Laparoscopic transperitoneal sublay mesh repair: a newtechnique for the cure of ventral and incisional hernias

Alexander Daniel Schroeder • Eike Sebastian Debus •

Michael Schroeder • Wolfgang Matthias Johann Reinpold

Received: 19 March 2012 / Accepted: 3 July 2012 / Published online: 6 September 2012

� Springer Science+Business Media, LLC 2012

Abstract

Background Incisional hernia is a frequent complication

after abdominal surgery. Today open sublay mesh repair

and the laparoscopic intraperitoneal onlay mesh repair are

the most widely used techniques for its cure. We developed

a laparoscopic transperitoneal sublay mesh repair for the

treatment of small- and medium-size ventral and incisional

hernias. Outcomes of the new technique and the Rives–

Stoppa repair were compared.

Methods This prospective cohort study with a control

group involved 93 patients. Between 2008 and 2010, 43

patients underwent the laparoscopic transperitoneal sublay

mesh repair. During the same period of time, a control

group of 50 patients underwent an open sublay repair after

Rives and Stoppa. In 2011, all patients were invited for

follow-up. This included pain assessments and physical

examinations with use of ultrasound.

Results The two groups were comparable in terms of

patient characteristics and hernia data. The operating time

was slightly longer for the laparoscopic technique. The

hospital stay was shorter in the laparoscopy group. There

was less chronic pain in the laparoscopy group, but this

difference was not statistically significant. There was no

significant difference in postoperative complications, use

of analgetics, foreign body sensation, and paresthesia

between the two groups. We found one long-term hema-

toma in the laparoscopy group and one seroma in the open

group. In this series, there were no recurrences and no

wound infections.

Conclusions Our initial results indicate that the new

laparoscopic transperitoneal sublay mesh repair is a safe

and effective method for the treatment of small- and

medium-size ventral and incisional hernias.

Keywords New technique � Laparoscopic repair � Sublay

repair � Ventral hernia � Incisional hernia

The development of an incisional hernia is one of the most

common complications after abdominal surgery. The

incidence of this complication is approximately 10–20 %

[1–4]. Suture repair of primary and incisional abdominal

wall hernia is reported to have a recurrence rate of

approximately 25–63 %. Mesh repair is reported to have a

lower recurrence rate of 2–32 % [5–10]. For the Rives–

Stoppa repair, retromuscular mesh placement is performed

via an open approach [10, 11]. Today, it is the most widely

used technique for the treatment of abdominal wall hernias

[12]. In recent years, the laparoscopic intraperitoneal onlay

mesh (IPOM) repair has become increasingly popular. In

the literature, laparoscopic IPOM repair is associated with

similar recurrence rates, longer operating time, and fewer

infections compared with open mesh repair [13–22]. Nev-

ertheless, the laparoscopic IPOM repair requires intra-

peritoneal mesh placement with a higher risk for adhesions,

fistulas, and bowel damage. It is widely accepted that the

sublay position, i.e., preperitoneal or retromuscular mesh

position, is the most advantageous of abdominal wall

A. D. Schroeder

University of Hamburg, University Medical Center

Hamburg-Eppendorf, Hamburg, Germany

e-mail: alexander.d.schroeder@gmail.com

E. S. Debus

Department of Vascular Medicine, University Heart Center

Hamburg-Eppendorf, Hamburg, Germany

M. Schroeder � W. M. J. Reinpold (&)

Department of Surgery, Wilhelmsburg Gross-Sand Hospital,

Gross-Sand 3, 21107 Hamburg, Germany

e-mail: w.reinpold@gross-sand.de

123

Surg Endosc (2013) 27:648–654

DOI 10.1007/s00464-012-2508-9

and Other Interventional Techniques

hernia repairs. We developed a new laparoscopic trans-

peritoneal sublay mesh repair for the treatment of ventral

and incisional abdominal wall hernias. The new technique

was analyzed prospectively with a control group that was

treated with an open sublay repair.

