Is there a role for prophylactic mesh in abdominal wall closure after emergency laparotomy? A systematic review and meta-analysis

Abstract

Background 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. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy. Methods A 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). 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. 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. Conclusion This 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.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

PREEMER trial: Study protocol for a randomized controlled trial

“…In the two previous studies on this topic, the SSI rate in a Swiss study was 60% and, respectively, only 17% in a Spanish study (11,12) .This reflects differences in their patient selection, as there were only subjects with peritonitis in the first study, while all kinds of emergency laparotomies were included in the latter. Neither of the studies included in the only meta-analysis on the topic were randomized controlled trials (2). There were also many methodological differences in both the mesh itself and the mesh placement in these two studies.…”

“…There were also many methodological differences in both the mesh itself and the mesh placement in these two studies. Thus, the conclusion of the only systematic review paper published on the topic was that there is a limited amount of data available for assessing the effect and safety of the use of prophylactic mesh in an emergency laparotomy setting (2). Thus, randomized control trials are required to address this important clinical question.…”

“…Emergency midline laparotomy is, in itself, a known risk factor of incisional hernia development with up to 33% incisional hernia incidence (1)(2)(3)(4). However, no evidence-based recommendations have been given on the optimal technique for closing midline emergency laparotomy incisions (5,6).…”

“…However, there have only been a few studies on incisional hernia prophylaxis within an emergency setting. In a recent systematic review and meta-analysis, the results of two studies, and altogether 299 patients, were eligible to be analyzed (2). A case-control study from Switzerland reported an incisional hernia rate of 3.2% (2/63) in its intra-abdominal mesh group and 28.6% (20/70) in its sutured control group after emergency midline laparotomy for peritonitis (11).…”

Long-term Follow-Up of Prophylactic Mesh Reinforcement After Emergency Laparotomy. Cohorts Study.

“…Mesh reinforcement in emergencies is controversial, and there is a lack of high-quality studies on this issue. On the one hand, a recent meta-analysis concluded that there was inadequate evidence to recommend its use in a standardized approach 17 ; on the other hand, a randomized control trial demonstrated that prophylactic mesh in EMLs reduced the incidence of dehiscence fascia when analyzing short-term outcomes, but with a higher incidence of surgical site infection (SSI) in the mesh group 18 . Surgical site occurrences (SSO) and acute and chronic infection are the main concerns for surgeons when implementing a prophylactic mesh, especially in the emergency setting, apart from other complications such as chronic pain and intestinal stulas 19 .…”