Prophylactic Mesh Reinforcement for Prevention of Midline Incisional Hernias: A Publication Bias Adjusted Meta-analysis

Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy.

METHODS

We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934).

RESULTS

We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation.

CONCLUSIONS

Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.

[Incisional hernias: epidemiology, evidence and guidelines]

BACKGROUND

From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2‑year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance.

OBJECTIVE

To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation.

MATERIAL AND METHODS

A concise summary was prepared incorporating the current literature and existing guidelines.

RESULTS

According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included.

CONCLUSION

The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.

Hernia Prevention Using Biologic Mesh and/or Small Bites: A Multispecialty 2 × 2 Factorial Randomized Controlled Trial

BACKGROUND

Ventral incisional hernias are the most common complication after abdominal operation. Randomized trials have shown efficacy of prophylactic synthetic mesh and small bites. Adoption of these practices has been limited due to concerns with placement of synthetic mesh in contaminated cases and small bites in an overweight population. We sought to assess the efficacy of prophylactic biologic mesh and small bites to prevent postoperative major complications: ventral incisional hernias, surgical site infection, reoperation, and death.

STUDY DESIGN

High-risk patients (overweight/obese, current smoker) undergoing abdominal operation with a midline incision (5 cm or greater) were randomized (2 × 2 factorial trial) to receive either sublay biologic mesh or no mesh and either small bites (0.5 × 0. 5cm) or large bites (1 × 1 cm) fascial closure. The primary outcome measure was major complications at 1 year postoperative. CONSORT guidelines were followed, and this study was registered on clinicaltrials.gov (NCT03148496). Assuming α = 0.05, β = 0.20, and Δ = 20%, it was estimated that 105 patients were needed. Primary outcome was assessed using Fisher's exact test.

RESULTS

A total of 107 patients were randomized: 52 (49%) to mesh, 55 (51%) to no mesh, 55 (51%) to small bites, and 52 (49%) to large bites. Of the patients, 16% were smokers, 31% were overweight, and 55% were obese. At 1 year postoperative, there were no differences in major complications between groups (mesh vs no mesh 21% vs 16%, p = 0.62; small vs large bites 18% vs 19%, p = 1.00).

CONCLUSIONS

In this trial, biologic mesh and small bites appear to have no benefit. Further randomized trials are needed among high-risk patients before widespread adoption of prophylactic biologic mesh or small bites.

What is the ideal mesh location for incisional hernia prevention during elective laparotomy? A network meta-analysis of randomized trials

BACKGROUND

Incisional hernia (IH) represents an important complication after surgery. Prophylactic mesh reinforcement (PMR) with different mesh locations [onlay (OL), retromuscular (RM), preperitoneal (PP), and intraperitoneal (IP)] has been described to possibly reduce the risk of postoperative IH. However, data reporting the 'ideal' mesh location are sparse. The aim of this study was to evaluate the optimal mesh location for IH prevention during elective laparotomy.

METHODS

Systematic review and network meta-analysis of randomized controlled trials (RCTs). OL, RM, PP, IP, and no mesh (NM) were compared. The primary aim was postoperative IH. Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Fourteen RCTs (2332 patients) were included. Overall, 1052 (45.1%) had no mesh (NM) while 1280 (54.9%) underwent PMR stratified in IP ( n =344 pts), PP ( n =52 pts), RM ( n =463 pts), and OL ( n =421 pts) placement. Follow-up ranged from 12 months to 67 months. RM (RR=0.34; 95% CrI: 0.10-0.81) and OL (RR=0.15; 95% CrI: 0.044-0.35) were associated with significantly reduced IH RR compared to NM. A tendency toward reduced IH RR was noticed for PP versus NM (RR=0.16; 95% CrI: 0.018-1.01), while no differences were found for IP versus NM (RR=0.59; 95% CrI: 0.19-1.81). Seroma, hematoma, surgical site infection, 90-day mortality, operative time and hospital length of stay were comparable among treatments.

CONCLUSIONS

RM or OL mesh placement seems associated with reduced IH RR compared to NM. PP location appears promising; however, future studies are warranted to corroborate this preliminary indication.

Prophylactic mesh reinforcement for midline incisional hernia prevention: systematic review and updated meta-analysis of randomized controlled trials

BACKGROUND

Incisional hernia (IH) is a common complication after abdominal surgery. Prevention of IH is matter of intense research. Prophylactic mesh reinforcement (PMR) has been shown to be promising in the minimization of IH risk after elective midline laparotomy.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PMR vs. primary suture closure (PSC). Risk ratio (RR) and standardized mean difference (MD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference.

RESULTS

Fourteen RCTs (2332 patients) were included. Overall, 1280 (54.9%) underwent PMR while 1052 (45.1%) PSC. Postoperative follow-up ranged from 12 to 67 months. The incidence of IH was reduced for PMR vs. PSC (13.4% vs. 27.5%). The estimated pooled IH RR for PMR vs. PSC is 0.38 (95% CI 0.24-0.58; p < 0.001). Stratified subgroup analysis according to mesh location shows a risk reduction for intraperitoneal (RR = 0.65; 95% CI 0.48-0.89), preperitoneal (RR = 0.18; 95% CI 0.04-0.81), retromuscular (RR = 0.47; 95% CI 0.24-0.92) and onlay (RR = 0.24; 95% CI 0.12-0.51) compared to PSC. The seroma RR was higher for PMR (RR = 2.05; p = 0.0008). No differences were found for hematoma (RR = 1.49; p = 0.34), surgical site infection (SSI) (RR = 1.17; p = 0.38), operative time (OT) (MD = 0.27; p = 0.413), and hospital length of stay (HLOS) (MD = -0.03; p = 0.237).

CONCLUSIONS

PMR seems effective in reducing the risk of IH after elective midline laparotomy compared to PSC in the medium-term follow-up. While the risk of postoperative seroma appears higher for PMR, hematoma, SSI, HLOS and OT seems comparable.

The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery

BACKGROUND

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair.

METHODS

The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews.

RESULTS

A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction.

CONCLUSION

Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.