Role of prophylactic mesh in emergency midline laparotomy: a systematic review and meta-analysis

PURPOSE: The role of prophylactic mesh reinforcement in emergency laparotomy closure remains controversial. While prophylactic mesh may reduce incisional hernia, its use in unstable and contaminated settings raises concerns regarding operative time, seroma development, and wound complications. This meta-analysis of randomized controlled trials (RCTs) evaluated the safety and efficacy of prophylactic mesh versus primary suture closure in emergency midline laparotomy. METHODS: A systematic search was performed for RCTs comparing prophylactic mesh with suture closure in adult patients undergoing emergency midline laparotomy. Primary outcomes were overall wound complications (OWC) and incisional hernia (IH). Secondary outcomes included superficial and deep surgical site infection, wound dehiscence (WD), seroma, hematoma, operative time, postoperative pain, quality of life, hospital and ICU stay, transfusion, and mortality. RESULTS: Seven RCTs comprising 643 patients were included. Mesh reinforcement reduced incisional hernia incidence, with significant reductions at 1 month (RR 0.29, 95% CI 0.12-0.68), 6 months (RR 0.11, 95% CI 0.01-0.86), 12 months (RR 0.21, 95% CI 0.09-0.49), and 24 months (RR 0.27, 95% CI 0.15-0.49). Mesh increased seroma risk (RR 2.45, 95% CI 1.38-4.35) and, was associated with higher overall wound complications (RR 1.50, 95% CI 1.04-2.18). No significant differences were found in SSI, wound dehiscence, hematoma, transfusion, ICU or hospital stay, pain, quality of life, or mortality. Operative time was longer with mesh (MD 26 min, 95% CI 15.9-36.9). CONCLUSION: Prophylactic mesh in emergency laparotomy closure poses a clinical dilemma: it lowers the risk of incisional hernia but prolongs surgery and increases seroma and wound complications. Current evidence underscores the trade-off between long-term prevention and short-term morbidity. Larger, protocol-driven trials with long-term follow-up are needed to determine in which patients and wound classes mesh reinforcement is justified.