Sublay Retromuscular & Inlay Mesh Hernia Repair

Mesh placement in ventral hernia repair is classified by anatomic plane: onlay (above the anterior fascia), inlay (interposition within the defect), sublay (between rectus muscle and posterior fascia or pre-peritoneal), and intraperitoneal (in contact with viscera). Sublay placement, particularly retromuscular (Rives-Stoppa technique) and pre-peritoneal positioning, has emerged as the gold standard due to mechanical force distribution and lower complication rates.

Retromuscular sublay mesh placement involves opening the posterior rectus sheath, creating a retro-rectus space between the rectus muscle and posterior sheath, and placing wide-overlap mesh (5-7 cm beyond defect edges) before posterior sheath closure. The Rives-Stoppa repair has recurrence rates as low as 4-8% in long-term series. Pre-peritoneal placement extends the dissection below the arcuate line into the pre-peritoneal plane.

Inlay mesh — bridging the defect at fascial level without underlay or overlay coverage — has fallen out of favor due to high recurrence rates (15-30%) and is reserved only for select cases without primary fascial closure option. Mesh selection includes lightweight macroporous synthetic (polypropylene), composite intraperitoneal mesh, or biologic mesh in contaminated fields. Recurrence depends on adequate overlap, mesh fixation, fascial closure, and patient optimization.