Menoufia Medical Journal

: 2014  |  Volume : 27  |  Issue : 2  |  Page : 353--358

Sublay hernioplasty versus onlay hernioplasty in incisional hernia in diabetic patients

Mohamed Leithy, Magdy Loulah, Hesham Abu Greida, Fawzy Abu Baker, Atef Moussa Hayes 
 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Correspondence Address:
Atef Moussa Hayes
MBBCh, Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia


Objective This study aims to compare between sublay hernioplasty and onlay hernioplasty in incisional hernia repair in diabetic patients. Background Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. A wide spectrum of surgical techniques have been developed, ranging from suturing techniques to various types of prosthetic mesh repair. Use of a preperitoneal mesh repair technique showed a reduced number of postoperative complications and recurrence compared with other techniques. Materials and methods A prospective study was carried out on 30 diabetic patients who underwent incisional hernia repair with sublay hernioplasty or onlay hernioplasty between January 2012 and February 2013 in Sherbin Central Hospital and Menoufia University Hospital. The patients were divided into two equal groups (groups A and B). Patients in group A were treated with sublay repair, whereas patients in group B were treated with onlay repair. All patients underwent a preoperative assessment and postoperative follow-up. Outpatient clinical notes, discharge summary, operative notes, and laboratory data were reviewed. Results Sublay hernioplasty proved to be better with fewer complications compared with onlay hernioplasty. There was a statistically significant difference between the two groups regarding postoperative wound infection and seroma (40% in the onlay group; P > 0.0005). There was no statistically significant difference between two groups as regards postoperative recurrence (P < 0.0005). Conclusion Sublay mesh repair showed excellent short-term results, with minimal morbidity. It resulted in fewer postoperative complications and no recurrence. Compared with the onlay technique (in the literature) sublay mesh repair is a gold standard treatment for incisional hernia repair.

How to cite this article:
Leithy M, Loulah M, Greida HA, Baker FA, Hayes AM. Sublay hernioplasty versus onlay hernioplasty in incisional hernia in diabetic patients.Menoufia Med J 2014;27:353-358

How to cite this URL:
Leithy M, Loulah M, Greida HA, Baker FA, Hayes AM. Sublay hernioplasty versus onlay hernioplasty in incisional hernia in diabetic patients. Menoufia Med J [serial online] 2014 [cited 2020 Feb 23 ];27:353-358
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Incisional hernias are ventral hernias that occur through an operation scar and are a serious complication of abdominal surgery. Incisional hernias occur in 2-11% of laparotomies [1]. Incisional hernias enlarge over time and can give rise to such complications as pain, discomfort, bowel obstruction, incarceration, and strangulation. Furthermore, incisional hernias reduce the quality of life and the chances for employment.

Improvement in the quality of life is the major reason for seeking surgical care [2].

Incisional hernia surgery is still a challenge for the general surgeon. Repair of these hernias comes with a high recurrence rate, high morbidity, and therefore high costs. Frequent complications are reherniation, seroma formation, and wound infection [2].

The repair can be done by either an open or a laparoscopic technique. The open technique can be a simple hernioplasty (Mayo duplication or fascia-adaptation), a components separation technique, or a mesh repair. Laparoscopic correction is always performed with a mesh. The recurrence rate after open suture repair may be as high as 54%, and for open mesh repair up to 32% [3]. The recurrence rate for laparoscopic repair appears to be comparable to that of the open mesh procedure, but with a shorter hospital stay [4].

The prosthetic mesh can be placed between the subcutaneous tissues of the abdominal wall and the anterior rectus sheath (onlay mesh repair) as well as in the preperitoneal plane created between the rectus muscle and posterior rectus sheath (sublay mesh repair). The latter technique has several advantages, one of which is that it does not transmit the infection from subcutaneous tissues to the mesh as it lies quite deep in the preperitoneal plane [5].

The preperitoneal (sublay) mesh hernia repair is considered by many surgeons to be the gold standard for the open repair of abdominal incisional hernias [6].

 Materials and methods

A prospective study was conducted on 30 diabetic patients who underwent incisional hernia repair with sublay hernioplasty or onlay hernioplasty between January 2012 and February 2013 in Sherbin Central Hospital and Menoufia University Hospital. The patients were divided into two equal groups (groups A and B). Patients in group A were treated with sublay repair, whereas patients in group B were treated with onlay repair. All patients were subjected to preoperative assessment and postoperative follow-up. Outpatient clinical notes, discharge summary, operative notes, and laboratory data were reviewed.


Each patient underwent the following evaluations:

Complete blood picture,Liver function tests,Fasting and postprandial blood glucose,Kidney function,Radiograph of the abdomen, in erect and supine positions if there was obstruction,Abdominal ultrasound,Computer tomography, andECG.

