Prophylactic mesh versus primary closure in emergency and elective surgeries: a systematic review and meta-analysis of randomized clinical trials

Incisional hernia is one of the most common post-operative complications. Previous studies showed that prophylactic mesh placement in laparotomy closure is safe and reduces the incidence of incisional hernia. We aimed to perform a meta-analysis comparing post-operative complications after the use of prophylactic permanent mesh placement versus primary closure in patients undergoing elective or emergency laparotomies. A systematic review of Cochrane Central Register of Controlled Trials, Embase and PubMed was performed in April 2024. Only randomized clinical trials were included. 1,234 studies were imported for screening. 280 were duplicated reports, 923 were excluded for irrelevancy and 16 were excluded after full-text review. Data were extracted in accordance with PRISMA guidelines and pooled by a random-effects model. The primary outcome was incidence of incisional hernia. Secondary outcomes included post-operative complications and period of hospitalization. Fifteen studies and 2,108 patients were included. Incisional hernia incidence was different between groups (risk ratio [RR] 0.30; 95% CI 0.21-0.43; p < 0.00001; I²=39%). This finding was confirmed in a subgroup analysis of elective (RR 0.29; 95% CI 0.18-0.46; p < 0.00001; I²=48%) versus emergency laparotomies (RR 0.28; 95% CI 0.19-0.43; p = 0.0001; I²=0%). There was no significant difference in incisional hernia incidence by locals of mesh placement. Secondary outcomes had shown no statistically significant difference between groups, except for seroma wherein primary closure had lower events (RR 1.80; CI 95% 1.21-2.68; p = 0.38; I²=7%). In patients undergoing laparotomy, prophylactic permanent mesh placement is associated with a significant reduction on incidence of incisional hernia as compared to primary closure.