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Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis



With many different operative techniques in use to reduce the incidence of incisional hernias (IH) following a midline laparotomy, there is no consensus among the clinicians on the efficacy and safety of any particular repair technique. This meta-analysis compares the prophylactic onlay mesh repair (POMR) and primary suture repair (PSR) for the incidence of IH.


A meta-analysis and systematic review of MEDLINE, PubMed Central (via PubMed), Embase (via Ovid), SCOPUS, ScienceDirect, Google Scholar, SCI and Cochrane Library databases were undertaken. Seven randomized controlled trials assessing the outcomes of PSR and POMR were analyzed in accordance with the PRISMA statement. The risk of bias was assessed using the Rob2 tool.


According to the pooled analysis, POMR significantly reduced the incidence of IH compared to the PSR (OR 5.82 [95% CI 2.69, 12.58] P < 0.01) with a significantly higher seroma formation rate post-surgery (OR 0.35 [95% CI 0.18, 0.67] P < 0.01). Furthermore, the length of hospital stay (WMD −0.78 [95% CI −1.58, 0.02] P = 0.05) was significantly shorter for PSR compared to POMR group. Comparable effects were noted for reintervention, postoperative ileus, postoperative hematoma, postoperative mortality, long-term intervention and long-term deaths between the two groups.


POMR significantly reduces the risk of IH when compared to the PSR, with an increased risk of postoperative seroma formation and longer hospital stay. However, more RCTs with standardized protocols are needed for meaningful comparisons of the two interventions, along with longer duration of follow-up to assess the impact on the occurrence of IH.

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  1. 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

    Article  CAS  Google Scholar 

  2. Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A et al (2014) Incisional hernia rate 3 years after midline laparotomy. Br J Surg [Internet]. 2014 Jan [cited 2020 Sep 19] 101(2):51–54.

  3. Zhang L (2015) Incidence of abdominal incisional hernia in developing country: a retrospective cohort study. Int J Clin Exp Med [Internet]. 2015 [cited 2020 Sep 19]; 8(8):13649–13652.

  4. 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 [Internet]. 2010 Feb 1 [cited 2020 Sep 19]; 210(2): 210–219.

  5. Flum DR, Horvath K, Koepsell T (2003) Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg [Internet]. 2003 Jan 1 [cited 2020 Sep 19]; 237(1):129–135.

  6. Bhangu A, Fitzgerald JE, Singh P, Battersby N, Marriott P, Pinkney T (2013) Systematic review and meta-analysis of prophylactic mesh placement for prevention of incisional hernia following midline laparotomy [Internet]. Vol. 17, Hernia. Hernia; 2013 [cited 2020 Sep 19]. pp 445–455.

  7. 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 [Internet]. 2013 [cited 2020 Sep 19]; 30(4–6):401–409.

  8. 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 [Internet]. 2016 [cited 2020 Sep 19]; 263(4):638–645.

  9. Baylón K, Rodríguez-Camarillo P, Elías-Zúñiga A, Díaz-Elizondo JA, Gilkerson R, Lozano K (2017) Past, present and future of surgical meshes: a review [Internet]. Vol. 7, Membranes. MDPI AG; 2017 [cited 2020 Sep 19]. /pmc/articles/PMC5618132/?report=abstract

  10. Surgical mesh: a brief (and checkered) history—drug safety news [Internet]. [cited 2020 Sep 19].

  11. Luijendijk RW, Hop WCJ, van den Tol MP, de Lange DCD, Braaksma MMJ, IJzermans JNM et al (2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med [Internet]. 2000 Aug 10 [cited 2021 Jun 10]; 343(6):392–398.

  12. Cassar K, Munro A (2002) Surgical treatment of incisional hernia [Internet]. Vol. 89, British Journal of Surgery. Br J Surg; 2002 [cited 2021 Jun 10]. pp 534–545.

  13. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D et al European Hernia Society guidelines on the closure of abdominal wall incisions

  14. 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 (United States) 161(4):1149–1163

    Google Scholar 

  15. Wang XC, Zhang D, Yang ZX, Gan JX, Yin LN (2017) Mesh reinforcement for the prevention of incisional hernia formation: a systematic review and meta-analysis of randomized controlled trials [Internet]. Vol. 209, Journal of Surgical Research. Academic Press Inc.; 2017 [cited 2021 Jun 10]. pp 17–29.

  16. 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 [Internet]. Vol. 21, Hernia. Springer-Verlag France; 2017 [cited 2021 Jun 10]. pp 843–853.

