The role of prophylactic mesh placement to prevent incisional hernia in laparotomy. Is it time to change practice?

Background
Incisional hernia (IH) occurs in approximately 25% of laparotomies. Prophylactic mesh placement (PMP) may significantly reduce IH but is not widely used. This paper will review the evidence relating to the role of PMP in laparotomy and its ability to effectively and safely have an impact on hernia reduction.

Methods
An ethically approved review of all published English articles relating to IH prevention following laparotomy was undertaken at Letterkenny University Hospital by searching PubMed, Scopus, and electronic databases over a 20-year period from January 1999 to March 2019. The search terms “incisional hernia”, “laparotomy”, “mesh placement”, “reoperation”, “readmitted”, and “rates” were used in combination.

Results
The literature identified 17 publications, of which 14 were randomised, controlled trials and three were prospective cohort studies from 22 countries. Bariatric surgery accounted for eight of the 17 studies. Onlay mesh placement was used in five studies. Preperitoneal, retrorectus, intra-peritoneal, combinations of and sublay were used in 4, 3, 2, 2, and 1 studies, respectively. In two studies both sublay and onlay were performed. A total of 2777 patients were reported. One study had two publications with different lengths of follow-up.

Conclusions
Currently surgeons need to consider changing practice to firstly ensure they practice optimum laparotomy closure technique and potentially use PMP. If not using PMP they need to question why, because PMP will more than halve the IH rate, especially in higher risk patients undergoing laparotomy.