Hernia mesh placement

Each year, 70-82% of hernia repair surgeries performed in the United States use some type of mesh. The widespread use of hernia mesh in surgeries to fix hernias is attributed to their lower risk of causing hernia recurrence.

This complication, however, is still possible with the use of these medical devices. In fact, these implants have also been causing several serious injuries and complications since they were made available on the market and implanted in millions of people.

When these complications occur, mesh revision surgery may be necessary. Needless to say, this repeat surgery can be more complicated and can present additional risks to the patient.

Several hernia mesh lawsuits have been filed by patients against the manufacturers of these devices. According to plaintiffs, they suffered from serious and at times life-threatening injuries because the mesh can fail due to design defects.

Another common yet major complication that can occur with mesh repair is hernias coming back, also known as hernia recurrence. Mesh placement has been considered as one of the factors that may reduce this occurrence.

Read on to learn more about the basic types of hernia mesh placement and how it can possibly affect your hernia surgery and even the procedure needed to remove it in case it fails.

What is mesh placement and why is it important?

The different types of mesh placement are techniques that surgeons use to place the surgical mesh in a certain layer of tissue on your body. These procedures are often used during a ventral hernia repair.

A ventral or abdominal hernia is a bulge of tissues through a weakness or gap within your abdominal wall muscles. Some specific types of ventral hernias are umbilical and incisional hernia.

A ventral hernia doesn’t go away or get better on its own. Therefore, it requires surgery to be repaired. In fact, untreated ventral hernias can get bigger and may worsen over time.

During a ventral hernia surgery, your surgeon has to go through several layers of tissue before they can repair the hole or defect in your abdominal wall. This way, your intestine or other abdominal tissue won’t bulge through the wall again.

These layers of tissue create several places where surgical mesh can be placed during a hernia repair. Each placement or mesh position, however, also presents a different set of benefits and risks for the patient.

Mesh placement is important when your surgeon uses a mesh implant to fix your hernia. This is true regardless of the type of hernia that was repaired.

Types of Mesh Placement

The three basic types of mesh placement include:

  • Onlay mesh placement
  • Inlay mesh placement
  • Underlay mesh placement

Over the years, experts have been debating about which mesh placement is the most ideal. Several studies, reviews, and meta-analyses have investigated this topic as well. However, there’s still no clear consensus on which of the three is the ideal location for the hernia mesh.

After all, each type of placement has its own function, advantages, and disadvantages. Furthermore, the placement of the mesh can also influence how the mesh is integrated into the tissues, the strength of the repair and the abdominal wall, and the reaction that can take place between the mesh and the tissue.

Onlay Mesh Placement

Onlay mesh placement is one of the procedures used for hernia repair. The strength layers of the abdominal wall are called fascia. When someone has a hernia, that patient has a hole or defect in the fascia.

With the onlay technique, the surgical mesh is positioned above the layer of fascia in front of the rectus muscles. The rectus muscle is also referred to as the abdominal muscle, or simply the abs muscle.

In this procedure, the surgeon creates a skin flap by dissecting apart the skin and tissue over this layer of fascia.

The hernia is closed with sutures and the mesh is fixed to the pocket of tissue between the tissue and the fascia. This method can be used to close both smaller and larger hernia defects or openings.


Some benefits of this technique include:

  • The mesh is placed outside of the abdominal cavity, which decreases the risk of bowel injuries
  • Patients seem to experience less pain
  • It is largely applicable for atypical hernias, which are hernias located near the abdominal wall margins.


Although the onlay mesh placement is relatively easy to perform, it also has some disadvantages. It’s worth noting that there are blood vessels in the skin that go through the section that’s dissected apart. Naturally, these blood vessels are going to be affected to a certain degree during this operation.

This is especially true and should be an utmost concern for patients who have had abdominal operations or aortic surgery prior to mesh repair.