Materials and methods

Patients

Between January 2008 and December 2010, 43 patients

underwent the new laparoscopic transperitoneal sublay

technique for repair of primary or incisional abdominal

wall hernia. During the same period of time, a control

group of 50 patients was treated with an open sublay mesh

repair according to Rives and Stoppa. All operations were

performed in our institution. The following variables of this

prospective study were documented: patient age, gender,

comorbidities, previous operations, preoperative pain, size

of the hernia defect, size and type of the prosthetic mesh

used, operating time, length of hospital stay, and intraop-

erative and postoperative complications. All patients were

invited for follow-up in our institution. Postoperative pain

([6 months after surgery) was assessed by using the Visual

Analogue Scale. A physical examination and ultrasound of

the abdominal wall were performed to evaluate for com-

plications, such as seroma, hematoma, dislocation, or

bulging of the mesh, and hernia recurrence.

Laparoscopic transperitoneal sublay mesh repair

We developed a laparoscopic transperitoneal sublay mesh

repair. With the patient in the supine position, three trocars

are placed in the left lateral abdominal wall. The first

10-mm trocar is placed immediately below the costal

margin in the anterior axillary line. Pneumoperitoneum

with 10 mmHg is applied. A 30� laparoscope is used.

Under vision, a second 10-mm trocar and a 5-mm trocar

are inserted (Fig. 1). The hernia is visualized and adhesi-

olysis is performed if necessary. Lateral from the hernia, a

vertical 10- to 15-cm incision through peritoneum and

posterior rectus sheath is performed by using an ultrasound

scalpel. The dissection is performed ventral to the posterior

rectus sheath under protection of the epigastric vessels. At

the medial border of the rectus muscle, the posterior rectus

sheath is incised and dissection continues in the preperi-

toneal plane (Fig. 2). The hernia sac is visualized and

mobilized. At the medial border of the right rectus muscle,

the right posterior rectus sheath is vertically incised. The

retromuscular dissection is performed to the lateral border

of the right rectus muscle. A low tension hernia defect

closure with 0-PDS sutures by intracorporeal knotting is

attempted (Fig. 3). The circumferential dissection is per-

formed with a radius of at least 6 cm around the hernia

defect. Defects of the peritoneum are closed by absorbable

3-0 sutures. A standard polypropylene mesh previously

impregnated with gentamycin (80 mg) is inserted via a

10-mm port and placed in the retrorectal position on both

sides (Fig. 4). The posterior rectus sheath remains open. In

the area of the linea alba, the mesh lies in the preperitoneal

position. The mesh is fixated circumferentially with inter-

rupted 2-0 absorbable sutures, laterally to the posterior

rectus sheath, and in the midline to the linea alba. Alter-

natively a self-fixating mesh can be used. The peritoneum

with the left posterior rectus sheath is closed with a running

2-0 absorbable suture (Fig. 5). In all cases, the mesh is

completely covered by peritoneum. The 10-mm trocar

incisions are closed with interrupted sutures.

Fig. 1 Placement of trocars and marking of hernia (inner circle) with

overlap of 6 cm (outer circle)

Fig. 2 Intraoperative view of retromuscular plane and medial border

of the left rectus muscle

Surg Endosc (2013) 27:648–654 649

123

Open sublay repair

The open sublay repair was performed as described by Jean

Rives and Rene Stoppa [10, 11]. Skin disinfection and

wound rinsing with gentamicin solution were applied every

30 min as described by Maximo Deysine [23]. The incision

is created above the hernia defect. Large hernia sacs are

removed. The hernia defect is visualized. In the area of the

linea alba, the dissection is performed preperitoneally and

laterally in the retrorectal plane. The peritoneum is closed

completely. To avoid tension, the posterior rectus sheath

remains open. Range of dissection, type and size of mesh,

mesh fixation, and defect closure were the same as in the

laparoscopic transperitoneal sublay mesh repair.

Statistical analysis

For statistical analysis, we used SPSS 16 for Windows. For

the comparison of our data, we used Fisher’s exact test and

t test. Differences were considered significant at P \ 0.05.

Results

Patient characteristics

Patient characteristics are shown in Table 1. There was no

difference between the two groups for gender, age, or

comorbidities (P [ 0.05). There were 27 and 33 (62.8 vs.

66 %, P = 0.955) incisional hernias in the laparoscopy and

open groups, respectively. The most common comorbidi-

ties were morbid obesity (BMI [ 40), hypertension, and

diabetes (44.2 vs. 38 %, P = 0.673). All fascial defects

were midline hernias, mostly located in the epigastric or

umbilical region (P = 0.788). The number of multiple

defects was similar in both groups (32.6 vs. 30 %,

P = 0.825).

