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

OBJECTIVE To systematically review the published literature on the use of prophylactic mesh reinforcement of midline laparotomy closures for prevention of ventral incisional hernias (VIH) SUMMARY BACKGROUND DATA:: VIH are common complications of abdominal surgery. Prophylactic mesh has been proposed as an adjunct to prevent their occurrence. METHODS PubMed, Embase, Scopus and Cochrane were reviewed for randomized controlled trials (RCTs) that compared prophylactic mesh reinforcement versus conventional suture closure of midline abdominal surgery. Primary outcome was the incidence of VIH at post-operative follow-up ≥24 months. Secondary outcomes included surgical site infection (SSI) and surgical site occurrence (SSO). Pooled risk ratios were obtained through random effect meta-analyses and adjusted for publication bias. Network meta-analyses were performed to compare mesh types and locations. RESULTS Of 1969 screened articles, twelve RCTs were included. On meta-analysis there was a lower incidence of VIH with prophylactic mesh (11.1%vs21.3%, RR = 0.32; 95%CI = 0.19-0.55, P < 0.001) however publication bias was highly likely. When adjusted for this bias, prophylactic mesh had a more conservative effect (RR = 0.52; 95%CI = 0.39-0.70). There was no difference in risk of SSI (9.1%vs8.9%, RR = 1.08, 95%CI = 0.82-1.43; P = 0.118), however, prophylactic mesh increased the risk of SSO (14.2%vs8.9%, RR = 1.57, 95%CI = 1.19-2.05; P < 0.001). CONCLUSION Current RCTs suggest that in mid-term follow-up prophylactic mesh prevents VIH with increased risk for SSO. There is limited long-term data and substantial publication bias.