Preoperative preparation

Patients who had hypertension, diabetes mellitus, or cough were controlled preoperatively.Preoperative, perioperative, and postoperative monitoring of blood glucose levels was performed.The night before surgery nil orally was advised and enema was advised once at night and once in the morning.A nasogastric tube and Foley catheter were inserted at the start of the procedure.Patients were explained about the effects and complications of the procedure.A broad-spectrum antibiotic was given to all patients before the procedure.The anesthetist was informed that the patient is diabetic.Diabetic patients should be placed first in the morning operating list to ensure timings as predictable as possible for blood sugar management.

Operative methods

The operations were performed under general anesthesia or spinal or epidural anesthesia.

In all cases the old scar was excised, and the hernial sac and defect were exposed adequately.

The sac was opened and the content was reduced after lysis of the adhesions. The excess sac was excised.

In onlay repair, the hernia defect was closed primarily with an interrupted or running continuous nonabsorbable suture. After that, the mesh was cut to a diameter 10 cm greater than the defect and fixed to the fascia with two concentric rings of interrupted 2/0 polypropylene sutures. A suction drain was used and the skin was closed [Figure 1].{Figure 1}

In sublay repair, the preperitoneal, retromuscular space was dissected about 5-6 cm beyond the edge of the defect where the mesh was positioned and fixed by 2/0 polypropylene sutures. Suction drains were laid on the mesh and brought out through a separate stab. The muscular aponeurotic structures were repaired with prolene no. 1, followed by skin closure [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

In all patients a polypropylene mesh was used. A suction drain was laid on the mesh and removed when drainage was less than 20 cm with no infection.

No major postoperative bleeding occurred in any patient and there was no incidence of perioperative mortality.

Postoperative management

All patients received postoperative analgesia on the first and second postoperative days with 75 mg diclofenac once per day intramuscularly. Antibiotics were given as prophylactic measures up to the eighth day, except in two cases in which antibiotics were given for 15 days because of wound infection.

The nasogastric tube was removed once the patient passed flatus. Deep breathing exercises and limbs movements in bed were advised once the patient had recovered from anesthesia. The patients were encouraged for early gradual ambulation. Skin sutures were removed on the 10th day and in a few cases after the 10th day.

At the time of discharge, patients were advised to avoid carrying heavy weights and to wear an abdominal belt.

Each patient was assessed in the postoperative period before discharge for early postoperative complications such as postoperative fever, pain, subcutaneous seroma, hematoma, wound infection, chest infection, ileus, and urine retention.

Thereafter, all patients were followed up monthly for 1 year to evaluate the outcome of the operation and detect delayed postoperative complications such as wound sinus, recurrence of hernia, intestinal obstruction, and enterocutaneous fistula.


Out of 30 patients, 25 (83.33%) were female and five (16.66%) were male, with a female to male ratio of 5 to 1. Ages ranged from 23 to 65 with a mean age of 43.7 years. Twenty-five patients had primary incisional hernia, three patients had one recurrence, and two patients had two recurrences [Table 1].{Table 1}

All 30 patients presented with swelling, of whom 18 (60%) also presented with pain. On examination, swelling was reducible in 25 cases (83.33%) and irreducible in five cases (16.66%) [Table 2] and [Table 3].{Table 2}{Table 3}

In this study, the original surgical incisions were lower midline incision in 10 patients (33.33%), upper midline incision in five patients (16.66%), subcostal in three patients (10%), lumbar in three patients (10%), left upper paramedian in three patients (10%), right lower paramedian in three patients (10%), and Pfannenstiel incision in another three patients (10%) [Table 4] and [Table 5],[Table 6].{Table 4}{Table 5}{Table 6}

The presenting risk factors that resulted in hernia formation were postoperative wound infection in 15 patients (50%), obesity in nine patients (30%), and chronic obstructive pulmonary disease in six patients (20%) [Table 7],[Table 8] and [Table 9].{Table 7}{Table 8}{Table 9}

The following postoperative complications were seen in the onlay group: wound infection, which was simple and occurred in six patients (40%) and resolved with antibiotics and simple dressing and longer hospital stay (10 days); flap necrosis, which occurred in one patient (6.7%) and was managed with debridement of necrotic tissue, antibiotics, dressing, and secondary sutures with longer hospital stay (2 weeks); seroma, which occurred in six patients (40%) and was managed with frequent aspiration and compression with an abdominal belt; mesh infection, which occurred in one patient (6.66%) with chronic pus discharge for 7 months without response to antibiotics and requiring mesh removal. Recurrence occurred in two patients (13.32%) and the presenting cause was mesh infection and removal of mesh in one case (recurrent incisional hernia after 2 months from the mesh extraction); the other case of recurrence was due to chronic pulmonary disease and occurred 6 months after repair [Table 10].{Table 10}

The following postoperative complications were seen in the sublay group: superficial wound infection, which was simple and occurred in one patient (6.66%) and was managed with antibiotics; and seroma, which occurred in one patient (6.66%) and disappeared spontaneously. In this case aspiration under ultrasound was a possibility [Table 11].{Table 11}

Comparison of complications between the two groups revealed that wound infection and seroma were more common in the onlay repair group (P > 0.0005) with significant difference between the two groups [Table 6].

Average time of the procedures was 80 min.


