By Dr. Nadav Nevo | Last updated: May 2026 | Read: 8 minutes

There is more than one way to repair a hernia. And they are not equal. The central question in every hernia operation is where the mesh goes -- and how you get it there. In this guide, I explain the main techniques available today, who each one is suited for, and why retromuscular repair remains the standard against which everything else is measured.

The Standard -- Retromuscular Repair (Rives-Stoppa)

The best hernia repair we can achieve is retromuscular -- meaning the mesh is placed behind the muscle. This principle was established by Jean Rives and René Stoppa between the 1960s and 1980s. The mesh sits in a protected anatomical plane: separated from the bowel by the posterior rectus sheath, supported from above by the muscle, and held in position by intra-abdominal pressure.

The result: low recurrence rates. No mesh-bowel contact. No intraperitoneal foreign body reaction. This is the gold standard against which every other technique is measured.

But it comes at a cost. This is open surgery -- a large incision, extensive tissue dissection, and weeks of recovery.

The Laparoscopic Revolution -- IPOM

In 1993, LeBlanc described laparoscopic ventral hernia repair using an intraperitoneal onlay mesh (IPOM). This changed everything. Suddenly, hernia repair could be done through small incisions -- faster recovery, less pain, smaller scars.

But there was a trade-off. The mesh was placed inside the abdominal cavity, directly on the bowel. It was fixed with tackers that penetrated the full thickness of the abdominal wall. The consequences: foreign body reaction inside the abdomen. Pain from the tackers. Adhesions forming between mesh and intestine. Poor aesthetic outcomes in larger hernias -- no restoration of the linea alba, no functional reconstruction of the abdominal wall.

And because IPOM was technically straightforward, hernia repair became something almost anyone could do. The field was flooded with surgeons performing hernia operations without deep anatomical understanding. Overuse became the norm. Every general surgeon became a "hernia specialist." The technique was applied to cases it was never designed for.

Back to Principles -- eTEP

Then came eTEP -- the enhanced-view Totally Extra-Peritoneal approach. First described by Dr. Jorge Daes and standardized by Igor Belyansky's group. eTEP brought retromuscular mesh placement into the minimally invasive era. The same anatomical principles as Rives-Stoppa -- mesh behind the muscle, separated from the bowel -- but through small incisions.

This was a paradigm shift. But technically, eTEP is extraordinarily demanding. The working space is created within the layers of the abdominal wall itself -- between the muscle and the posterior sheath. This requires precise anatomical knowledge and advanced laparoscopic skills. Very few surgeons worldwide can perform it laparoscopically. A somewhat larger group can do it robotically, where the robot's articulating instruments and 3D visualization help navigate this confined space. This is not a procedure for the occasional hernia surgeon.

Ideal candidates for eTEP:

• Overweight patients who benefit most from a minimally invasive approach
• Medium-sized ventral and incisional hernias
• Patients without significant skin excess or problematic scars
• Functional diastasis recti where structural reconstruction matters more than skin removal

SCOLA -- For Diastasis and Lean Women

SCOLA (SubCutaneous OnLay endoscopic Approach) is a fundamentally different technique -- a pre-fascial approach where the mesh is placed in the subcutaneous plane, on top of the fascia. The procedure includes plication of the diastasis and onlay mesh reinforcement.

It is best suited for lean women with diastasis recti and small midline hernias (umbilical or epigastric). It is not appropriate for large hernias, obese patients, or cases that require retromuscular reconstruction.

Frequently Asked Questions

Disclaimer: The information on this page is for educational purposes only and does not constitute medical advice, diagnosis, or treatment recommendations. The choice of surgical technique should be based on a personal examination and consultation with the surgeon. Dr. Nadav Nevo specializes in abdominal wall surgery in Israel. For more information, visit our About page.