Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy



The prevalence of incisional hernias (IHs) is still high after midline laparotomy (ML). There is an increasing body of evidence that prophylactic mesh placement (PMP) can be safe and efficient in the short-term outcomes, but there still are some concerns about the potential long-term complications of these meshes. This study describes our long-term PMP experience.


Observational and prospective study including all patients undergoing the use of prophylactic onlay large-pore polypropylene meshes for the closure of ML since 2008 to 2014. Outcome measures included demographics, perioperative details, wound complications, recurrences, reoperations and chronic complications.


A cohort of 172 patients was analysed: 75% elective surgery, 25% emergency cases. Mean age was 68 years with mean body mass index (BMI) of 28.6 kg/m2. Wound classification: 6.4% clean; 85% clean-contaminated; 1.2% contaminated and 8.1% dirty. Follow-up of patients was up to 8 years (mean: 5 ± 1.6). Two meshes were removed due to chronic infection in first six postoperative months. Of the 13 patients (9.02%) who developed IH, 5 of them have been reoperated for IH repair without any difficulty related to previous mesh. During follow-up, 8 patients have been reoperated for other reasons and the integrity of abdominal wall was also checked. After the comparative study, higher BMI and emergency surgery were still risk factors for IH despite PMP.


In our setting, the use of polypropylene prophylactic meshes in MLs is safe, efficient and durable.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7



American Society of Anesthesiologists


Body mass index


Chronic obstructive pulmonary disease


Computed tomographic scan


Incisional hernia


Midline laparotomy


Prophylactic mesh placement


Quality of life


Randomized controlled trial


Risk ratio


Statistical package for the social sciences


Surgical site infection


  1. 1.

    Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A (2010) Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg 210(2):210–219

  2. 2.

    Rhemtulla IA, Messa CA, Enriquez FA, Hope WW, Fischer JP (2018) Role of prophylactic mesh placement for laparotomy and stoma creation. Surg Clin North Am 98(3):471–481

  3. 3.

    Jairam AP, Timmermans L, Eker HH, Pierik REGJM, van Klaveren D, Steyerberg EW et al (2017) Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial. Lancet 390(10094):567–576

  4. 4.

    Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M et al (2016) Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Ann Surg 263(4):638–645

  5. 5.

    Alnassar S, Bawahab M, Abdoh A, Guzman R, Al Tuwaijiri T, Louridas G (2012) Incisional hernia postrepair of abdominal aortic occlusive and aneurysmal disease: five-year incidence. Vascular 20(5):273–277

  6. 6.

    Mingoli A, Puggioni A, Sgarzini G, Luciani G, Corzani F, Ciccarone F et al (1999) Incidence of incisional hernia following emergency abdominal surgery. Ital J Gastroenterol Hepatol 31(6):449–453

  7. 7.

    Argudo N, Pereira JA, Sancho JJ, Membrilla E, Pons MJ, Grande L (2014) Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis. Surgery 156(5):1238–1244

  8. 8.

    Burger JWA, Luijendijk RW, Hop WCJ, Halm JA, Verdaasdonk EGG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240(4):578–583

  9. 9.

    Borab ZM, Shakir S, Lanni MA, Tecce MG, MacDonald J, Hope WW et al (2017) Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis. Surgery 161(4):1149–1163

  10. 10.

    Gillion J-F, Sanders D, Miserez M, Muysoms F (2016) The economic burden of incisional ventral hernia repair: a multicentric cost analysis. Hernia 20(6):819–830

  11. 11.

    Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y et al (2014) Incidence of and risk factors for incisional hernia after abdominal surgery. Br J Surg 101(11):1439–1447

  12. 12.

    Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D et al (2015) European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 19(1):1–24

  13. 13.

    Timmermans L, de Goede B, Eker HH, van Kempen BJH, Jeekel J, Lange JF (2013) Meta-analysis of primary mesh augmentation as prophylactic measure to prevent incisional hernia. Dig Surg 30(4–6):401–409

  14. 14.

    García-Ureña M, López-Monclús J, Hernando LAB, Montes DM, Valle de Lersundi AR, Pavón CC et al (2015) Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery. Ann Surg 261(5):876–881

  15. 15.

    STROBE statement (2017) Accesed 30 Oct 2017

  16. 16.

    Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR et al (2017) Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 152(8):784

  17. 17.

    Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R et al (2015) A classification of chronic pain for ICD-11. Pain 156(6):1

  18. 18.

    Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E et al (2009) Classification of primary and incisional abdominal wall hernias. Hernia 13(4):407–414

  19. 19.

    Millbourn D, Cengiz Y, Israelsson LA (2009) Effect of stitch length on wound complications after closure of midline incisions. Arch Surg 144(11):1056

  20. 20.

    Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J et al (2015) Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 386(10000):1254–1260

  21. 21.

    Wang X-C, Zhang D, Yang Z-X, Gan J-X, Yin L-N (2017) Mesh reinforcement for the prevention of incisional hernia formation: a systematic review and meta-analysis of randomized controlled trials. J Surg Res 209:17–29

  22. 22.

    Payne R, Aldwinckle J, Ward S (2017) Meta-analysis of randomised trials comparing the use of prophylactic mesh to standard midline closure in the reduction of incisional herniae. Hernia 21(6):843–853

  23. 23.

