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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 231-233

De-epitheliazation (DEEP) and fascial closure with onlay mesh repair: An alternative technique for ventral hernia repair: A case report

1 Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA
2 250 E Main St 1st Floor, Bay Shore, NY 11706, USA

Date of Submission07-Apr-2021
Date of Decision10-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Dr. Vicki Suzanne Klimberg
Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_25_21

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Management of incisional hernias in patients with cirrhosis, ascites, or bowel covered only by skin poses a challenge for the reconstructive surgeon. We hypothesized that a completely extraperitoneal repair with coverage of the hernia defect with autologous tissue and onlay mesh reinforcement could be an alternative for a durable repair.

Keywords: DEEP, de-epitheliazation, onlay

How to cite this article:
Tastaldi L, Suzuki Y, Galvin D, Klimberg VS. De-epitheliazation (DEEP) and fascial closure with onlay mesh repair: An alternative technique for ventral hernia repair: A case report. Int J Abdom Wall Hernia Surg 2021;4:231-3

How to cite this URL:
Tastaldi L, Suzuki Y, Galvin D, Klimberg VS. De-epitheliazation (DEEP) and fascial closure with onlay mesh repair: An alternative technique for ventral hernia repair: A case report. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Aug 8];4:231-3. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/231/334558

  Introduction Top

Outcomes of incisional hernia repair (IHR) significantly improved with the advent of modern reconstructive techniques that facilitate fascial closure under physiologic tension and wide overlap mesh reinforcement on a sublay position.[1] Such techniques require access to the abdominal cavity, lysis of adhesions, and dissection into the retromuscular and/or pre-transversalis/preperitoneal spaces.[2] Cirrhotic patients with portal hypertension and ascites or those with extensive intra-abdominal adhesions and bowel directly under the skin, the risk for bleeding, inadvertent enterotomies, and contamination of ascitic fluid with concurrent mesh placement are some of the challenges while performing hernia repair.

We hypothesized that performing a completely extraperitoneal repair with initial superficial de-epitheliazation of the hernia sac back to fascia followed by an effective known double repair first with closure of the hernia defect with autologous tissue followed by onlay mesh reinforcement could avoid the enterotomies and contamination of ascites.

  Case Report and Technique Description Top

A 53-year-old woman with cirrhosis, ascites, and chronic pancreatitis secondary to alcoholism presented to surgery clinic for evaluation of a symptomatic incisional hernia. She was a non-smoker and had a body mass index of 32 kg/m2. Patient history is pertinent for an exploratory laparotomy due to perforated gastric ulcer with subsequent episodes of small bowel obstruction that required repeated laparotomies for lysis of adhesions and resulted on the current incisional hernia. Main complaints were pain and a midline abdominal bulge but no obstructive symptoms. A 12 cm wide midline defect with hernia contents covered by fragile and thin skin was noted on examination [Figure 1]A.
Figure 1: (A) Midline incisional hernia—12 x 25 cm showing de-epitheliazation of the skin over the hernia using scalpel. (B) The hernia sac with dermis on it is dissected free down to the anterior fasica. (C) The sac with dermis is invaginated and the fascial edges are closed with slowly absorbable running suture. (D) Aspect of fascial closure. (E) Onlay placement of polypropylene mesh fixated with monofilament non-absorbable suture. (F) Skin closure over drains

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Preoperative optimization included ascites control with adjustment on diuretics doses and preoperative paracentesis. The patient was taken to the operating room, and the skin was meticulously dissected free of the underlying hernia sac (de-epitheliazation—[Figure 1B]). Minimal raising of subcutaneous flaps was done bilaterally sufficient to expose the anterior rectus fascia [Figure 1C]. Relaxing incisions over the anterior rectus sheaths were performed bilaterally, simultaneously rotating the anterior rectus fascia medially aiming to cover the hernia sac recreate the midline. The sac was invaginated and the anterior rectus fascial flaps were closed under physiologic tension with non-absorbable suture in a running fashion [Figure 1D]. Repair was then reinforced with placement of 15 × 25 cm piece of macroporous polypropylene mesh on onlay position, fixated to the cut edges of the anterior fascia [Figure 1E]. A 19-French closed suction drain was positioned above the mesh [Figure 1F], and the subcutaneous tissue and skin were closed in layers.

