Pitfalls in retromuscular mesh repair for incisional hernia: The importance of the ?fatty triangle?

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Abstract
Open retromuscular mesh repair has become a standard procedure in incisional hernia repair. This technique led to a significant decrease of recurrences. Recurrences after this technique typically occur at the upper mesh border and are a result of the technical complexity of reaching the postulated underlay of 5 cm in the region of the linea alba. We performed an anatomical study in human corpses to investigate the abdominal wall with its different structures, with emphasis on the overlap of the mesh under the linea alba. The overlap can be achieved by incision of the posterior lamina of the rectus sheath, on both sides close to the linea alba. The incision opens the preperitoneal space and appears in the shape of a “fatty triangle”. The anterior lamina of the rectus sheath above the hernia defect remains intact and facilitates a sufficient thrust bearing for a retromuscular mesh implantation. Knowledge of the anatomy and preparation of the “fatty triangle” enables a mesh positioning according to the principles of retromuscular mesh repair.