Perioperative findings

Perioperative information is shown in Table 2. The hernia

sizes in both groups were comparable (mean, 23.8 vs.

24.5 cm2, P = 0.976). Likewise, the meshes used were

similar in size for both groups (mean, 404.6 vs. 409.2 cm2,

P = 0.927). We measured the hernia sizes by using the

diameter as a variable for primary abdominal wall hernias

and width and length for incisional abdominal wall hernias.

Surgical needles were inserted transcutaneously to mark

the edges of the fascial defects. This allowed us to measure

the size of the hernias extra-abdominally in accordance

Fig. 3 Schematic horizontal

section showing the lateral

vertical incision of the

peritoneum and posterior rectus

sheath, the retromuscular

dissection (dotted line), and

closure of a midline defect by

intracorporeal knotting

Fig. 4 Positioning of mesh on both sides lateral in the retromuscular

position, median preperitoneally

Fig. 5 Closure of peritoneum and posterior rectus sheath

650 Surg Endosc (2013) 27:648–654

123

with the European Hernia Society Classification of

abdominal wall hernias [24]. The average operating time

was slightly longer for the new laparoscopic technique than

for the open Rives-Stoppa repair (mean, 125 vs. 115 min,

P = 0.13). However, operating time was reduced by

20 min when self-fixating meshes were used. There were

no conversions from laparoscopic to open repair. For all

repairs, we used standard polypropylene mesh (Prolene,

Johnson and Johnson). Hospital stay was shorter in the

laparoscopy group (mean, 3.4 vs. 4.0 days, P = 0.295). In

this study, there were no intraoperative complications. In

the laparoscopy group, there were a total of three

complications during the first 30 days after surgery (7 %):

two hematomas and one umbilical skin necrosis. The

umbilical skin necrosis required excision of the necrotic

area under local anesthesia with primary skin closure. The

hematomas were treated conservatively. We recommend

performing the dissection of the hernia sack very carefully.

Damage to the overlaying skin layers caused by electro-

coagulation should be avoided. In the open group, there

were four postoperative complications (8 %): three hema-

tomas and one hypertensive crisis. The hematomas did not

require reoperation.

Follow-up

The follow-up outcome is shown in Table 3. In the lapa-

roscopy group, complete sets of data were obtained from

40 of 43 patients (93 %). In the open group, complete data

sets were obtained from 46 of 50 patients (92 %). The

average follow-up times were 17 and 18 months in the

laparoscopy and open groups, respectively (P = 0.792).

Between the two groups, there was no significant differ-

ence for preoperative pain (45 vs. 56.5 %, P = 0.262) and

postoperative chronic pain (12.5 vs. 13.0 %, P = 1). There

was no difference in analgesic use, pressure-related pain,

foreign body sensation, or paresthesia between the two

Table 1 Patient characteristics

Variable Laparoscopy group Open group P value

No. of patients 43

(100 %)

50

(100 %)

Sex 1.0

Female 16

(37.2 %)

19

(38 %)

Male 27

(62.8 %)

31

(62 %)

Age (year)a 57

(29–83)

61

(39–84)

0.18

Comorbidities 19

(44.2 %)

19

(38 %)

0.673

Type of hernia 0.955

Primary 16

(37.2 %)

17

(34.0 %)

Incisional 23

(53.5 %)

27

(54.0%)

Recurrent 4

(9.3 %)

6

(12.0 %)

Location of hernia 0.788

Midline

Subxyphoidal – 1

(2 %)

Epigastric 32

(74.4 %)

33

(66 %)

Umbilical 10

(23.3 %)

13

(26 %)

Infraumbilical 1

(2.3 %)

1

(2 %)

Suprapubic – 2

(4 %)

Type of defect 0.825

Single 29

(67.4 %)

35

(70 %)

Multiple 14

(32.6 %)

15

(30 %)

a Values are mean (range)

Table 2 Perioperative findings

Variable Laparoscopy

group

Open

group

P value

Hernia size (cm2)a 23.8

(4–100)

24.5

(4–132)

0.976

Mesh size (cm2)a 404.6

(150–912)

409.2

(64–900)

0.927

Operating time (min)a 125

(55–195)

115

(50–180)

