Hernia

DOI 10.1007/s10029-016-1524-4

LETTER TO THE EDITOR

Defects and donuts: the importance of the mesh:defect area ratio

B. Tulloh1 • A. de Beaux1

Received: 28 February 2016 / Accepted: 29 July 2016

Ó Springer-Verlag France 2016

To the Editor: 3. The forces which oppose eventration—that is, those

that keep the mesh in place—come from mesh fixation
Techniques in laparoscopic ventral and incisional hernia
and tissue ingrowth.
repair (LVIHR) have changed little since Leblanc and
Booth published the first series in 1993 [1] and the bridging
repair they described is still widely practised today. In the
absence of high-quality studies into operative technique, The mathematical argument
much of current practice is based on expert opinion and one
such example is the widespread acceptance that a mesh Pressure can be defined as force per unit area: P = F/A.
overlap of 5 cm in all directions is adequate to minimise This equation can be transformed to F = PA, which
recurrence. This is not the result of research, but a misin- means that for any given P (intra-abdominal pressure), the
terpretation of Leblanc himself who stated, in a 2003 force (F) on the unsupported mesh bridging across the
review of 200 LVIHR, that a 5-cm overlap was better than defect is proportional to the area (A) of the defect. The
3 cm in terms of preventing recurrence [2]. The fact that a larger the defect, the greater the force acting to displace the
greater overlap correlates with reduced recurrence rate has mesh.
been borne out by clinical experience, recently reported by The resistance to the displacing force comes from the
Leblanc again in a meta-analysis of over 100 studies [3], fixation and tissue ingrowth, both of which depend on the
but the old dogma recommending a 5-cm overlap remains area of mesh overlap. The greater the area of mesh in
entrenched [4, 5]. contact with the surrounding tissues, the more tacks and/or
Although we are not aware of any experimental data, a sutures may be used and the greater the degree of tissue
strong mathematical argument can be made to show the ingrowth.
need for a greater mesh overlap with larger hernias. This Consider a round hernia defect of radius r, covered
requires that the following facts are agreed: with a circular mesh of radius R. The area of the defect
is pr2 and the area of the mesh is pR2. The force acting
1. In a bridging repair of a ventral hernia, intra-abdominal
to displace the mesh out through the defect varies with
pressure creates a constant force pushing against the
the area of the defect, or pr2. The force resisting this
unsupported mesh.
displacement varies with the area of mesh overlap, which
2. If unopposed, this force would eventually lead to
is the donut-shaped area defined by (pR2 - pr2). See
eventration of the mesh through the hernia defect.
Fig. 1.
The relative strengths of the displacing forces and the
resisting forces determine whether or not the mesh will
& B. Tulloh migrate through the defect. The ratio of resisting forces
[email protected] to displacing forces is the same as the ratio of the area
of the overlapping mesh-donut to the area of the defect,
1
Royal Infirmary of Edinburgh, 41 Little France Crescent, or
Edinburgh EH16 4SA, UK

123
 Hernia

Fig. 1 a Diagram of mesh Area of mesh available for

overlapping a ventral hernia
defect. The displacing force is Mesh of radius R fixation and tissue ingrowth
proportional to the area of the
defect, pr2. b The ‘‘donut- Defect of radius r
shaped’’ area of mesh that is in
contact with surrounding
tissues. Its area can be expressed
as (pR2 - pr2)

(a) (b)

Resisting forces=displacing forces ¼ ‘‘donut’’ area=defect area is 25/2.75 = 9 times more likely to migrate through the
2 2
¼ ðpR  pr Þ=pr 2 defect.
What is the ‘‘safe minimum’’ mesh:defect area ratio?
¼ ðpR2 =pr 2 Þ  1
This has not been established, but we can estimate it with
common sense. From the earlier example one could infer
The ‘‘-1’’ is easy to explain and easy to ignore. If the
that a mesh:defect area ratio of 36 is adequate but one of 4
mesh has (say) 5 times the radius of the defect, then the
is not. Can we narrow it down? A 15 9 15 cm mesh
mesh area is 25 times that of the defect. However, the area
covering a 5 9 5 cm defect gives a ratio of 9. Many of us
of mesh available for fixation/ingrowth is only 24 times the
who have repaired 5 cm umbilical hernias with a
defect area because of the ‘‘hole in the donut’’.
15 9 15 cm mesh have seen mesh migration as a result
and would now agree that a larger mesh is better. A
20 9 20 cm mesh over the same defect gives a ratio of 16
The mesh:defect area ratio
and is less likely to displace; indeed, the forces resisting
mesh displacement are 16/9 = 1.8 times stronger.
The equation shows that the ratio of forces varies with the
If, for the purposes of this thought experiment, we
ratio of mesh area and defect area—that is, the mesh:defect
accept that a ratio of 16 is around the lower limit of
area ratio. As r (defect size) rises, R (mesh size) must rise
acceptability, there are further implications for a laparo-
proportionally. Thus the length of linear overlap must also
scopic repair. Any mesh with a diameter four times that of
increase, in order to preserve the mesh:defect area ratio and
the defect will have a mesh:defect area ratio of 16, so a
maintain the balance between mesh fixation and mesh
6 9 6 cm defect would require a 24 9 24 cm mesh to
displacement.
achieve this and a 7 9 7 cm defect would require a mesh
Consider a 2 9 2 cm ventral hernia defect. Many sur-
approaching 30 9 30 cm in size. Such meshes are
geons would accept intuitively that placing a 12 9 12 cm
unwieldy to insert, position and fix. Given that there is
mesh over this is likely to remain secure. The overlap is
barely room in the abdomen for a 25 9 25 cm mesh,
5 cm all around and the mesh:defect area ratio in this case
especially laterally where space is required for port entry
is 36. Next consider placing a 20 9 20 cm mesh over a
and camera work and where suture and tack placement can
10 9 10 cm defect. In this case the mesh:defect area ratio
be hazardous, aiming for a mesh:defect area ratio of 16
is 4. Even though the mesh overlap is still 5 cm, experi-
indicates that a 6 9 6 cm defect is about the largest that
enced surgeons would appreciate that this is much more
can be reasonably attempted laparoscopically.
likely to fail. The increased likelihood of mesh displace-
ment can be confirmed mathematically as follows: the
defect in the second example has 5 times the radius of that Discussion
in the first, so the mesh-displacing force is 25 times greater.
However, the larger mesh in is only 1.66 times the radius of The argument proposed here is theoretical. The idea arose
the smaller one so the forces resisting displacement have from established observations that the risk of mesh
only risen by (1.66)2, or 2.75. Accordingly, the larger mesh migration and recurrence is more common with larger

