Prophylactic Mesh Reinforcement Versus Primary Suture for Midline Laparotomy Closure: An Updated Systematic Review and Meta-Analysis

Incisional hernia remains a common postoperative complication following elective midline laparotomy. Prophylactic mesh reinforcement has been proposed to reduce hernia formation, although concerns regarding postoperative complications and variation in operative technique have limited routine adoption. This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and registered on PROSPERO (CRD420251172749). A comprehensive search identified RCTs comparing prophylactic mesh reinforcement with primary suture closure in elective midline laparotomy. The primary outcome was incisional hernia incidence at ≥12 months follow-up. Data were pooled using fixed-effects meta-analysis. Four RCTs comprising 1,006 patients met criteria for quantitative synthesis. Prophylactic mesh significantly reduced the incidence of incisional hernia compared with primary suture closure (relative risk (RR) 0.39, 95% confidence interval (CI) 0.27-0.57). Heterogeneity was moderate (I² = 44.6%). Observational studies supported similar trends without evidence of increased clinically significant wound morbidity. Prophylactic mesh reinforcement reduces the risk of incisional hernia following elective midline laparotomy without clear evidence of increased postoperative complications. Selective use in high-risk patients may improve long-term abdominal wall outcomes, although further standardized studies are warranted.