0.13

Hospital stay (days)a 3.4

(1–7)

4.0

(1–13)

0.295

Type of mesh

Polypropylene (PP) 40

(93 %)

50

(100 %)

PP ? PLA microgrips 3

(7 %)

–

Complications (30-

day)

1

Hematoma 2

(4.7 %)

3

(6 %)

Others 1b

(2.3 %)

1c

(2 %)

a Values are mean (range)b Reoperation of umbilical skin necrosisc Hypertensive crisis

Surg Endosc (2013) 27:648–654 651

123

groups (P [ 0.05). During the physical examinations, we

found one long-term hematoma in the laparoscopy group

and one seroma in the open group, no dislocation or

bulging of the mesh, no wound infection, and no hernia

recurrence.

Discussion

In this paper, the authors describe a new laparoscopic

transperitoneal sublay mesh repair for the cure of ventral

and incisional hernias. This prospective cohort study

describes the initial results of the novel technique com-

pared with a control group that was treated with the open

sublay repair. The laparoscopic transperitoneal approach

via the left flank for the sublay repair of abdominal wall

hernias has not been described earlier. Currently, laparo-

scopic IPOM repair is the only commonly used laparo-

scopic technique for abdominal wall hernia repair. There

are only very few reports on endoscopic sublay repair of

abdominal wall hernias [25]. A disadvantage of the lapa-

roscopic IPOM technique is the intraperitoneal position of

the mesh, which may lead to adhesions, fistula formation,

and further damage of the bowel and other viscera. For the

prevention of these complications, expensive compound

meshes with antiadhesive properties have to be used.

Compared with conventional polypropylene and polyester

meshes, many of the available compound meshes seem to

reduce adhesion formation at least in the animal model

Table 3 Follow-up outcome

Variable Laparoscopy

group

Open

group

P value

No. of patients 40

(93 %)

46

(92.0 %)

Follow-up time (months)a 17

(6–38)

18

(6–38)

0.792

Preoperative pain 0.262

Yes

VAS 1-3 2

(5 %)

9

(19.6 %)

VAS 4-6 9

(22.5 %)

10

(21.7 %)

VAS 7-10 7

(17.5 %)

7

(15.2 %)

No 22

(55 %)

20

(43.5 %)

Postoperative pain

([6 months)

1

Yes

VAS 1-3 3

(7.5 %)

3

(6.5 %)

VAS 4-6 – 1

(2.2 %)

VAS 7-10 2

(5 %)

2

(4.3 %)

No 35

(87.5 %)

40

(87 %)

Pressure-related pain 1

Yes

VAS 1-3 4

(10 %)

4

(8.7 %)

VAS 4-6 2

(5 %)

3

(6.5 %)

VAS 7-10 – 1

(2.2 %)

No 34

(85 %)

38

(82.6 %)

Analgesic use 0.756

Yes

Infrequently 4

(10 %)

4

(8.7 %)

Frequently – 2

(4.3 %)

Daily 1

(2.5 %)

2

(4.3 %)

No 35

(87.5 %)

38

(82.6 %)

Foreign body sensation 1

Yes 5

(12.5 %)

5

(10.9 %)

Table 3 continued

Variable Laparoscopy

group

Open

group

P value

No 35

(87.5 %)

41

(89.1 %)

Paresthesia 1.0

Yes 5

(12.5 %)

5

(10.9 %)

No 35

(87.5 %)

41

(89.1 %)

Hematoma 0.465

Yes 1

(2.5 %)

–

No 39

(87.5 %)

46

(100 %)

Seroma 1

Yes – 1

(2.2 %)

No 40

(100 %)

45

(97.8 %)

a Values are mean (range)