The patient recovered uneventfully and was discharged on the first postoperative day. Currently with a 6-month follow-up, no wound complications occurred, and patient remains recurrence-free.

  Discussion Top

De-epitheliazation is a critical step of transverse rectus abdominis muscle flaps, commonly used for breast reconstruction. We used de-epitheliazation of the hernia sac to permit hernia dissection while obviating entrance into the abdominal cavity and the risk for the enterotomy or wound infection which is commonly seen in repairing hernias with bowel directly under the skin obviating the use of permanent mesh. Use of de-epitheliazation during hernia repair with the objective to remain extraperitoneal has been previously reported.[3] Traditional onlay hernia repair on large hernias requires extensive subcutaneous flaps raising, which are linked to wound complications.[1] Extension of the subcutaneous dissection to allow for external oblique release further increases such risk. As an attempt to minimize such skin de-vascularization, we raised subcutaneous flaps only to the extent necessary for incision and rotation of the anterior fascia. Last, we covered the hernia sac with this native tissue and reinforced the repair with large overlap of synthetic mesh on onlay position. With such, hernia sac is covered by a double layer (fascia/mesh) preventing increased tension on central area of the mesh leading to mesh fractures,[4] bulging of mesh, and other inconveniences of inlay repairs that are often used as an alternative to formal reconstruction in high-risk patients.

Optimal mesh position remains debatable. During open hernia repair, the onlay and sublay positions are most performed. In general, the sublay retromuscular position is preferred as the prosthesis is placed on the well-vascularized retrorectus space favoring mesh incorporation and where it remains protected from superficial wound morbidity. In contrast, the onlay mesh position is faster, obviates entering the abdominal cavity, and can provide similar long-term outcomes with respect to recurrence. The need for subcutaneous flaps raising and resultant division of periumbilical perforators increased odds for wound complications and remains the Achilles’ heel of such technique.[5] Haskins et al.[6] compared outcomes of sublay with onlay mesh repair (with adhesive mesh fixation described by Voeller and co-workers[7]). After 2:1 matched analysis, they found comparable rates of wound complications between techniques, at least in the short term. The authors appropriately mention that long-term mesh-related complications, recurrence, and those outcomes in higher risk patients, as ours, remain to be determined.

The approach presented herein could be an alternative for a durable repair in high-risk patients with large hernias in whom entering the abdominal cavity can be problematic. Larger experiences and long-term follow-up are needed to determine the utility of this technique on the armamentarium of the reconstructive surgeon.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Itani KM, Hur K, Kim LT, Anthony T, Berger DH, Reda D, et al; Veterans Affairs Ventral Incisional Hernia Investigators. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: A randomized trial. Arch Surg 2010;145:322-8; discussion 328.  Back to cited text no. 1
Tastaldi L, Alkhatib H. Incisional hernia repair: Open retromuscular approaches. Surg Clin N Am 2018;98:511-35. doi: 10.1016/j.suc.2018.02.006.  Back to cited text no. 2
Gibreel W, Sarr MG, Rosen MJ, Novitsky Y. Technical considerations in performing posterior component separation with transversus abdominis muscle release. Hernia 2013;20:449-59. doi: 10.1007/s10029-016-1473-y. Epub February 22, 2016.  Back to cited text no. 3
Bartsich SA, Schwartz MH. Deepithelialization of a complex ventral hernia for completely extraperitoneal Rives-Stoppa herniorrhaphy. Hernia 2005;9:280-3.  Back to cited text no. 4
Tastaldi L, Alkhatib H. Incisional hernia repair: Open retromuscular approaches. Surg Clin N Am2008;98:511-35.  Back to cited text no. 5
Haskins IN, Krpata DM, Rosen MJ, Perez AJ, Tastaldi L, Butler RS, et al. Online surgeon ratings and outcomes in hernia surgery: An Americas Hernia Society Quality Collaborative Analysis. J Am Coll Surg 2017;225:582-9.  Back to cited text no. 6
Stoikes N, Webb D, Powell B, Voeller G. Preliminary report of a sutureless onlay technique for incisional hernia repair using fibrin glue alone for mesh fixation. Am Surg 2013;79:1177-80.  Back to cited text no. 7


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