Transfascial Fixation vs No Fixation for Open Retromuscular Ventral Hernia Repairs—Set It and Forget It

Abstract

Hernia recurrences can be physically, mentally, and financially challenging for patients and can pose a conundrum for the most experienced abdominal wall surgeons. For years, it was believed that transfascial fixation (TF) would prevent mesh migration, decrease tension at the midline, and potentially lower the chance of repair failure. In this issue of JAMA Surgery, Ellis et al 1 investigate the role of TF in open ventral hernia repairs and report that patients without TF had similar rates of recurrence, pain, and quality of life at 1 year after operation as patients with TF, although with a higher risk of wound morbidity. Overall, the results suggest that TF may not be necessary during complex hernia repairs.Anecdotally, surgeons have noted during early reoperations that robust incorporation of permanent synthetic mesh in the retromuscular space occurs within a few days after placement, supporting the idea that long-term fixation may not be required. Importantly, this study suggests that patients without fixation may be at higher risk of wound morbidity such as seromas. It is possible that TF helps reduce the potential space that allows seromas to develop. Use of drains may help overcome this difference and should be considered in patients without TF, whether undergoing open or minimally invasive repairs. 2,3 This is especially worth considering given the over-