Abandoning mesh "overlap" in favor of "width" and its importance in open retromuscular midline incisional hernia repair: a nationwide database study.

Purpose: Recurrence after open incisional hernia repair remains an issue. Where the mesh preferably is placed in a retrorectus position, it is undetermined what the optimal mesh overlap is. This study aimed to assess the effect of mesh width on long-term recurrence after open incisional hernia repair.

Method: The Danish Ventral Hernia Database was merged with The Danish National Patients Registry allowing a 100% follow-up. From 2011 to 2023 we included patients who underwent elective incisional hernia repair with vertical incision, retromuscular mesh placement, and linea alba reconstruction. Mesh and hernia size and repair type were registered. Kaplan-Meier plots showed cumulative incidences of operation for hernia recurrence over a 5-year period. Possible confounders were included in Cox proportional hazard and logistic regression analyses.

Results: We included 1,539 patients. Mean (sd) age was 61.2 (12.4) years, 46.2% were females. Mean horizontal defect size was 8.4 (4.2) cm. Seventy-two (4.7%) patients underwent reoperation within 90 days and 112 (7.3%) developed recurrence (median follow-up 3.8 (IQR 1.8-6.1) years). Mesh width of 10-15 cm was associated with significantly decreased risk of operation for recurrence compared to both smaller and larger sizes (HR 0.38, CI 0.16-0.90, P = 0.029). Interestingly, fascial defect width was not associated with recurrence risk when adjusting for mesh width.

Conclusion: A 10-15 cm mesh width is associated with lower risk of recurrence for patients undergoing elective open midline retromuscular incisional hernia repair: this "golden mean" should be of aim rather than "too little" or "as much as possible".