The use of mesh in the repair of ventral hernias has been associated with significantly decreased rates of recurrence [1] and is the current standard of care. This benefit does not come without risks however and direct contact of the mesh with the intestinal loops is associated with complications such as adhesions, bowel obstructions, and enterocutaneous fistulae formation [2].

One technique which has allowed surgeons a safe option for using synthetic mesh in cases with peritoneal violation is the interposition of omentum between an onlay position and the abdominal viscera [3].

Herein, we present our experience with creating an omental patch to cover a synthetic mesh placed intraperitoneally.

A 66-year-old male was evaluated in our clinic with a symptomatic umbilical port-site hernia, one year after a laparoscopic cholecystectomy for a large gallbladder polyp. An elective, outpatient repair of the hernia was performed.

In the operating room, after the incision was carried down through the dermis, the hernia was found to contain exposed omentum without a hernia sac (Figure 1). The size of the hernia defect was 2.5x3 cm. We then decided to repair the hernia using The Prolene® Hernia System (Ethicon; Somerville, NJ, USA) (Figure 2), which consists of two layers of polypropylene mesh (underlay and onlay patches) joined by a connector, which plugs the fascial defect and virtually eliminates mesh migration [4].

To avoid the direct contact between the bowels and the underlay component of the Prolene hernia system, we decided to interposition an omental patch. Using interrupted polyglactin sutures, a piece of the herniated omentum was sutured as a patch to the sublay component of the hernia system (Figure 3).

The sublay component of the mesh with the attached omental path was then introduced into the peritoneal cavity and the onlay component of the hernia system was sutured to the fascia with interrupted non-absorbable sutures. The wound was then closed in two layers.

Postoperative follow-up shown a well-healed wound, without evidence of seroma, infection, or recurrence.

The incidence of laparoscopic port-site hernia varies from 1–22% [5][6]. They are potentially dangerous and can lead to considerable morbidity requiring surgical interventions.

The port-site hernias are classified into three types [7] as follows:

• Early onset type: Dehiscence of anterior and posterior fascial plane and peritoneum characterized by early onset after surgery. It usually occurs as a small bowel obstruction.
• Late onset type: Dehiscence of anterior and posterior fascial plane. Peritoneum constitutes the hernia sac. Hernias usually develop several months after surgery and they are not associated with small bowel obstruction. They appear as an asymptomatic swelling by the wound site.
• Special type: Dehiscence of the whole abdominal wall. Intestine and/or omentum protrusion. There is no sac, being not a typical herniation.

Herein, we report a case of a special type port-site hernia, with protrusion of omentum, without a hernia sac. During repair, synthetic mesh was placed intraperitoneally, but the visceral aspect of the mesh was covered with an omental patch to prevent a direct mesh-to-bowel contact.

An alternative to our hernia repair technique in the presented scenario could have been the use of a composite mesh. Composite, two-sided mesh is often used intraperitoneally as they can minimize the mesh-to-viscera adhesions. They have a polypropylene layer on the parietal side to enhance rapid abdominal wall integration, and a coated, absorbable collagen barrier on the visceral side to minimize visceral attachments to the mesh. However, the parietal synthetic layer of the composite mesh can contract by 30–50% leading to rolling of composite meshes, exposing the polypropylene component to the bowel surface [8]. Furthermore, the composite mesh systems are expensive and are not necessarily available at every institution.

This case report is significant because it presents a safe, durable, and cost effective option for the surgeon who finds him or herself in the peritoneal cavity with a synthetic mesh that would otherwise be in contact with bowel.

This case report is significant because it presents a safe, durable, and cost effective option for the surgeon who finds him or herself in the peritoneal cavity with a synthetic mesh that would otherwise be in contact with bowel.

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2. Chew DK, Choi LH, Rogers AM. Enterocutaneous fistula 14 years after prosthetic mesh repair of a ventral incisional hernia: A life-long risk? Surgery 2000 Mar;127(3):352–3.   [Pubmed]    
3. Sorour MA. Interposition of the omentum and/or peritoneum in the emergency repair of large ventral hernias with polypropylene mesh. International Journal of Surgery 2014;12.    
4. PROLENE® Polypropylene Hernia System. [Available at: [Available at: http://www.ethicon.com/healthcare-professionals/products/hernia-repair-and-fixation/hernia-mesh-devices/prolene-polypropylene-hernia-system]    
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7. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004 Nov;139(11):1248–56.   [CrossRef]   [Pubmed]    
8. FitzGerald JF, Kumar AS. Biologic versus synthetic mesh reinforcement: What are the pros and cons? Clin Colon Rectal Surg 2014 Dec;27(4):140–8.   [CrossRef]   [Pubmed]