World J Surg DOI 10.1007/s00268-017-4301-3
LETTER TO THE EDITOR
Nomenclature in Ventral Hernia Repair Julie L. Holihan1 • Mike K. Liang1
Ó Socie´te´ Internationale de Chirurgie 2017
Dear editor, The article by Parker et al. describes the variability in ventral hernia nomenclature, particularly in regard to the anatomic planes for mesh implantation [1]. The authors identified an important problem in this article, as these anatomical mesh locations are frequently referred to with inconsistent terminology, leading to misinterpretations of data. However, there are a few nuances which warrant further discussion. Parker et al. classify onlay as mesh laid on top of the ‘‘external oblique over the defect.’’ This definition is flawed, as mesh over the external oblique (in situations where the defect lies beyond the semilunar line) as well as mesh over the rectus muscle and anterior rectus sheath are both considered onlay. For this reason, we define onlay as mesh laid on top of the muscle and fascia [2, 3]. Next, the authors define inlay as mesh sutured to the edges of a hernia defect. We agree with this definition. The authors define sublay as mesh posterior to the rectus muscle but anterior to the posterior rectus sheath (‘‘retro-rectus’’), while underlay is defined as anterior to the peritoneum but posterior to the posterior rectus sheath (pre-peritoneal). These definitions of sublay and underlay are problematic
due to a lack of the posterior rectus sheath inferior to the arcuate line (Fig. 1) [4]. As defined, there is no clear distinction between sublay and underlay mesh inferior to the arcuate line, as both will lie anterior to the peritoneum and posterior to the rectus or oblique muscle. Thus, according to the author’s definitions, mesh repair of all hernias that cross the arcuate line would be both sublay and underlay. For this reason, we choose to refer to the retro-muscular and pre-peritoneal locations as the same location, which we term sublay [2, 3]. Furthermore, we should move away from the term retro-rectus and instead use retro-muscular because if the mesh crosses the semilunar line, it is incorrect to term it retro-rectus [5]. Finally, Parker et al. define intra-peritoneal onlay as mesh (IPOM) in the abdominal compartment deep to the peritoneum. We refer to this intra-peritoneal location as underlay. Either term is acceptable for this intra-peritoneal mesh location, as long as it is consistent among clinicians and researchers. Differences in definitions and nomenclature in abdominal wall reconstruction can be confusing and misleading. A clear understanding of abdominal wall anatomy is pertinent in defining anatomic mesh locations. A consensus on abdominal wall terminology is clearly needed.
& Julie L. Holihan [email protected] Mike K. Liang [email protected] 1
University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 4.331, Houston, TX 77030, USA
123
World J Surg
Fig. 1 a Abdominal wall superior to arcuate line. b Abdominal wall inferior to arcuate line
References 1. Parker SG, Wood CPJ, Sanders DL, Windsor ACJ (2017) Nomenclature in abdominal wall hernias: is it time for consensus? World J Surg. doi:10.1007/s00268-017-4037-0
123
2. Holihan JL, Nguyen DH, Nguyen MT, Mo J, Kao LS, Liang MK (2016) Mesh location in open ventral hernia repair: a systematic review and network meta-analysis. World J Surg 40(1):89–99 3. Holihan JL, Hannon C, Goodenough C et al (2017) Ventral hernia repair: a meta-analysis of randomized controlled trials. Surg Infect (Larchmt) 18:647–658 4. Seymour NE, Bell RL, Brunicardi FC et al (2014) Abdominal wall, omentum, mesentery, and retroperitoneum. In: Schwartz’s principles of surgery, 10e. McGraw-Hill Education, New York 5. Muysoms F, Jacob B (2017) International hernia collaboration consensus on nomenclature of abdominal wall hernia repair. World J Surg. doi:10.1007/s00268-017-4115-3
LETTER TO THE EDITOR
Nomenclature in Ventral Hernia Repair Julie L. Holihan1 • Mike K. Liang1
Ó Socie´te´ Internationale de Chirurgie 2017
Dear editor, The article by Parker et al. describes the variability in ventral hernia nomenclature, particularly in regard to the anatomic planes for mesh implantation [1]. The authors identified an important problem in this article, as these anatomical mesh locations are frequently referred to with inconsistent terminology, leading to misinterpretations of data. However, there are a few nuances which warrant further discussion. Parker et al. classify onlay as mesh laid on top of the ‘‘external oblique over the defect.’’ This definition is flawed, as mesh over the external oblique (in situations where the defect lies beyond the semilunar line) as well as mesh over the rectus muscle and anterior rectus sheath are both considered onlay. For this reason, we define onlay as mesh laid on top of the muscle and fascia [2, 3]. Next, the authors define inlay as mesh sutured to the edges of a hernia defect. We agree with this definition. The authors define sublay as mesh posterior to the rectus muscle but anterior to the posterior rectus sheath (‘‘retro-rectus’’), while underlay is defined as anterior to the peritoneum but posterior to the posterior rectus sheath (pre-peritoneal). These definitions of sublay and underlay are problematic
due to a lack of the posterior rectus sheath inferior to the arcuate line (Fig. 1) [4]. As defined, there is no clear distinction between sublay and underlay mesh inferior to the arcuate line, as both will lie anterior to the peritoneum and posterior to the rectus or oblique muscle. Thus, according to the author’s definitions, mesh repair of all hernias that cross the arcuate line would be both sublay and underlay. For this reason, we choose to refer to the retro-muscular and pre-peritoneal locations as the same location, which we term sublay [2, 3]. Furthermore, we should move away from the term retro-rectus and instead use retro-muscular because if the mesh crosses the semilunar line, it is incorrect to term it retro-rectus [5]. Finally, Parker et al. define intra-peritoneal onlay as mesh (IPOM) in the abdominal compartment deep to the peritoneum. We refer to this intra-peritoneal location as underlay. Either term is acceptable for this intra-peritoneal mesh location, as long as it is consistent among clinicians and researchers. Differences in definitions and nomenclature in abdominal wall reconstruction can be confusing and misleading. A clear understanding of abdominal wall anatomy is pertinent in defining anatomic mesh locations. A consensus on abdominal wall terminology is clearly needed.
& Julie L. Holihan [email protected] Mike K. Liang [email protected] 1
University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 4.331, Houston, TX 77030, USA
123
World J Surg
Fig. 1 a Abdominal wall superior to arcuate line. b Abdominal wall inferior to arcuate line
References 1. Parker SG, Wood CPJ, Sanders DL, Windsor ACJ (2017) Nomenclature in abdominal wall hernias: is it time for consensus? World J Surg. doi:10.1007/s00268-017-4037-0
123
2. Holihan JL, Nguyen DH, Nguyen MT, Mo J, Kao LS, Liang MK (2016) Mesh location in open ventral hernia repair: a systematic review and network meta-analysis. World J Surg 40(1):89–99 3. Holihan JL, Hannon C, Goodenough C et al (2017) Ventral hernia repair: a meta-analysis of randomized controlled trials. Surg Infect (Larchmt) 18:647–658 4. Seymour NE, Bell RL, Brunicardi FC et al (2014) Abdominal wall, omentum, mesentery, and retroperitoneum. In: Schwartz’s principles of surgery, 10e. McGraw-Hill Education, New York 5. Muysoms F, Jacob B (2017) International hernia collaboration consensus on nomenclature of abdominal wall hernia repair. World J Surg. doi:10.1007/s00268-017-4115-3