652 Surg Endosc (2013) 27:648–654

123

[26]. However, the problem of a foreign body inside the

abdominal cavity has not been solved yet. Additionally, in

the laparoscopic IPOM repair the mesh has to be fixed very

intensively with many non- or long-term absorbable

sutures, tacks, or staples, which again may lead to adhe-

sions, fistula formation and other damage to the bowel and

acute and chronic pain. This problem of mesh fixation

might explain the literature finding that the laparoscopic

IPOM repair does not lead to less acute and chronic pain

compared with open mesh repair [13, 20]. Another disad-

vantage of the laparoscopic IPOM repair is that in most of

the cases the hernia defect is not closed and only bridged

by the mesh [12]. Accordingly, the laparoscopic IPOM

repair relies on the strength of the mesh and its fixation

[13]. Another flaw is that the hernia sack stays in situ and

can lead to chronic seroma formation. The open sublay

repair with retromuscular mesh placement avoids direct

contact between intestine and synthetic prosthesis. It allows

easy dissection and removal of the hernia sack and

reconstruction of the abdominal wall with defect closure. A

disadvantage of open sublay repair is a significantly higher

infection rate, which has been reported in the literature

[13–22]. The laparoscopic transperitoneal sublay technique

combines the advantages of the open sublay repair and

laparoscopic IPOM repair. It allows the use of standard

polypropylene and polyester meshes. Hospital stay is

reported to be shorter for laparoscopic hernia repair than

for open repair [13–22]. In our study, there was a trend of

shorter hospital stay in the laparoscopy group (mean, 3.4

vs. 4.0 days, P = 0.295). Trials measuring postoperative

pain reported similar pain intensity in laparoscopic repair

and open techniques for abdominal wall hernia repair [13,

20]. The meta-analysis by Sauerland et al. shows that data

for chronic pain ([6 months after surgery) is limited and

varying. There are trials that indicate similar chronic pain

in both techniques but trials also report less chronic pain in

laparoscopic repair. In this study, there was no significant

difference in chronic pain between the two groups. Overall

complication rates are reported as being similar or less

frequent in laparoscopic than in open abdominal wall

hernia repair [13–22]. Although, there might be a higher

risk for enterotomy in laparoscopic IPOM repair due to

adhesiolysis [19, 21, 27]. In this study, there was no

intraoperative complication in both groups. Postoperative

complications occurred with equal low frequency in both

groups (7 vs. 8 %, P = 1). Published data about seroma in

laparoscopic or open abdominal wall hernia repair vary

[13, 17, 19, 21], although an early transient seroma is found

frequently in laparoscopic repair [14, 16–18, 20]. Local

hematoma is reported to occur similarly in laparoscopic or

open abdominal wall hernia repair [13, 21]. At the time of

follow-up, one long-term hematoma was found in the

laparoscopy group and one seroma in the open group. The

relatively small number of experiences with the new

technique limits our study. In this series, the laparoscopic

technique had the same outcome as the open technique. All

patients included in this study benefit from the fact that

there were no wound infections or recurrences at the time

of follow-up. The laparoscopic transperitoneal sublay mesh

repair is a safe and effective technique for the treatment of

small- and medium-size ventral and incisional hernias. It

combines the advantages of the lap. IPOM repair and open

sublay repair. In our hands, it is a technically demanding

but safe alternative procedure for the repair of small- and

medium-size ventral and incisional hernias.

Acknowledgments The authors thank Dr. Dan N. Tran for his

suggestions on preparing the manuscript.

Disclosures Drs. Eike Sebastian Debus, Michael Schroeder, Wolf-

gang Matthias Johann Reinpold, and Alexander Daniel Schroeder

have no conflicts of interest or financial ties to disclose.

References

1. Hoer J, Lawong G, Klinge U, Schumpelick V (2002) Factors

influencing the development of incisional hernia. A retrospective

study of 2,983 laparotomy patients over a period of 10 years.

Chirurg 73:474–480

2. Franchi M, Ghezzi F, Buttarelli M, Tateo S, Balestreri D, Bolis P

(2001) Incisional hernia in gynecologic oncology patients: a

10-year study. Obstet Gynecol 97:696–700

3. Mudge M, Hughes LE (1985) Incisional hernia: a 10-year pro-

spective study of incidence and attitudes. Br J Surg 72:70–71

4. Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM (2002)

Wound complications of laparoscopic vs open colectomy. Surg

Endosc 16:1420–1425

5. Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege

RV, Turnage RH (2000) Factors affecting recurrence following

incisional herniorrhaphy. World J Surg 24:95–100

6. Luijendijk RW, Hop WC, van den Tol MP, De Lange DC, Bra-

aksma MM, Ijzermans JN, Boelhouwer RU, De Vries BC, Salu

MK, Wereldsma JC, Bruijninckx CM, Jeekel J (2000) A com-

parison of suture repair with mesh repair for incisional hernia.