    Díaz-Godoy A, García-Ureña MA, López-Monclús J, Vega V, Melero D, Erquinigo N (2011) Searching for the best polypropylene mesh to be used in bowel contamination. Hernia 15(2):173–179

  24. 24.

    Bevis PM, Windhaber RAJ, Lear PA, Poskitt KR, Earnshaw JJ, Mitchell DC (2010) Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery. Br J Surg 97(10):1497–1502

  25. 25.

    Strzelczyk JM, Szymański D, Nowicki ME, Wilczyński W, Gaszynski T, Czupryniak L (2006) Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery. Br J Surg 93(11):1347–1350

  26. 26.

    Abo-Ryia MH, El-Khadrawy OH, Abd-Allah HS (2013) Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development. Obes Surg 23(10):1571–1574

  27. 27.

    Hidalgo MP, Ferrero EH, Ortiz MA, Castillo JMF, Hidalgo AG (2011) Incisional hernia in patients at risk: can it be prevented? Hernia 15(4):371–375

  28. 28.

    Bali C, Papakostas J, Georgiou G, Kouvelos G, Avgos S, Arnaoutoglou E et al (2015) A comparative study of sutured versus bovine pericardium mesh abdominal closure after open abdominal aortic aneurysm repair. Hernia 19(2):267–271

  29. 29.

    Llaguna OH, Avgerinos DV, Nagda P, Elfant D, Leitman IM, Goodman E (2011) Does prophylactic biologic mesh placement protect against the development of incisional hernia in high-risk patients? World J Surg 35(7):1651–1655

  30. 30.

    Söderbäck H, Mahteme H, Hellman P, Sandblom G (2016) Prophylactic resorbable synthetic mesh to prevent wound dehiscence and incisional hernia in high-risk laparotomy: a pilot study of Using TIGR Matrix Mesh. Front Surg 3:28

  31. 31.

    Timmermans L, Eker HH, Steyerberg EW, Jairam A, de Jong D, Pierik EGJM et al (2015) Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia. Ann Surg 261(2):276–281

  32. 32.

    Gurusamy KS, Allen VB (2013) Wound drains after incisional hernia repair. Cochrane Database Syst Rev 17(12):CD005570

  33. 33.

    Fortelny RH, Petter-Puchner AH, Glaser KS, Redl H (2012) Use of fibrin sealant (tisseel/tissucol) in hernia repair: a systematic review. Surg Endosc 26(7):1803–1812

  34. 34.

    Plencner M, East B, Tonar Z, Otáhal M, Prosecká E, Rampichová M et al (2014) Abdominal closure reinforcement by using polypropylene mesh functionalized with poly-ε-caprolactone nanofibers and growth factors for prevention of incisional hernia formation. Int J Nanomedicine 9:3263–3277

  35. 35.

    Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C et al (2009) Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions. Ann Surg 249(4):576–582

  36. 36.

    Fischer JP, Basta MN, Wink JD, Krishnan NM, Kovach SJ (2015) Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia. Surgery 158(3):700–711

  37. 37.

    Pans A, Elen P, Dewé W, Desaive C (1998) Long-term results of polyglactin mesh for the prevention of incisional hernias in obese patients. World J Surg 22(5):479–482

  38. 38.

    Mangano A, Lianos GD, Rausei S, Boni L, Dionigi G (2014) Incisional hernia rate 3 years after midline laparotomy. Br J Surg 101(8):1032–1032

Download references


We would like to thank Dr. Tobby Hammond, from Broomfield Hospital, Mid Essex Hospital Trust, UK, for his careful and extensive revision of the English grammar and composition of this manuscript.


This study was not funded.

Author information

MAGU, LAB and JLM conceived of the presented idea. MAGU, CS and DM designed the study. CS, EJ, CJ and PL collected data from the registry and AR verified the analytical methods. MAGU and EG encouraged CS, DM and EJ to investigate and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.

Correspondence to C. San Miguel.

Ethics declarations

Conflict of interest

Dr. San Miguel reports no biomedical financial interests or potential conflicts of interest. Dr. Melero reports no biomedical financial interests or potential conflicts of interest. Dra. Jiménez E reports no biomedical financial interests or potential conflicts of interest. Dra. López reports no biomedical financial interests or potential conflicts of interest. Dr. Robin reports no biomedical financial interests or potential conflicts of interest. Dr. Blázquez reports having received lecture fees from WL Gore & Associates. Dr. López-Monclús reports having received grants from Gore. Dr. González reports no biomedical financial interests or potential conflicts of interest. Dra. Jiménez C reports no biomedical financial interests or potential conflicts of interest. Dr. García-Ureña reports having received lecture fees from Covidien and B Braun, grants from Gore and fees for development of educational presentations from Gore and Medtronic.

Ethical approval

Approval from the institutional review board was not required for this study.

Human and animal rights

The study including human participants has been performed in accordance with the ethical standards of the Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was obtained from all patients prior to all surgical procedures.

Additional information

This study has not been previously published or submitted elsewhere for publication and it will not be sent to another journal until a decision will be made concerning publication by HERNIA.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MP4 141266 KB)

Supplementary material 1 (MP4 141266 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

San Miguel, C., Melero, D., Jiménez, E. et al. Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy. Hernia 22, 1113–1122 (2018).

Download citation


  • Incisional hernia
  • Prophylactic mesh
  • Midline laparotomy
  • Polypropylene mesh