Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis

Background Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia. Methods A meta-analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow-up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random-effects model was used for the meta-analysis, and trial sequential analysis was conducted. Results Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0 center dot 35, 95 per cent c.i. 0 center dot 21 to 0 center dot 57; P < 0 center dot 001). Both onlay (RR 0 center dot 26, 0 center dot 11 to 0 center dot 67; P = 0 center dot 005) and retromuscular (RR 0 center dot 28, 0 center dot 10 to 0 center dot 82; P = 0 center dot 02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2 center dot 23, 1 center dot 10 to 4 center dot 52; P = 0 center dot 03). PMR did not result in an increased rate of surgical-site infection. Conclusion PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high-risk patients. Individual risk factors should be taken into account to select patients who will benefit most.