Lower Risk of Recurrence After Mesh Repair Versus Non-Mesh Sutured Repair in Open Umbilical Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background and Aims: The use of mesh repair in a small- or middle-sized umbilical hernia remains controversial, and evidence is based on only few and small heterogeneous randomized trials. The primary aim was to assess differences, if any, in recurrence (clinical and reoperation), and secondary aim was to assess differences in infections, seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. Method: A systematic review (predefined search strategy) and meta-analyses were conducted based on pre-study strict and well-defined methodology. The literature search was completed on 1 January 2018. The study protocol was registered in PROSPERO. Results: Five randomized controlled trials were identified (mesh repair, n = 326 versus non-mesh sutured repair, n = 330) and 602 records were excluded. Randomized controlled trials included patients with defect diameters of ⩾1 to 4 cm. Mesh repair reduced the risk of recurrence compared with sutured repair with a relative risk of 0.28 (95% confidence interval = 0.13–0.58, I2 = 0%, number needed to treat = 13 patients). Additional analyses found no differences between the two surgical techniques regarding infection (relative risk = 0.80, 95% confidence interval = 0.36–1.79), seroma formation (relative risk = 1.38, 95% confidence interval = 0.57–3.32), or hematomas (relative risk = 0.55, 95% confidence interval = 0.23–1.30). Lack of sufficient data precluded meta-analysis evaluating risk of seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. Conclusion: Mesh repair is recommended for umbilical hernia of ⩾1 to 4 cm. More evidence is needed for the optimal placement of the mesh (sublay or onlay) and the role of mesh in patients with an umbilical hernia <1 cm.

Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis

“…There was no difference between the groups regarding the risks of SSI, haematoma or chronic pain. These findings are in agreement with other reviews, in which mesh repair was associated with a lower rate of recurrence and an increased rate of seroma compared with suture.…”

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

“…All concluded that mesh is superior to sutures in terms of decreasing recurrence. The most recent high-quality meta-analysis 44 included data from RCTs 37,38,46 -48 , retrospective cohort studies 26,49 -51 prospective observational studies 25,31 and studies from hernia registries 40,52,53 . All found that the recurrence rate decreased with the use of mesh compared with sutures, without increasing surgical-site infections, seroma, haematoma or chronic pain.…”

“…Evidence is limited for hernia defects smaller than 1 cm. A subgroup analysis of a meta-analysis 44 suggested that mesh is also beneficial for small defects, in decreasing recurrence rates. More evidence is needed concerning the role and optimal placement of mesh in patients with an umbilical hernia smaller than 1 cm 44 .…”

“…The majority of umbilical and epigastric hernias are small or medium-sized, and an open repair with mesh reduces the recurrence rate without increasing complications, although data are limited for defects of 0-1 cm 44 . For all types of ventral hernia, sublay mesh placement has been associated with the lowest risk of surgical-site infection and/or recurrence 75,76 .…”

In support of mesh for hernia repair

“…Subsequent RCTs and registry studies have highlighted the effectiveness of laparoscopic mesh repair for inguinal hernia, with similar recurrence rates and risk profiles, but less postoperative pain, quicker recovery and less chronic pain. The benefits of mesh repair in inguinal hernia are replicated in primary ventral (umbilical and epigastric) hernia, with significantly lower recurrence rates compared with non‐mesh repair demonstrated in high‐quality RCTs, national registry studies and meta‐analyses.…”