• Rudolf Schrittwieser, Ferdinand Köckerling, Daniela Adolf, Martin Hukauf, Simone Gruber-Blum, René H Fortelny, and Alexander H Petter-Puchner.
• Department of General Surgery, Country Hospital Hochsteiermark, Steiermärkische Krankenanstaltengesellschaft m.b.H., Tragösserstrasse 1 und 1a, 8600, Bruck an der Mur, Austria.
• World J Surg. 2019 Aug 1; 43 (8): 1921-1927.

IntroductionIn meta-analyses and systematic reviews, clear advantages have been identified for the sublay versus onlay technique for treatment of incisional hernias. Nonetheless, an expert panel has noted that the onlay mesh location may be useful in certain settings.Materials And MethodsFirst, unadjusted analysis of data from the Herniamed Registry was performed to compare 6797 sublay operations with 1024 onlay operations for repair of incisional hernias. Then, using propensity score matching to account for the influence of variables age, gender, ASA score, BMI, risk factors, preoperative pain, defect size, and defect localization, 1016 pairs were formed and compared with each other.ResultsUnadjusted analysis revealed that the onlay operation was used significantly more often for small defects, lateral defect localization, and in women. After comparing the propensity score-matched pairs, no significant difference was found between the sublay and onlay technique in the outcome criteria intra- and postoperative complications, general complications, complication-related reoperations, pain at rest, pain on exertion, chronic pain requiring treatment, and recurrence on 1-year follow-up. But that was true only for this carefully selected patient collective.ConclusionIn a selected patient collective with small and lateral incisional hernias and with a large proportion of women, outcomes obtained for the onlay and sublay techniques do not differ significantly.

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