  17. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J et al (2020) Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS open [Internet]. 2020 Jun 1 [cited 2021 Jun 10]; 4(3):357–368.

  18. Meta-analysis—methods for health and experimental studies|Shahjahan Khan|Springer [Internet]. [cited 2020 Nov 6].

  19. Viechtbauer W (2010) Conducting meta-analyses in R with the metafor. J Stat Softw [Internet]. 2010 Aug 5 [cited 2021 Feb 15]; 36(3):1–48.

  20. R: a language and environment for statistical computing [Internet]. [cited 2021 Feb 15].

  21. Cochran WG (1954) The combination of estimates from different experiments. Biometrics 10(1):101

    Article  Google Scholar 

  22. Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med [Internet]. 2002 Jun 15 [cited 2021 Feb 15]; 21(11):1539–1558.

  23. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J (2006) Assessing heterogeneity in meta-analysis: Q statistic or I 2 Index? Psychol Methods [Internet]. 2006 Jun [cited 2021 Feb 15]; 11(2):193–206.

  24. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol [Internet]. 2005 Apr 20 [cited 2021 Feb 15]; 5(1):13.

  25. Dersimonian R, Laird N Meta-analysis in clinical trials*

  26. Cochrane training|Trusted evidence. Informed decisions. Better health. [Internet]. [cited 2020 Sep 19].

  27. Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Br Med J [Internet]. 1997 Sep 13 [cited 2021 Feb 15]; 315(7109):629–634.

  28. Tang JL, Liu JL (2000) Misleading funnel plot for detection of bias in meta-analysis. J Clin Epidemiol [Internet]. 2000 May [cited 2021 Feb 15]; 53(5):477–484.

  29. Sutton AJ, Abrams KR, Jones DR, Sheldon T, Song F (2000) The James Lind Library The James Lind Library [Internet]. [cited 2021 Feb 15].

  30. Caro-Tarrago A, Olona Casas C, Jimenez Salido A, Duque Guilera E, Moreno Fernandez F, Vicente GV (2014) Prevention of incisional hernia in midline laparotomy with an onlay mesh: a randomized clinical trial. World J Surg 38(9):2223–2230.

    Article  CAS  PubMed  Google Scholar 

  31. Caro-Tarrago A, Olona C, Millán M, Olona M, Espina B, Jorba R (2019) Long-term results of a prospective randomized trial of midline laparotomy closure with onlay mesh. Hernia [Internet] 23(2):335–340.

    Article  CAS  Google Scholar 

  32. De La Peña CG, Medina Achirica C, Domínguez-Adame E, Medina Díez J (2003) Primary closure of laparotomies with high risk of incisional hernia using prosthetic material: analysis of usefulness. Hernia 7(3):134–136

    Article  Google Scholar 

  33. Timmermans L, Eker HH, Steyerberg ES, 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

    Article  Google Scholar 

  34. 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

    Article  Google Scholar 

  35. García-Ureña MÁ, López-Monclús J, Hernando LAB, Montes DM, De Lersundi ARV, 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

    Article  Google Scholar 

  36. Venclauskas L, Maleckas A, Kiudelis M (2010) One-year follow-up after incisional hernia treatment: results of a prospective randomized study. Hernia 14(6):575–582

    Article  CAS  Google Scholar 

  37. 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

    Article  CAS  Google Scholar 

  38. Lima HVG, Rasslan R, Novo FCF, Lima TMA, Damous SHB, Bernini CO et al (2020) Prevention of fascial dehiscence with onlay prophylactic mesh in emergency laparotomy: a randomized clinical trial. J Am Coll Surg 230(1):76–87

    Article  Google Scholar 

  39. Scott N, Go PMNY, Graham P, McCormack K, Ross SJ, Grant AM (2001) Open mesh versus non-mesh for groin hernia repair. Cochrane Database Syst Rev [Internet]. 2001 Jul 23 [cited 2020 Sep 19]; (4).

  40. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW (2008) Open surgical procedures for incisional hernias. Cochrane Database Syst Rev [Internet]. 2008 Jul 16 [cited 2020 Sep 19]; (3).

  41. Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS et al (2014) Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA Surg [Internet]. 2014 [cited 2020 Sep 19]; 149(5):415–421.

  42. Indrakusuma R, Jalalzadeh H, van der Meij JE, Balm R, Koelemay MJW (2018) Prophylactic mesh reinforcement versus sutured closure to prevent incisional hernias after open abdominal aortic aneurysm repair via midline laparotomy: a systematic review and meta-analysis [Internet]. Vol. 56, European Journal of Vascular and Endovascular Surgery. W.B. Saunders Ltd; 2018 [cited 2020 Sep 19]. pp 120–128.