123
Hernia

defects and that greater mesh overlap reduces this risk. eventually cut through and allow the mesh to migrate. With
Thus our theory fits observed facts, although it has not been a strong force such as a sudden cough, this could occur
tested on its own. We are putting it forward here for others very quickly, but with ‘‘normal’’ intra-abdominal pressure
to appraise and evaluate. it typically takes a year or more and is recognised as
We have shown that maintaining a 5-cm overlap pseudorecurrence [7].
regardless of the defect size is illogical. Doing so means
that the mesh:defect area ratio becomes smaller for larger
defects, and mesh displacement becomes more likely. Conclusion
However, this argument is simplistic and overlooks several
important factors that impact on clinical practice. There are still many surgeons who bridge defects without
First, it assumes a bridging repair. Defect closure dra- closure believing that a 5-cm mesh overlap is adequate.
matically alters the array of forces acting on the mesh and This figure was not derived from scientific study and there
should, at least in theory, reduce the risk of mesh dis- is mounting clinical evidence to suggest that larger defects
placement. There is some evidence for this in the literature require more overlap. We have now provided mathematical
[6]. One could argue that defect closure should be a routine confirmation of this concept. We recommend that surgeons
practice, but some defects are frankly impossible to close reflect on their practice: close defects where appropriate,
without undue tension. Partial defect closure may be an consider the mesh:defect area ratio instead of the arbitrary
option in such cases; after all, this would favourably alter 5-cm ‘‘rule’’, and even abandon laparoscopy altogether in
the mesh:defect area ratio. Conversely, one could also favour of open repair when the numbers simply do not add
argue that small defects do not need any closure at all if the up.
mesh is large enough: for example, a 15 9 15 cm mesh
Compliance with ethical standards
over a 1 9 1 cm defect provides a mesh:defect area ratio
of 225. The risk of mesh eventration is vanishingly small. Conflict of interest The Authors declare that they have no conflict of
Would there be any extra benefit here in closing the tiny interest.
defect?
Second, our argument is based on a circular defect in the Ethical approval This article does not contain any studies with
human participants or animals performed by the authors.
midline. Although the underlying principles would still
apply, the forces described in this article would not apply Informed consent None.
directly to elliptical or multiple defects, where the radius to
use in the calculations would be difficult to define.
Peripheral defects are probably different again because References
forces are undoubtedly different in the flanks and close to
bony landmarks. Non-circular meshes also have a different 1. LeBlanc KA, Booth WV (1993) Laparoscopic repair of incisional
abdominal hernias using expanded polytetrafluoroethylene: pre-
‘‘donut’’ shape to consider. liminary findings. Surg Laparosc Endosc 3:39–41
Third, it assumes that the overlapping mesh is smooth 2. LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK (2003)
and flat and fixed to a strong fascial layer. Extraperitoneal Laparoscopic incisional and ventral hernioplasty: lessons learned
fat, and in particular the central strip that is part of the from 200 patients. Hernia 7:118–124
3. LeBlanc K (2016) Proper mesh overlap is a key determinant in
falciform ligament and median umbilical fold, provides a hernia recurrence following laparoscopic ventral and incisional
poor bed for mesh fixation and will reduce the strength of hernia repair. Hernia 20(1):85–99
the mesh–tissue interface. Wrinkles and folds in the mesh 4. Alexander AM, Scott DJ (2013) Laparoscopic ventral hernia
will have a similar effect. repair. Surg Clin North Am 93:1091–1110
5. Bittner R, Bingener-Casey J, Dietz U et al (2014) Guidelines for
Finally, we recognise that mesh migration is a function laparoscopic treatment of ventral and incisional abdominal wall
not only of abdominal pressure but time as well. In a hernias (International Endohernia Society)—Part 2. Surg Endosc
bridging repair, intra-abdominal pressure provides a con- 28:353–379
stant force pushing outward on the unsupported mesh. 6. Nguyen DH, Nguyen MT, Askenasy EP, Kao LS, Liang MK
(2014) Primary fascial closure with laparoscopic ventral hernia
Fixation from sutures, tacks and tissue ingrowth resist this repair: systematic review. World J Surg 38:3097–3104
force, but such fixation to living tissue is a dynamic process 7. Tse G, Stuchfield BM, Duckworth AD, de Beaux AC, Tulloh B
and subject to the ‘‘seton effect’’ over time. Because of the (2010) Pseudo-recurrence following laparoscopic ventral and
constant intra-abdominal pressure, tacks and sutures will incisional hernia repair. Hernia 14:583–587

123