Prophylactic Mesh Placement for the Prevention of Incisional Hernia in High-Risk Patients After Abdominal Surgery: A Systematic Review and Meta-Analysis

Background and objectives In high-risk populations, the efficacy of mesh placement in incisional hernia (IH) prevention after elective abdominal surgeries has been supported by many published studies. This meta-analysis aimed at providing comprehensive and updated clinical implications of prophylactic mesh placement (PMP) for the prevention of IH as compared to primary suture closure (PSC). Materials and methods PubMed, Science Direct, Cochrane, and Google Scholar were systematically searched until March 3, 2020, for studies comparing the efficacy of PMP to PSC in abdominal surgeries. The main outcome of interest was the incidence of IH at different follow-up durations. All statistical analyses were carried out using Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and Stata 11.0 (Stata Corporation LP, College Station, TX). The data were pooled using the random-effects model, and odds ratio (OR) and weighted mean differences (WMD) were calculated with the corresponding 95% confidence interval (CI). Results A total of 3,330 were identified initially and after duplicate removal and exclusion based on title and abstract, 26 studies comprising 3,000 patients, were included. The incidence of IH was significantly reduced for PMP at follow-up periods of one year (OR= 0.16 [0.05, 0.51]; p=0.002; I(2)=77%), two years (OR= 0.23 [0.12, 0.45]; p<0.0001; I(2)=68%), three years (OR= 0.30 [0.16, 0.59]; p=0.0004; I(2)= 52%), and five years (OR=0.15 [0.03, 0.85]; p=0.03; I(2)=87%). However, PMP was associated with an increased risk of seroma (OR=1.67 [1.10, 2.55]; p= 0.02; I(2)=19%) and chronic wound pain (OR=1.71 [1.03, 2.83]; p= 0.04; I(2)= 0%). No significant difference between the PMP and PSC groups was noted for postoperative hematoma (OR= 1.04 [0.43, 2.50]; p=0.92; I(2)=0%), surgical site infection (OR=1.09 [0.78, 1.52]; p= 0.62; I(2)=12%), wound dehiscence (OR=0.69 [0.30, 1.62]; p=0.40; I(2)= 0%), gastrointestinal complications (OR= 1.40 [0.76, 2.58]; p=0.28; I(2)= 0%), length of hospital stay (WMD= -0.49 [-1.45, 0.48]; p=0.32; I(2)=0%), and operating time (WMD=9.18 [-7.17, 25.54]; p= 0.27; I(2)=80%). Conclusions PMP has been effective in reducing the rate of IH in the high-risk population at all time intervals, but it is associated with an increased risk of seroma and chronic wound pain. The benefits of mesh largely outweigh the risk, and it is linked with positive outcomes in high-risk patients.