Types of Mesh Placement: Onlay, Inlay and Underlay

Hernia repair surgery is necessary for hundreds and thousands of people each year. Most of these operations are completed using hernia mesh implants. These implants, however, have been causing serious and sometimes life-threatening complications, and when they do, the mesh must be removed. Further, mesh removal due to mesh failure can be complicated by the placement of the implant.

If your body rejects the mesh used in your hernia repair surgery and if you suffered injury, you may be entitled to file a lawsuit as to the hernia mesh injuries. Here, our product liability and personal injury attorneys answer questions about the types of mesh placement and how it may or may not impact your hernia mesh repair surgery and/or hernia mesh removal surgery.

Mesh removal due to mesh failure can be complicated by the placement of the implant.

1. Does placement of hernia mesh matter for hernia repair surgery?

Mesh placement matters when your doctor uses a mesh implant to repair your hernia – regardless of the type of hernia. Given that there are high rates of complications related to mesh implants that require mesh removal, placement has been found to be one factor that may reduce the occurrence of one major complication: hernia recurrence.1

Of course, that's only if the mesh device is not defective. If defective, then placement may not matter anyway because injuries may result with or without proper mesh placement.

2. What are the basic types of mesh placement?

There are three basic types of mesh placement that you will hear about most often:

  1. Onlay mesh placement;
  2. Inlay mesh placement; and
  3. Underlay mesh placement.

Each type has its purpose as well as advantages and disadvantages. Below is a description of each to better understand them and when they are used.

2.1 What is onlay mesh placement?

Onlay mesh placement is a technique to surgically repair a hernia. The mesh is used to strengthen the repair and reinforce the abdominal wall. The mesh is placed overlying the defect (opening) made by the hernia. The mesh is fixed to the fascia using sutures to close the defect.2

This method is relatively easy to perform. It is used to close both smaller and larger hernia openings. It does, however, come with some disadvantages. These disadvantages include:

  • A lot of suturing is required in order to secure the mesh around and onto the fascia surface;
  • There is an increased chance of seroma formation over the mesh when placed using the onlay technique;3
  • Higher risk of recurrence due to the mechanical disadvantage of the only placement of the mesh, such that there is significant pressure against the mesh.

2.2 What is inlay mesh placement?

The inlay technique involves placing the mesh between the edges of the fascia where the defect made by the hernia is. Inlay placement does not actually close the gap, rather the mesh is fixed with sutures to the edges of the gap to bridge the defect.

This technique is also relatively easy to perform. It is best used to address small gaps made by hernias. With less mesh used, there is less risk of seroma formation and infection. If used over larger defects, then the risk of recurrence increases as well as formation of seromas and infection. There is also the mechanical disadvantage here where pressure against the mesh can again lead to recurrence, but more so if the technique is applied to a large gap.

2.3 What is underlay mesh placement?

The underlay technique involves placing the mesh on the underside of the gap or inside the fascia. Because of this technique, it is also referred to as the inside-out technique for hernia repair. The sutures are circumferentially and evenly used to fix the mesh and close the gap.

This method helps improve the tension that results in the mechanical disadvantage of the inlay and onlay techniques. Because the pressure is stabilized, there is less risk of hernia recurrence.4 Because of its placement, too, there is less risk of seroma formation and infection.

The disadvantage of this method is the process itself. It is not as easy to place, for instance:

  • It is difficult to determine how much space there is for the mesh; and
  • it is difficult to suture or tack the mesh in place because it is done from under the fascia.

3. What are the factors to decide which mesh placement is right for the patient?

There are several factors that influence which mesh placement will be used. These factors include:

  • Size of the hernia and gap made by the hernia;
  • Underlying conditions of the patient;
  • Overall medical status of the patient; and
  • Surgeon preference.

Your doctor should review with you which placement method will work best for your unique situation. Make certain your doctor explains to you why he or she prefers a certain placement method and what the possible consequences -- either good or bad -- may be.

4. When should you contact a personal injury lawyer?

If you have had hernia repair surgery, placement of the mesh can play a key part in how successful the surgery is. But things do not always go right, and sometimes that is because the mesh used was inherently bad due to some defect. You should make sure you know your rights with regard to hernia mesh repair surgery and if you are entitled to compensation for any injury you experience as a result of a defective device. Contact an experienced hernia mesh personal injury and product liability attorney today.

At Shouse Law Group, our personal injury lawyers are experienced, insightful, and resourceful. We have local offices throughout California but represent clients throughout the U.S. in hernia mesh claims. Contact our office today at (855) 396-0370 to discuss the specifics of your case.


  1. Sri Vengadesh Gopal, Achuthan Warrier. Recurrence after groin hernia repair-revisited. Int'l J. of Surgery, 11:5, June 2013, pp. 374-377. doi.org/10.1016/j.ijsu.2013.03.012. See also, Albino FP, Patel KM, Nahabedian MY, Sosin M, Attinger CE, Bhanot P. Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations. Plast Reconstr Surg. 2013 Nov;132(5):1295-304. doi: 10.1097/PRS.0b013e3182a4c393.
  2. Walgenbach M, Mathes T, Siegel R, Eikermann M. Mesh fixation techniques in primary ventral or incisional hernia repair. Cochrane Database of Systematic Reviews. 2015, Issue 3. Art. No.: CD011563. doi:10.1002/14651858.CD011563.
  3. Zachary M. Borab, BA,a Sameer Shakir, MD,b Michael A. Lanni, BS,b Michael G. Tecce, DO,bJohn MacDonald, MA,c William W. Hope, MD,d and John P. Fischer, MD, MPH,b Philadelphia, PA, London, Ontario, Canada, and Wilmington, NC. Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis. Surgery J., April 2017, Vol. 161, No. 4, pp. 1149-1163.

Berhanu AE, Talbot SG. The "Inside-out" Technique for Hernia Repair with Mesh Underlay. Plast Reconstr Surg Glob Open. 2015 Jul 8;3(6):e422. doi: 10.1097/GOX.0000000000000377. eCollection 2015 Jun.

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