Prophylactic mesh placement in midline laparotomy for patients with obesity: A systematic review and meta-analysis of evidence on safety, efficacy, and clinical guidelines

Omar Alaidaroos; Raghad Ahmed; Nabeel Aldinar; Joud Asfari; Abdulrahman Alsarari; Sara Alqazanli; Norah Abuwathlan; Abdulrahman Almasood; Lara Aljohani; Abdullah Bohairi; Omar Alaidaroos; Raghad Ahmed; Nabeel Aldinar; Joud Asfari; Abdulrahman Alsarari; Sara Alqazanli; Norah Abuwathlan; Abdulrahman Almasood; Lara Aljohani; Abdullah Bohairi

doi:10.3934/medsci.2026007

AIMS Medical Science

2026, Volume 13, Issue 1: 89-110. doi: 10.3934/medsci.2026007

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Research article

Prophylactic mesh placement in midline laparotomy for patients with obesity: A systematic review and meta-analysis of evidence on safety, efficacy, and clinical guidelines

College of Medicine, Almaarefa University, Riyadh, Saudi Arabia

Received: 03 December 2025 Revised: 15 February 2026 Accepted: 10 March 2026 Published: 26 March 2026

Background
A midline laparotomy causes an incisional hernia that is still prevalent and aggravated by obesity and comorbid conditions. Prophylactic mesh reinforcement (PMR) has also been suggested as a way to transform a high-tension suture line into a load-sharing repair, although concerns have been raised about patient selection, plane, and safety.
Methods
Our preferred Reporting items for systemic review and meta-analysis (PRISMA)-compliant systematic review took randomized trials that compared PMR and primary suture in an elective midline laparotomy and was supplemented by modern meta-analyses, a network meta-analysis of mesh planes, and its safety data over long term. The main outcome was an incisional hernia (IH) at 12 months; secondary outcomes were surgical-site infection (SSI), seroma, chronic pain, reoperation, and quality of life. Grading of recommendations assessment, development and evaluation (GRADE) was used to assess the certainty.
Results
Across randomized evidence, PMR reduced the IH with a pooled risk ratio near 0.38 (95% CI ~ 0.24–0.58) over 12–67 months. Long-term extensions confirmed the durability to five years. For obesity-restricted datasets, the effects trended towards being beneficial, but did not reach statistical significance (OR 0.59, 95% CI 0.34–1.01; p = 0.06), thus reflecting imprecision and heterogeneity. SSI did not increase with PMR in clean fields, whereas seroma was more frequent, especially with onlay placement without a consistent rise in chronic pain. Reoperation and explantation were uncommon and numerically lower after retromuscular placement than after onlay among reoperated patients. The network meta-analysis ranked onlay and retromuscular as the highest for IH prevention; taken with safety profiles, retromuscular emerged as a preferred option in experienced centers when the anatomy permits. The overall certainty for IH prevention was moderate; for obesity-restricted estimates, the overall certainty is low due to imprecision.
Conclusions
In patients with obesity, the current evidence suggests a possible benefit of PMR, but estimates remain imprecise and not statistically definitive, thus highlighting the need for targeted, adequately powered trials.
- prophylactic mesh,
- incisional hernia,
- midline laparotomy,
- obesity,
- retromuscular (sublay),
- onlay,
- randomized controlled trials,
- meta-analysis,
- surgical-site infection (SSI),
- seroma
Citation: Omar Alaidaroos, Raghad Ahmed, Nabeel Aldinar, Joud Asfari, Abdulrahman Alsarari, Sara Alqazanli, Norah Abuwathlan, Abdulrahman Almasood, Lara Aljohani, Abdullah Bohairi. Prophylactic mesh placement in midline laparotomy for patients with obesity: A systematic review and meta-analysis of evidence on safety, efficacy, and clinical guidelines[J]. AIMS Medical Science, 2026, 13(1): 89-110. doi: 10.3934/medsci.2026007

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Abstract

Background

A midline laparotomy causes an incisional hernia that is still prevalent and aggravated by obesity and comorbid conditions. Prophylactic mesh reinforcement (PMR) has also been suggested as a way to transform a high-tension suture line into a load-sharing repair, although concerns have been raised about patient selection, plane, and safety.

Methods

Our preferred Reporting items for systemic review and meta-analysis (PRISMA)-compliant systematic review took randomized trials that compared PMR and primary suture in an elective midline laparotomy and was supplemented by modern meta-analyses, a network meta-analysis of mesh planes, and its safety data over long term. The main outcome was an incisional hernia (IH) at 12 months; secondary outcomes were surgical-site infection (SSI), seroma, chronic pain, reoperation, and quality of life. Grading of recommendations assessment, development and evaluation (GRADE) was used to assess the certainty.

Results

Across randomized evidence, PMR reduced the IH with a pooled risk ratio near 0.38 (95% CI ~ 0.24–0.58) over 12–67 months. Long-term extensions confirmed the durability to five years. For obesity-restricted datasets, the effects trended towards being beneficial, but did not reach statistical significance (OR 0.59, 95% CI 0.34–1.01; p = 0.06), thus reflecting imprecision and heterogeneity. SSI did not increase with PMR in clean fields, whereas seroma was more frequent, especially with onlay placement without a consistent rise in chronic pain. Reoperation and explantation were uncommon and numerically lower after retromuscular placement than after onlay among reoperated patients. The network meta-analysis ranked onlay and retromuscular as the highest for IH prevention; taken with safety profiles, retromuscular emerged as a preferred option in experienced centers when the anatomy permits. The overall certainty for IH prevention was moderate; for obesity-restricted estimates, the overall certainty is low due to imprecision.

Conclusions

In patients with obesity, the current evidence suggests a possible benefit of PMR, but estimates remain imprecise and not statistically definitive, thus highlighting the need for targeted, adequately powered trials.

Conflict of interest

The authors declare no conflict of interest.

References

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