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Mesh location in open ventral hernia repair: a systematic review and network meta-analysis
Abstract
There is no consensus on the ideal location for mesh placement in open ventral hernia repair (OVHR). We aim to identify the mesh location associated with the lowest rate of recurrence following OVHR using a systematic review and meta‐analysis. A search was performed for studies comparing at least two of four locations for mesh placement during OVHR (onlay, inlay, sublay, and underlay). Outcomes assessed were hernia recurrence and surgical site infection (SSI). Pairwise meta‐analysis was performed to compare all direct treatment of mesh locations. A multiple treatment meta‐analysis was performed to compare all mesh locations in the Bayesian framework. Sensitivity analyses were planned for the following: studies with a low risk of bias, incisional hernias, by hernia size, and by mesh type (synthetic or biologic). Twenty‐one studies were identified (n = 5,891). Sublay placement of mesh was associated with the lowest risk for recurrence [OR 0.218 (95 % CI 0.06–0.47)] and was the best of the four treatment modalities assessed [Prob (best) = 94.2 %]. Sublay was also associated with the lowest risk for SSI [OR 0.449 (95 % CI 0.12–1.16)] and was the best of the 4 treatment modalities assessed [Prob (best) = 77.3 %]. When only assessing studies at low risk of bias, of incisional hernias, and using synthetic mesh, the probability that sublay had the lowest rate of recurrence and SSI was high. Sublay mesh location has lower complication rates than other mesh locations. While additional randomized controlled trials are needed to validate these findings, this network meta‐analysis suggests the probability of sublay being the best location for mesh placement is high.
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“Several studies have demonstrated similar ratios of 2–3 times greater onlay recurrence rates compared to retrorectus recurrence rates, comparable to the current study [[30], [31], [32], [33], [34], [35]].”
From Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up (2021) · cites this paper as [33]
In the citing paper
“With follow-up ranging from 12 to 98 months, Holihan et al. reported a significantly higher recurrence rate (16.5% vs. 7%, OR 0.218) and incidence of SSI (16.9% vs. 3.7%, OR 0.449) for onlay repairs compared to retrorectus repairs (2.4 times greater recurrences for onlay vs. retrorectus).”
From Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up (2021) · cites this paper as [33]
In the citing paper
“With follow-up ranging from 12 to 98 months, Holihan et al. reported a significantly higher recurrence rate (16.5% vs. 7%, OR 0.218) and incidence of SSI (16.9% vs. 3.7%, OR 0.449) for onlay repairs compared to retrorectus repairs (2.4 times greater recurrences for onlay vs. retrorectus).”
From Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up (2021) · cites this paper as [33]
In the citing paper
“While synthetic non‐resorbable meshes, such as those based on polypropylene or polyester, remain the standard for clean cases due to their mechanical strength and low recurrence rates, they are associated with notable long‐term complications including chronic pain, infection, and fistula formation [2, 10, 17].”
From Long‐Term Outcomes After Slowly Resorbable P4HB Mesh Implantation: A Multicenter Analysis From European Registry (2026) · cites this paper as [2]
In the citing paper
“A recent meta‐analysis reported a pooled recurrence rate of 9% with a median follow‐up of over 5 years [2].”
From Long‐Term Outcomes After Slowly Resorbable P4HB Mesh Implantation: A Multicenter Analysis From European Registry (2026) · cites this paper as [2]
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Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2009.06.005 · Cited by 19,575
Demystifying trial networks and network meta-analysis
Mills, E. J., Thorlund, K., & Ioannidis, J. P. A. (2013) · BMJ · doi:10.1136/bmj.f2914 · Cited by 742
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Cited by
Capella-Monsonís, H., Crum, R. J., Hussey, G. S., & Badylak, S. F. (2024) · Advanced Drug Delivery Reviews · doi:10.1016/j.addr.2024.115347 · Cited by 84
Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus?
Parker, S. G., Wood, C. P. J., Sanders, D. L., & Windsor, A. C. J. (2017) · World Journal of Surgery · doi:10.1007/s00268-017-4037-0 · Cited by 40
Roth, J. S., Anthone, G. J., Selzer, D. J., Poulose, B. K., Pierce, R. A., Bittner, J. G., Hope, W. W., Dunn, R. M., Martindale, R. G., Goldblatt, M. I., et al. (2021) · Annals of Medicine and Surgery · doi:10.1016/j.amsu.2020.12.002 · Cited by 40
van den Berg, R., Wieser, M., López‐Cano, M., Bueno‐Lledó, J., Köckerling, F., Chatzimavroudis, G., Gonella‐Pacchiotti, C., Stabilini, C., Ortega‐Deballon, P., Romain, B., et al. (2026) · World Journal of Surgery · doi:10.1002/wjs.70331 · Cited by 1
Metadata
- Authors
- Holihan, J. L., Nguyen, D. H., Nguyen, M. T., Mo, J., Kao, L. S., & Liang, M. K.
- Affiliations
- Department of General Surgery University of Texas Health Science Center 6431 Fannin St 77030 Houston TX USA
- Venue
- World Journal of Surgery
- Publisher
- Wiley
- Published
- 2015-09-30
- Volume
- 40
- Issue
- 1
- Pages
- 89-99
- ISSN
- 0364-2313
- 1432-2323
- Cited by
- 314
- References
- 2
- Language
- en
- Licence
- onlinelibrary.wiley.com/termsAndConditions#vor (vor)
- www.springer.com/tdm (tdm)
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