The Rives-Stoppa Technique
The Rives-Stoppa technique repairs midline defects by placing the mesh in the retromuscular space (sublay): the posterior rectus sheath is closed again, the mesh reinforces it from within and the rectus muscles are re-approximated on the midline in front of it.
Developed in France between the 1970s and 1980s from the work of Jean Rives and René Stoppa, this technique changed incisional hernia surgery by introducing two principles that still hold: the mesh should not bridge the defect but reinforce a reconstructed wall; and its ideal site is the retromuscular space, protected between two vascularised layers.
The technical steps
- Skin incision over the defect and isolation of the hernia sac, which is resected
- Opening of the anterior rectus sheath and dissection of the retromuscular space as far as the semilunar lines
- Reconstruction of the posterior plane (posterior sheath or peritoneum) with a slowly absorbable running suture
- Placement of the mesh covering the whole pocket, with an overlap of at least 5 cm beyond the defect margins
- Re-approximation of the rectus muscles on the midline, in front of the mesh, and layered closure with drains
Why the retromuscular plane
In the sublay plane the intra-abdominal pressure distributes the mesh against the wall instead of pushing it outwards: the mesh works "from the inside", like a single reinforcing fascia. It also remains separated from the viscera by the reconstructed posterior plane and from the skin by the rectus muscles, with advantages in integration and infection compared with the onlay and intraperitoneal positions. It is the plane that the guidelines indicate as preferable whenever technically reachable.
Indications and limits
It is the reference for elective midline defects of small and medium width (W1–W2 of the EHS classification), in a clean field. The limit is geometric: the retromuscular pocket stops at the semilunar lines and the tension on the midline suture grows with the width of the defect. Beyond a certain width (generally over 8–10 cm) reconstruction requires muscle advancement with component separation, of which Rives-Stoppa represents the first step.
Modern developments
The same dissection plane can now be reached minimally invasively with the eTEP technique or with robotic assistance: the access changes, the reconstructive principle does not. The choice of mesh material and its characteristics is covered in the page on meshes and placement planes.