  43. Giordano S, Garvey PB, Baumann DP, Liu J, Butler CE (2017) The impact of body mass index on abdominal wall reconstruction outcomes: a comparative study. J Am Coll Surg [Internet]. 2017 Oct 1 [cited 2021 Feb 4]; 225(4):S167.

  44. Alizai PH, Andert A, Lelaona E, Neumann UP, Klink CD, Jansen M (2017) Impact of obesity on postoperative complications after laparoscopic and open incisional hernia repair – A prospective cohort study. Int J Surg [Internet]. 2017 Dec 1 [cited 2021 Feb 4]; 48:220–224.

  45. Valverde S, SánchezLuis JL, Pereira JA, Armengol M, López-Cano M (2019) Elective and emergent laparotomy closure: the importance of protocolizing the technique. Cir Esp [Internet]. 2019 Feb 1 [cited 2020 Sep 19]; 97(2):97–102.

  46. Kurmann A, Barnetta C, Candinas D, Beldi G (2013) Implantation of prophylactic nonabsorbable intraperitoneal mesh in patients with peritonitis is safe and feasible. World J Surg [Internet]. 2013 [cited 2021 Jun 10]; 37(7):1657–1660.

  47. Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM (2012) Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases. Ann Surg [Internet]. 2012 Jan [cited 2021 Jun 10]; 255(1):176–180.

  48. Fortelny RH (2018) Abdominal wall closure in elective midline laparotomy: the current recommendations [Internet]. Vol. 5, Frontiers in Surgery. Frontiers Media S.A.; 2018 [cited 2021 Feb 3].

  49. Diener MK, Voss S, Jensen K, Büchler MW, Seiler CM (2010) Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg [Internet]. 2010 May [cited 2021 Feb 3]; 251(5):843–856.

  50. Cengiz Y, Blomquist P, Israelsson LA (2001) Small tissue bites and wound strength: an experimental study. Arch Surg [Internet]. 2001 Mar 1 [cited 2021 Feb 3]; 136(3):272–275.

  51. 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 [Internet]. 2015 Sep 26 [cited 2021 Feb 3]; 386(10000):1254–1260.

  52. Muysoms FE, Jairam A, López-Cano M, Śmietański M, Woeste G, Kyle-Leinhase I et al (2016) Prevention of incisional hernias with biological mesh: a systematic review of the literature [Internet]. Vol. 3, Frontiers in Surgery. Frontiers Media S.A.; 2016 [cited 2021 Feb 3].

  53. Salamone G, Licari L, Agrusa A, Romano G, Cocorullo G, Gulotta G (2015) Deep seroma after incisional hernia repair Case reports and review of the literature. Ann Ital Chir [Internet]. 2015 May 1 [cited 2021 Jun 10]; 2015-May(ePub):1–5.

  54. Höer J, Lawong G, Klinge U, Schumpelick V (2002) Einflussfaktoren der Narbenhernienentstehung: Retrospektive Untersuchung an 2.983 laparotomierten Patienten über einen Zeitraum von 10 Jahren. Chirurg [Internet]. 2002 May 1 [cited 2021 Jun 10]; 73(5):474–480.

  55. Köckerling F, Sheen AJ, Berrevoet F, Campanelli G, Cuccurullo D, Fortelny R et al (2019) The reality of general surgery training and increased complexity of abdominal wall hernia surgery [Internet]. Vol. 23, Hernia. Springer; 2019 [cited 2020 Oct 29]. pp 1081–91.

  56. Aquina CT, Fleming FJ, Becerra AZ, Xu Z, Hensley BJ, Noyes K et al (2017) Explaining variation in ventral and inguinal hernia repair outcomes: a population-based analysis. Surgery (United States) [Internet]. 2017 Sep 1 [cited 2020 Oct 29]; 162(3):628–639.

  57. Köckerling F (2018) What is the influence of simulation-based training courses, the learning curve, supervision, and surgeon volume on the outcome in hernia repair?—a systematic review [Internet]. Vol. 5, Frontiers in Surgery. Frontiers Media S.A.; 2018 [cited 2020 Nov 21]. p 57. /pmc/articles/PMC6172312/?report=abstract

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Hassan, M.A., Yunus, R.M., Khan, S. et al. Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis. World J Surg 45, 3080–3091 (2021).

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