By Dr. Nadav Nevo | Last updated: May 2026 | Read: 7 minutes

"Do I need mesh?" and "Is mesh safe?" -- the two most common questions patients ask before hernia surgery. The answers are simpler than you might think, but they require precise explanation. This guide gives you everything you need to know -- clearly, directly, and without unnecessary complexity.

Before Mesh -- Hernia Recurrence Rates

Before mesh became standard, hernia repair relied on suturing tissue together (primary repair). Recurrence rates were high -- 30-50% for incisional hernias, 10-15% even for inguinal hernias. The tissue was often weak to begin with, and suturing it under tension meant the repair frequently failed over time.

Mesh changed the equation. By reinforcing the abdominal wall with a synthetic scaffold, recurrence rates dropped dramatically -- below 10% for most hernia types, and below 5% in experienced hands with proper technique. Mesh is now used in the vast majority of hernia repairs worldwide. It's not optional in most cases -- it's the standard of care.

Mesh Position -- What Actually Matters

Not all mesh placements are equal. Where the mesh sits matters more than which mesh you use.

Retromuscular (Behind the Muscle)

The gold standard. The mesh is placed between the muscle and the posterior fascia. No contact with bowel. Not palpable. Supported by intra-abdominal pressure pushing the mesh against the muscle. Lowest recurrence rates. But technically demanding -- it requires advanced surgical skill.

Intraperitoneal (IPOM -- Inside the Abdomen)

The mesh is placed directly on the bowel, fixed with tackers or sutures. Technically simpler. But the mesh contacts the intestine -- risk of adhesions, tacker pain, and the mesh can sometimes be felt. This was the standard laparoscopic approach for years before eTEP made retromuscular placement possible minimally invasively.

Onlay (On Top of the Fascia, Under the Skin)

Used in SCOLA and some open repairs. The mesh sits in the subcutaneous plane. Appropriate for specific cases (lean women with diastasis and small hernias) but not for most hernias.

Preperitoneal

Between the peritoneum and the muscle. Used mainly in inguinal hernia repair (TEP/TAPP). Good results for groin hernias.

Mesh Types

Synthetic Mesh (Polypropylene, Polyester)

The workhorse. Strong, durable, well-studied over decades. In retromuscular position, synthetic mesh is ideal -- the body incorporates it, and it provides permanent reinforcement. This is what most hernia surgeons use for ventral and incisional hernias.

Biosynthetic / Biologic Mesh

Made from biological tissue (porcine, bovine) or absorbable synthetic materials. The body gradually absorbs or remodels them. Used in contaminated fields (where infection risk makes permanent synthetic mesh dangerous), or in specific situations where a permanent foreign body is undesirable. More expensive. Not stronger than synthetic -- in fact, they rely on the body building its own scar tissue around them.

Coated Mesh (for IPOM)

Synthetic mesh with an anti-adhesion barrier on one side (the side facing the bowel). Designed to prevent intestinal adhesions in intraperitoneal placement. Better than uncoated mesh inside the abdomen, but retromuscular placement avoids the problem entirely.

The Big Question -- Is Mesh Always Necessary?

This is what patients ask most. The honest answer: not always. But usually.

When Mesh Is NOT Needed -- Dr. Nevo's Approach

Diastasis recti repair: In most diastasis cases, mesh is not placed. The linea alba is sutured (plicated) and the structural repair is sufficient. Diastasis is not a true hernia -- there is no fascial defect to reinforce.

Small primary umbilical hernia (up to 2 cm): For a small, first-time umbilical hernia, primary suture repair without mesh can be appropriate. The defect is small enough that direct suturing holds.

When Mesh Becomes Important

Significant diastasis (over 6 cm separation): At this width, the tension on the suture line is higher. Dr. Nevo begins considering mesh reinforcement -- but never permanent synthetic mesh under the skin. When the repair uses a SCOLA approach for optimal aesthetic results and mesh is needed, biosynthetic mesh is chosen -- one that the body gradually absorbs. When maximum structural reinforcement is required, eTEP with synthetic mesh in retromuscular position is preferred.

Incisional hernias: Almost always require mesh. The tissue has already failed once -- suturing alone has unacceptable recurrence rates.

Large ventral hernias: Mesh is standard. The question is where to place it, not whether to use it.

Recurrent hernias: Absolutely require mesh if not used previously, and may require a different mesh position if the prior mesh-based repair failed.

What to Ask Your Surgeon

• Do you use mesh in my case? If not, why not?
• If yes -- where do you place it? (retromuscular is optimal for most ventral hernias)
• What type of mesh do you use?
• Is the mesh permanent or absorbable?
• What is your recurrence rate?

For more essential questions, read our guide to choosing a hernia surgeon. Learn more about Dr. Nadav Nevo and his approach.

Frequently Asked Questions

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