Abstract
BackgroundIncisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy.MethodsA systematic review was performed according to the PROSPERO registered protocol (CRD42018109283). Papers were dual screened for eligibility, and included when a comparison was made between closure with prophylactic mesh and closure with a standard technique, reported using a comparative design (i.e. case–control, cohort or randomised trial), where the primary outcome was incisional hernia. Bias was assessed using the Cochrane risk of bias in non-randomised studies tool. A meta-analysis of incisional hernia rate was performed to estimate risk ratio using a random effects model (Mantel–Haenszel approach).Results332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included. Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Both studies found significantly fewer incisional hernias in the mesh groups [3.2% vs 28.6% (p < 0.001) and 5.9% vs 33.3% (p = 0.0001)]. A meta-analysis of incisional hernia risk favoured prophylactic mesh closure [risk ratio 0.15 (95% CI 0.6–0.35, p < 0.001)]. Neither study found an association between mesh and infection or enterocutaneous fistula.ConclusionThis review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting. The current data cannot reliably assess the use of mesh due to confounding factors, and a randomised controlled trial is required to address this important clinical question.
Highlights
Incisional hernia (IH) is a protrusion of intra-abdominal contents through a surgically related defect in the anterior abdominal wall [1]
The Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) [11] and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines [12] were used to report the findings of the study
Reasons for exclusion were mesh as secondary closure (n = 3) [14–16], mesh as temporary closure (n = 1) [17], elective laparotomy (n = 4) [18–21], unable to retrieve article (n = 2) [22, 23], not in English language (n = 7) [24–30], conference proceedings (n = 5) [31–35], duplicate (n = 1) [36], case report (n = 1) [37], non-GI indication for laparotomy (n = 1) [38] and non-mesh closure (n = 1) [39]
Summary
Incisional hernia (IH) is a protrusion of intra-abdominal contents through a surgically related defect in the anterior abdominal wall [1]. There have been promising results in the elective setting, with a significant reduction in IHs seen in multiple randomised studies [6, 7]. Incisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. Results 332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Conclusion This review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting.
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