PRS Global Open Article Discussion: The “Inside-Out” Technique For Hernia Repair with Mesh Underlay

by Ibrahim Khansa, MD (@IbrahimKhansaMD)

Over the past two decades, the pendulum on hernia repair has swung from open repair with widely undermined skin flaps,1 to less invasive options that focus on maintaining as many blood vessels to the skin as possible. There is no doubt that minimizing undermining and maintaining vascularity to the skin improves outcomes (less dehiscence, less infection).2


Figure 1 from “The “inside-out” technique for hernia repair with mesh underlay”

At the extreme end of the spectrum of minimally-invasive hernia repair is laparoscopic repair.3 There is no skin undermining, and most vessels are preserved. However, with laparoscopic hernia repair, it is hard to close the fascia in addition to placing the mesh. This is where open hernia repair has an advantage: it is much easier to do a components separation, place the mesh and bring the fascia together.


Figure 2 from “The “inside-out” technique for hernia repair with mesh underlay”

What if we could borrow some principles, techniques and instruments from laparoscopic hernia repair, and apply them to open abdominal wall reconstruction? That’s exactly what Dr. Talbot, Dr. Berhanu and colleagues describe in this article.4 They use a laparoscopic Carter-Thomason suture passer to place transfascial sutures. In their description of the technique, they perform open components separation, undermining the skin flaps until the semilunar line, then use the suture passer to place the mesh in an underlay position with good underlap between the mesh and the fascia.

We have recently described a similar use of the Carter-Thomason suture passer in hernia repair with underlay mesh.5 The problem we were trying to solve is that of skin undermining: in order to obtain at least 5cm of underlap between the mesh and the fascia, the sutures between the mesh and the fascia have to be placed quite lateral. Undermining the skin that far lateral to place those transfascial sutures would sacrifice most of the perforators to the skin. In our technique, we do very minimal skin undermining. We first perform minimally-invasive components separation, a technique popularized by Dr. Rohrich,6 Dr. Dumanian7 and Dr. Butler.8 Then, when the time comes to place the mesh, instead of passing the suture passer in a transfascial fashion, we pass it in a percutaneous-transfascial fashion: a small stab incision is made in the skin at the proposed site of the suture. The Carter-Thomason suture passer is placed through that percutaneous incision and through the fascia to retrieve the tails of the suture. Two separate passes through the fascia are made to retrieve the two tails of each suture. When the suture is tied, the knot ends up on the fascia. The vascularity to the skin is not disturbed. Our results were similar to those of Berhanu et al, with low rates of infection and dehiscence.

It is fascinating and beautiful how plastic surgeons are always trying to solve problems in ingenious ways. It is wonderful articles like this one by Dr. Talbot, Dr. Berhanu and colleagues that demonstrate how plastic surgeons are truly the most general of surgeons, always able to adapt, learn and borrow from other specialties. It was truly a pleasure reading this article.



1. Ramirez OM, Ruas E, Dellon AL. ‘‘Components separation’’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519-526.
2. Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, Rosen M, Silverman RP, Vargo D. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544-558.
3. Liang MK, Berger RL, Li LT, Davila JA, Hicks SC, Kao LS. Outcomes of laparoscopic vs open repair of primary ventral hernias. JAMA Surg 2013;148:1043-1048.
4. Berhanu, Aaron E. BS; Talbot, Simon G MD. The “inside-out” technique for hernia repair with mesh underlay. PRS-GO 3(6):e422
5. Janis JE, Khansa I. Evidence-based abdominal wall reconstruction: the Maxi-Mini approach. Plast Reconstr Surg 2015;136:1312-1323.
6. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE. Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast Reconstr Surg 2000;105:720-729.
7. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg 2002;109:2275-2280.
8. Butler CE, Campbell KT. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg 2011;128:698-709.

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