Design: Nationwide survey and register cohort, Denmark
Population: 2,348 adults after elective incisional hernia repair, 2014 to 2024
Primary outcome: Patient-reported chronic pain, foreign body sensation, recurrence and physical impact
Effect: Foreign body sensation 37.1% onlay vs 30.3% retromuscular; difference 6.8% (95% CI 0.9 to 12.8)

A Danish nationwide study linked hernia database records with questionnaires from 2,348 people (83% response) who had elective incisional hernia repair between 2014 and 2024. Mesh had been placed onlay in 28%, retromuscular in 28%, preperitoneal in 13% and intraperitoneal with defect closure in 31%.

After adjustment, onlay mesh was associated with more foreign body sensation than retromuscular mesh (37.1% vs 30.3%; difference 6.8%, 95% CI 0.9 to 12.8). There was no difference across positions in severe chronic pain, self-reported recurrence or physical impact.

The result is reassuring about pain and recurrence across all four positions, and gives one patient-reported reason to prefer retromuscular placement where it is technically reasonable.

It is observational, and the choice of position reflects hernia size and surgeon preference, so residual confounding is likely.

Tell patients that roughly a third report feeling the mesh, whatever the position.
Onlay placement was linked to slightly more mesh awareness than retromuscular.
Chronic pain and recurrence did not differ by position in this cohort.
Record mesh position in the operation note for future follow-up.

Why it matters

Patients judge a hernia repair by how it feels, not only whether it recurs.

The statistics, in plain English

A 6.8-point difference with a confidence interval from 0.9 to 12.8 is statistically significant but could be as small as 1 point. The other outcomes showed no difference, which does not prove they are identical.