N Engl J Med 343:392–398

7. Liakakos T, Karanikas I, Panagiotidis H, Dendrinos S (1994) Use

of Marlex mesh in the repair of recurrent incisional hernia. Br J

Surg 81:248–249

8. Toniato A, Pagetta C, Bernante P, Piotto A, Pelizzo MR (2002)

Incisional hernia treatment with progressive pneumoperitoneum

and retromuscular prosthetic hernioplasty. Langenbecks Arch

Surg 387:246–248

9. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk

EG, Jeekel J (2004) Long-term follow-up of a randomized con-

trolled trial of suture versus mesh repair of incisional hernia. Ann

Surg 240:578–583

10. Stoppa RE (1989) The treatment of complicated groin and inci-

sional hernias. World J Surg 13:545–554

11. Rives J, Pire JC, Flament JB, Convers G (1977) Treatment of

large eventrations (apropos of 133 cases). Minerva Chir 32:

749–756

12. Schumpelick V, Binnebosel M, Conze J (2010) Clinical results

after open mesh repair. In: Schumpelick V, Fitzgibbons RJ (eds)

Hernia repair sequelae. Springer, New York, pp 227–232

Surg Endosc (2013) 27:648–654 653

123

13. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez

M (2011) Laparoscopic versus open surgical techniques for

ventral or incisional hernia repair. Cochrane Database Syst Rev.

doi:10.1002/14651858.CD007781.pub2, March 16, 2011

14. Park A, Birch DW, Lovrics P (1998) Laparoscopic and open inci-

sional hernia repair: a comparison study. Surgery 124:816–821

15. McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SR,

Laycock WS, Birkmeyer JD (2003) A prospective study com-

paring the complication rates between laparoscopic and open

ventral hernia repairs. Surg Endosc 17:1778–1780

16. Lomanto D, Iyer SG, Shabbir A, Cheah WK (2006) Laparoscopic

versus open ventral hernia mesh repair: a prospective study. Surg

Endosc 20:1030–1035

17. Bencini L, Sanchez LJ, Boffi B, Farsi M, Scatizzi M, Moretti R

(2003) Incisional hernia repair: retrospective comparison of lap-

aroscopic and open techniques. Surg Endosc 17:1546–1551

18. Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparo-

scopic repair of ventral hernias: nine years’ experience with 850

consecutive hernias. Ann Surg 238:391–399

19. Kingsnorth A, LeBlanc K (2003) Hernias: inguinal and inci-

sional. Lancet 362:1561–1571

20. Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK (2009)

Laparoscopic versus open repair of incisional/ventral hernia: a

meta-analysis. Am J Surg 197:64–72

21. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A (2009) Meta-

analysis of randomized controlled trials comparing open and

laparoscopic ventral and incisional hernia repair with mesh. Br J

Surg 96:851–858

22. Mason RJ, Moazzez A, Sohn HJ, Berne TV, Katkhouda N (2011)

Laparoscopic versus open anterior abdominal wall hernia repair:

30-day morbidity and mortality using the ACS-NSQIP Database.

Ann Surg 254:641–652

23. Deysine M (1998) Pathophysiology, prevention, and management

of prosthetic infections in hernia surgery. Surg Clin N Am 78:

1105–1115

24. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault

GG, Chelala E, Dietz UA, Eker HH, EL Nakadi I, Hauters P,

Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A,

Simmermacher RKJ, Simons MP, Smietanski M, Sommerling C,

Tollens T, Vierendeels T, Kingsnorth A (2009) Classification of

primary and incisional abdominal wall hernias. Hernia 13:

407–414

25. Miserez M, Penninckx F (2002) Endoscopic totally preperitoneal

ventral hernia repair. Surg Endosc 16:1207–1213

26. Huber A, McCabe GP, Boruch AV, Medberry C, Honerlaw M,

Badylak SF (2012) Polypropylene-containing synthetic mesh

devices in soft tissue repair: a meta-analysis. J Biomed Mater Res

B Appl Biomater 100:145–154

27. LeBlanc KA, Elieson MJ, Corder JM III (2007) Enterotomy and

mortality rates of laparoscopic incisional and ventral hernia

repair: a review of the literature. JSLS 11:408–414

654 Surg Endosc (2013) 27:648–654

123