Other disadvantages of this technique include:

  • Higher rates of infection and recurrence
  • Wound infection can travel to the mesh, infecting it as well
  • A great amount of suturing is required to secure the mesh in the fascia
  • There is an increased risk of developing seroma, a buildup of fluid under the skin.
  • Individuals who smoke and have to undergo this operation are at an increased risk of wound complications and the need for additional surgery.

Inlay Mesh Placement

The inlay procedure, also known as the interposition or bridging technique, doesn’t close the hernia but instead places the mesh between the edges of the fascia where the hernia defect is.

In other words, this approach doesn’t actually close the gap. Rather, sutures are used to place the mesh on the edges of the gap in order to bridge the defect.

Despite evidence that suggests the importance of sewing the hernia defect closed and making use of mesh to support this closure, several surgeons used to perform the bridging technique through a laparoscopic hernia repair.

The inlay mesh placement is best used on small gaps created by hernias.


  • It is a minimally invasive approach
  • Because less mesh is used to bridge the small gaps made by hernias, there’s also a decreased risk of infection and seroma formation.


  • When used over larger defects, the risk of recurrence, seroma, and infection also increases
  • If the technique is used on a larger gap, the increased pressure against the mesh can also result in a recurrent hernia

In a review of 20 studies that involved 821 patients, the overall infection rate with the inlay mesh placement was 12 percent. Furthermore, the rates of hernia recurrence with this approach was the highest among the three most common types of mesh positions at 21.6 percent three years following surgical repair with hernia mesh.

Underlay Mesh Placement

Surgical mesh is said to be in the underlay position when it is placed inside the peritoneal lining of the abdominal cavity. It can also be outside of the abdominal cavity but behind the layer of fascia at the back of the muscles.

In this procedure, the sutures are evenly used to position the mesh to close the gap.


  • Having the peritoneum between the mesh and the intestines decreases the risk of bowel injuries
  • Less pressure against the hernia mesh means less risk of recurrence
  • Decreased risk of seroma formation and infection


The disadvantages of this method can mainly be seen in how it’s done. This placement procedure is not as easy as the onlay and inlay techniques.

Some of its cons include:

  • It can be hard to determine how much space could be allotted for the mesh
  • It can be difficult to suture the mesh in place as it’s done from underneath the fascia.

In the same study mentioned above, the underlay technique was noted to have a high infection rate of around 17.7 percent and a low recurrence rate of 10.9 percent at two years.

However, the majority of these procedures were done through open surgery. Therefore, newer and minimally invasive procedures nowadays may largely change these results.

Which mesh placement is the most ideal for patients?

As mentioned, the topic of which mesh position is the most ideal is still an ongoing debate in the surgical community.

There are several factors, however, that may help your surgeon decide which type of mesh placement is right for you. These factors include:

  • Size of the hernia
  • Gap created by the hernia
  • Some preexisting conditions that you might have
  • Your overall health
  • The preference of your surgeon

Your surgeon should discuss with you which technique is the most suitable for your condition. It will also help to have your doctor explain to you why they prefer using a certain method.

Make sure to also ask about the possible risks and complications for each placement procedure.

The Bottom Line

There are three basic types of mesh placement that surgeons use to fix the device onto its designated position. These are the onlay, inlay, and underlay mesh placement methods.

It’s important for patients to be well-informed about these techniques because each method presents a different set of risks and benefits for them.

The topic of which mesh position is the most ideal is still up for debate among the surgical community. There are several factors that your surgeon may take into consideration when choosing which mesh placement technique will be used for your operation.

It’s best to ask your surgeon about the benefits and potential risks of the approach they will be using.

What You Can Do

Doctors perform more than a million hernia surgeries each year in the U.S. A large percentage of these procedures are performed with hernia mesh.

Since the approval of these devices, however, they have caused severe complications in patients that even needed revision surgery to fix.

Plaintiffs who have filed hernia mesh lawsuits also claim that the injuries and side effects they experienced were due to these devices having design defects.

If you or a loved one suffered from injuries after receiving a hernia mesh implant, you may qualify for compensation. Contact us today if you want to join the legal battle against hernia mesh manufacturers.

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