Ian Aird defines incisional hernia as a diffuse extrusion of the peritoneum and abdominal contents through a weak scar after an operation or accidental wound. The incidence of incisional hernia is probably between 2 and 11%. However, recent studies show that about 2/3 appear within the first 5 years and that at least another third appear 5-10 years after the operation. It is seen more in female patients, in the obese, and in the older age group [7].

Small hernias less than 2½ cm in diameter are often successfully closed with primary tissue repairs. However, larger ones have a recurrence rate of up to 30-50% when a tissue repair alone is performed. Hernia recurrence is distressing to patients and embarrassing to surgeons. Nowadays, tension-free repair using a prosthetic mesh has decreased recurrence to negligible. Despite excellent results, limitations due to increased risk of infection with placement of a foreign body and high cost still exist. Primary tissue repair is associated with a higher unacceptable recurrence rate [7].

Mesh repair is an excellent method of repair for patients with large defects of the anterior abdominal wall, especially for those larger than 4 cm. An excellent method is Rive's Stoppa technique, in which the mesh is placed between the peritoneum and abdominal wall or rectus muscle and posterior rectus sheath [8].

With open repairs, placing the mesh in the submuscular or sublay position is claimed to be technically difficult. It may be slightly more challenging but not beyond the competence of a trained general surgeon. We were also able to use the submuscular technique to repair hernias with subcostal, gridiron, and Pfannenstiel incisions. Placing the mesh in this plane has mechanical and physiologic advantages. Intra-abdominal pressure tends to push the mesh firmly against the adjacent abdominal wall. A large overlap gives a sufficient surface area for tissue ingrowth and firm fixation, providing strong reattachment for the lateral abdominal muscles. If the anterior sheath can be closed, the mesh is also separated from the subcutaneous tissues [6].

The main advantages of preperitoneal mesh repair are as follows: less chance of mesh infection and erosion through the skin because the graft lies in the preperitoneal plane between the posterior rectus sheath and the peritoneum; avoidance of adhesions, bowel obstruction, enterocutaneous fistula, and erosion of the mesh; and minimal morbidity. The main disadvantages are that the procedure is more time consuming and requires extensive preparation of the preperitoneal plane and surgical experience [4].

In contrast, with an onlay mesh, the repair is less mechanically sound as abdominal wall forces tend to push the mesh off the repair. In addition, an onlay mesh requires extensive subcutaneous dissection, increasing the risk of hematoma, seroma, and infection; it is associated with a high incidence of local wound problems, although a meeting of experts concluded that it was technically simpler than sublay repair and could be carried out by surgical residents [3].

Prevention of wound sepsis is therefore a prime objective in all abdominal operations. Other associated risk factors in the present study were obesity in nine patients (30%) and chronic obstructive pulmonary disease in six patients (20%).

In a similar international study conducted by Hamy et al., the complication rates from onlay hernioplasty were as follows: 25% for wound infection, 5.7% for flap necrosis, 30% for seroma, 3% for mesh infection, and 10% for recurrence.

In the present study the corresponding results were as follows: 40% for wound infection, 6.7% for flap necrosis, 40% for seroma, 6.7% for mesh infection, and 13.3% for recurrence.

The results of the international study were better than those of our study, especially for infection and seroma and recurrence, because all of our patients were diabetic.

For sublay hernioplasty the complication rates in the international study by De Vries Reilingh et al. were as follows: 7% for wound infection, 30% for seroma, and 7% for recurrence.

Our study gave the following results for complications from sublay hernioplasty: 6.7% for wound infection, 6.7% for seroma, no flap necrosis, no mesh infection, and no recurrence.


Open sublay repair of incisional hernias, placing a mesh in the submuscular plane, is highly effective with a low recurrence and acceptable complication rates. This is particularly so when carried out by experienced surgeons in appropriately selected patients.


Conflicts of interest

There are no conflicts of interest.


1Dur AH, den Hartog D, et al. Low recurrence rate of a two-layered closure repair for primary and recurrent midline incisional hernia without mesh. Hernia 2009; 13 :421-426.
2 Poelman MM, Langenhorst BL, et al. Modified onlay technique for the repair of the more complicated incisional hernias: single-centre evaluation of a large cohort. Hernia 2010; 14 :369-374.
3 Burger JW, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2005; 240 : 578-583.
4 Den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008.
5 Bhat MG, Somasundaram SK. Preperitoneal mesh repair of incisional hernia: a seven year retrospective study. Indian J Surg 2007; 69 :95-98.
6 Berry MF, Paisley S, Low DW, et al. Repair of large complex recurrent incisional hernia with retromuscular mesh repair and panniculectomy. Am J Surg 2007; 194 :199-204.
7 Carlson G. In: Achauer BM, Eriksson E, Guturon B, Coleman J, Russell R, Vander Kolk, CA, editors. Abdominal wall reconstruction. Plastic surgery: indications, operations, and outcomes. St Louis, MO: Mosby; 2011. 563-574.
8 DeBord JR. The historical development of prosthesis in hernia surgery. Surg Clin North Am 2008; 78 :973-1006.