh in a porcine model to assess its safety as an adjunct to posterior fascial closure during retromuscular mesh placement. Hernia 20:289–295CrossRefGoogle Scholar
  16. 16.
    Winder JS, Majumder A, Fayezizadeh M, Novitsky YW, Pauli EM (2018) Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation. Hernia 22:303–309CrossRefGoogle Scholar
  17. 17.
    Augenstein VA, Colavita PD, Wormer BA et al (2015) CeDAR: Carolinas equation for determining associated risks. J Am Coll Surg 221:S65–S66CrossRefGoogle Scholar
  18. 18.
    Muysoms FE, Miserez M, Berrevoet F et al (2009) Classification of primary and incisional abdominal wall hernias. Hernia 13:407–414CrossRefGoogle Scholar
  19. 19.
    Ventral Hernia Working G, Breuing K, Butler CE et al (2010) Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558CrossRefGoogle Scholar
  20. 20.
    Petro CC, O’Rourke CP, Posielski NM et al (2016) Designing a ventral hernia staging system. Hernia 20:111–117CrossRefGoogle Scholar
  21. 21.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Guideline for Prevention of Surgical Site Infection (1999) Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999(27):97–132CrossRefGoogle Scholar
  22. 22.
    Bueno-Lledo J, Torregrosa A, Ballester N et al (2017) Preoperative progressive pneumoperitoneum and botulinum toxin type A in patients with large incisional hernia. Hernia 21:233–243CrossRefGoogle Scholar
  23. 23.
    Stoppa RE (1989) The treatment of complicated groin and incisional hernias. World J Surg 13:545–554. CrossRefGoogle Scholar
  24. 24.
    Stoppa RE (2003) Wrapping the visceral sac into a bilateral mesh prosthesis in groin hernia repair. Hernia 7:2–12Google Scholar
  25. 25.
    Robin A, Blazquez Hernando L, López-Monclús J et al (2018) How we do it: down to up posterior components separation. Langenbecks Arch Surg 403(4):539–546CrossRefGoogle Scholar
  26. 26.
    von Elm E, Altman DG, Egger M et al (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 147:573–577CrossRefGoogle Scholar
  27. 27.
    Muysoms FE, Deerenberg EB, Peeters E et al (2013) Recommendations for reporting outcome results in abdominal wall repair: results of a consensus meeting in Palermo, Italy, 28–30 June 2012. Hernia 17:423–433CrossRefGoogle Scholar
  28. 28.
    Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196CrossRefGoogle Scholar
  29. 29.
    Petro CC, Nahabet EH, Criss CN et al (2015) Central failures of lightweight monofilament polyester mesh causing hernia recurrence: a cautionary note. Hernia 19:155–159CrossRefGoogle Scholar
  30. 30.
    Booth JH, Garvey PB, Baumann DP et al (2013) Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 217:999–1009CrossRefGoogle Scholar
  31. 31.
    Giordano S, Garvey PB, Baumann DP, Liu J, Butler CE (2017) Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: a propensity score analysis. Surgery 161:499–508CrossRefGoogle Scholar
  32. 32.
    Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE (2017) Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg 224:341–350CrossRefGoogle Scholar
  33. 33.
    Garcia-Urena M, Lopez-Monclus J, Blazquez Hernando L, et al (2016) Giant bilateral subcostal incisional hernia solved by rectromuscular repair and transversus abdomins release. In: Ciné-Med, Inc. Accessed 15 May 2018
  34. 34.
    Ross SW, Oommen B, Huntington C et al (2015) National outcomes for open ventral hernia repair techniques in complex abdominal wall reconstruction. Am Surg 81:778–785Google Scholar
  35. 35.
    Lopez-Cano M, Armengol M, Quiles MT et al (2013) Preventive midline laparotomy closure with a new bioabsorbable mesh: an experimental study. J Surg Res 181:160–169CrossRefGoogle Scholar
  36. 36.
    Veyrie N, Poghosyan T, Corigliano N, Canard G, Servajean S, Bouillot JL (2013) Lateral incisional hernia repair by the retromuscular approach with polyester standard mesh: topographic considerations and long-term follow-up of 61 consecutive patients. World J Surg 37:538–544. CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Miguel Ángel García-Ureña
    • 1
    Email author
  • Javier López-Monclús
    • 2
  • Diego Cuccurullo
    • 4
  • Luis Alberto Blázquez Hernando
    • 1
  • Providencia García-Pastor
    • 3
  • Stefano Reggio
    • 4
  • Elena Jiménez Cubedo
    • 2
  • Carlos San Miguel Méndez
    • 1
  • Arturo Cruz Cidoncha
    • 1
  • Alvaro Robin Valle de Lersundi
    • 1
  1. 1.Department of SurgeryHenares University Hospital, Francisco de Vitoria UniversityCoslada, MadridSpain
  2. 2.Department of SurgeryPuerta de Hierro University HospitalMadridSpain
  3. 3.Department of SurgeryLa Fe University HospitalValenciaSpain
  4. 4.Department of SurgeryMonaldi Azienda Ospedaliera dei ColliNaplesItaly

Personalised recommendations