Mesh OR Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS-Trial)

The Complete Two-Year Follow-Up

Jeroen E. H. Ponten, MD; Wouter K. G. Leclercq, MD, PhD; Tanja Lettinga, MD; Jeroen Heemskerk, MD, PhD; Joop L. M. Konsten, MD, PhD; Nicole D. Bouvy, MD, PhD; Simon W. Nienhuijs, MD, PhD


Annals of Surgery. 2019;270(1):33-37. 

In This Article

Abstract and Introduction


Objective: The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complications. Complications such as an extended operation duration, additional use of painkillers, reoperation, infection, seroma, extended wound care, extended hospitalization, and early recurrence were reported according to the Clavien–Dindo grading system.

Summary Background Data: Over the years mesh repair is proven the gold standard for umbilical and epigastric hernias. The question remains, which mesh should be used?

Methods: In this randomized controlled, multicenter trial, all patients ≥ 18 years with a single, symptomatic, and primary small umbilical or epigastric hernia qualified for inclusion. Flat preperitoneal polypropylene mesh repair was compared with patch repair (PROCEED Ventral Patch) (PVP).

Results: A total of 352 patients were randomized; 348 patients received the intervention (n = 177 PVP vs n = 171 mesh). One out of 4 suffered from any kind of complication within 2 years postoperative (27.6%). A significant difference in complications was seen, in favor of polypropylene mesh repair (P = 0.044, 22.1% mesh vs 32.5% PVP). Reoperation was performed in 19 PVP operated patients (10.7%) versus 7 patients with polypropylene mesh repair (4.0%, P = 0.021).

No significant differences were seen in recurrences (n = 13, 8.4% PVP vs n = 6, 4.1% mesh, P = 0.127).

Conclusions: In small epigastric and small umbilical hernia repair a flat polypropylene mesh repair was associated with a lower complication rate than PVP repair. No differences in recurrence rates were seen. Combining all complications, the preperitoneal positioned flat polypropylene mesh performed better.


The small umbilical and epigastric hernias are among the last abdominal wall defects for which mesh-based surgery is the standard. Until recently, there was a resisting preference for primary closure. A large nationwide registry study showed a reduction in recurrence from 6% to 2% when a mesh is used instead of primary closure, for the small umbilical and epigastric hernias.[1] For solely small umbilical hernias a recent randomized study showed a reduction in recurrence from 11.4% to 3.6% due to mesh reinforcement.[2] Older studies and meta-analysis already pointed in this direction.[3,4] The problem however is: which mesh is superior to use in this hernia repair?

Unlike other hernias, mesh placement is more demanding in an anterior or open approach, for small umbilical/epigastric hernias through the limited size of the defects. And appropriate hernia repair demands overlap. Several devices have been developed to provide this overlap, even though they entered through a small entrance. Remarkable short-term results of some of them have been published.[5,6] In these studies the focus was primarily on ease of the procedure, operation time, and short-term complications.[5,6] It remains of the greatest importance to investigate if these results are sustainable. Such reports are rare and, if done, with unfavorable results in long-term complications and recurrence rates.[7]

In this study, we investigated which mesh-based repair is indicated for small umbilical or epigastric hernias. To identify superiority of either the polypropylene flat mesh or the Proceed Ventral Patch (PVP) a randomized trial was conducted and besides perioperative complications, recurrences, pain, and cosmetic scores were investigated.