Mesh Safety Under Contamination Across Incarcerated Hernias: A Single-Center Cohort Analysis With a Systematic Review of Adult Bochdalek Hernia Complicated by Gastric Pathologies

BackgroundWhether prosthetic mesh increases infection in contaminated fields remains controversial, particularly in incarcerated hernias and adult Bochdalek hernia (BH) with gastric pathology.MethodsWe combined a PRISMA-guided systematic review of adult BH with gastric pathology (14 cases, 1981-2025) with a single-center retrospective cohort of incarcerated hernias treated laparoscopically or laparoscopy-assisted (n = 313; inguinal 177, incisional 111, diaphragmatic 10 [4 BH, 1 Morgagni], and hiatal 15). Pure open repairs were excluded. Intraoperative findings were stratified as clean, mild, or severe contamination. Primary endpoint: 3-month infectious outcomes (surgical site infection, intra-abdominal abscess, and mesh infection) comparing mesh vs non-mesh repair. A representative BH case with gastric antral perforation managed by one-stage gastric repair and mesh-reinforced diaphragmatic closure is presented.ResultsAmong clean cases receiving mesh, the 3-month infection rate was 1.5% (3/198). In mild contamination, mesh did not increase infection compared with non-mesh repair (10.0% [4/40] vs 6.7% [3/45]; RR 1.50, 95% CI 0.36-6.30; <i>P</i> = .702). In severe contamination, infection rates were also similar (21.4% [3/14] vs 18.8% [3/16]; RR 1.14, 95% CI 0.27-4.78; <i>P</i> = 1.000). The BH review showed 57.1% gastric volvulus and 42.9% perforation/necrosis; mesh was used selectively (21.4%) in staged or clean settings, and 37.5% of female cases occurred during pregnancy.ConclusionsIn this laparoscopic-dominant cohort, mesh repair after meticulous lavage was not associated with higher 3-month infection across contamination strata and appeared safe in selected severely contaminated cases. These findings support a contamination-aware, selective mesh strategy within a CT-first, laparoscopy-first pathway and warrant prospective validation, particularly for open repairs and longer follow-up.