Mesh exposure after ventral hernia repair with onlay biosynthetic mesh: a retrospective review of associated risk factors and management strategies.

Background: Although intraperitoneal and retromuscular mesh placement in ventral hernia repair (VHR) are associated with lower recurrence rates, the onlay plane remains a well-established option for certain clinical scenarios. A knowledge gap remains regarding resorbable biosynthetic onlay mesh and mesh exposure. We aim to determine exposure rate, risk factors, and treatment options.

Study design: A single-center, two-surgeon retrospective review was performed examining patients who underwent VHR with onlay, Poly-4-hydroxybutyrate (P4HB) mesh from 2015 to 2021. Demographics, operative characteristics, outcomes, and mesh exposure management were analyzed.

Results: Of 346 patients, 15 (4.3%) experienced mesh exposure. The mean age was 53 years and BMI of 33.6 kg/m². Patients were majority ASA class 3 (65%), female (64.2%), and averaged a defect size of 307.9 ± 235.2 cm². Independent risk factors included diabetes (AOR = 4.3,CI 1.5-12.5;p < 0.005) and COPD (AOR = 5.2,CI 1.3-21.8;p = 0.02). Mesh exposures were identified as outpatient (20%) or intraoperative (80%). All underwent operative debridement, in which nine were managed with skin reclosure, two with partial closure, and four healed by secondary intention. Five patients required excision of unincorporated mesh. Four patients required further debridement from chronic surgical site occurrences; however, all mesh exposure patents healed after a mean of 260.8 ± 313.2 days and retained original mesh. The recurrence rate was 6.7% for mesh exposure patients.

Conclusion: When faced with mesh exposure, resorbable biosynthetic mesh placed in onlay fashion was retained in all patients. Patients with a history of diabetes or COPD have increased risk of mesh exposure and should be counseled.