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Prophylactic mesh placement lowers incisional hernia risk, but the ideal mesh type and anatomical plane remain unclear. This study aims to determine which mesh and placement site are associated with the lowest rates of incisional hernia and surgical site infection after stoma closure.
Methods
A systematic review of PubMed, the Cochrane Library, and Embase was conducted to identify comparative studies evaluating the type of mesh and/or the anatomical plane of mesh placement in the abdominal wall following stoma closure for the prevention of incisional hernias. A network meta-analysis was performed to assess incisional hernia and surgical site infection.
Results
We included 11 included studies involving 2,148 patients. The use of prosthetic mesh (OR = 0.137, 95%CI 0.056–0.335), bioprosthetic mesh (OR = 0.171, 95%CI 0.061–0.473), and biological mesh (OR = 0.528, 95%CI 0.336–0.828) was associated with a lower risk of incisional hernia compared to no mesh use. Mesh placement in a retromuscular position (OR = 0.068, 95%CI 0.024–0.189), onlay position (OR = 0.224, 95%CI 0.095–0.524), and intraperitoneal position (OR = 0.564, 95%CI 0.366–0.869) was associated with a lower risk of incisional hernia compared to no mesh use. No statistically significant differences were observed in surgical site infection risk between the use of different mesh types or anatomical planes and no mesh placement.
Conclusion
Prophylactic placement of prosthetic or bioprosthetic mesh in the retromuscular plane at the time of stoma closure is the most effective approach for reducing the incidence of incisional hernia and surgical site infection.
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Introduction
Temporary stomas are an essential component of the surgical armamentarium for various procedures, including colorectal cancer surgery, trauma management, diverticulitis, and bowel obstruction, among others [1]. Incisional hernia following stoma closure is a common complication, with an estimated incidence of approximately 17% [2]. This condition is associated with reduced quality of life, increased healthcare costs, and complications such as incarceration, bowel obstruction, and pain [3, 4].
To mitigate this issue, the use of prophylactic mesh at the stoma site after closure has been investigated. This approach has been shown to significantly reduce the risk of incisional hernia without increasing the incidence of complications such as surgical site infection, hematoma, seroma, or the need for reoperation [5].
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However, there is still no consensus regarding the optimal type of mesh or the most suitable anatomical plane of the abdominal wall for its placement when used prophylactically after stoma closure. The types of mesh described in the literature include prosthetic, bioprosthetic, and biological meshes, while the reported anatomical placement options include onlay, retromuscular, and intraperitoneal positions [4, 6, 7].
Given this context, the objective of this study is to determine which type of mesh and anatomical placement are associated with the lowest risk of incisional hernia and infection when prophylactic mesh is used after stoma closure.
Methods
A systematic review and meta-analysis network were reported following the “Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for network meta-analysis (NMA)” guidelines [8] (supplement 1) and “A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2)” [9]. This protocol was registered on PROSPERO under number CRD420251010934.
Information sources and search strategy
A literature search was conducted in PubMed, Embase and Cochrane from January 2023 to March 2025. It was performed using the following search terms: (hernia[MeSH] OR hernia* OR"incisional hernia"OR"abdominal hernia"OR"stomal hernia") AND (stoma[MeSH] OR stoma* OR"surgical stoma"OR"colostomy"OR"ileostomy"OR"urostomy"OR"enterostomy") (supplement 2). All studies before 2023 were selected using a systematic review by Dewantoro, et al. [10], this study was selected because it is the most recent systematic review available that evaluates the use of prophylactic mesh for the prevention of incisional hernias following stoma closure. The search imposed no restrictions on language or publication type.
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Study selection
After identifying and removing duplicate studies, electronically identified published papers were screened based on their titles and/or abstracts. Full-text papers deemed relevant for inclusion were then reviewed. Two investigators (C.R.-G. and I.V.-L.) independently assessed the full texts of the selected records, resolving any discrepancies through consensus. All studies identified during the search process were organized using Rayyan® [11], a validated web and mobile application for systematic reviews.
Eligibility criteria
Studies were eligible for inclusion in the systematic review if they were randomized controlled trials or non-randomized comparative studies evaluating the type of mesh and/or the anatomical plane of the abdominal wall where the mesh was placed after stoma closure. When multiple publications from the same study population were available, they were reviewed to assess the outcomes of interest, which might have been reported in different articles. If multiple articles reported the same outcomes but with a larger sample size or a longer follow-up period, the study with the most comprehensive data was selected. Studies that did not specify the type of mesh or the anatomical plane of placement were excluded. Additionally, case reports, comments, editorials, and reviews were not considered for inclusion.
Data Extraction
Data extraction was performed independently by two authors (C.R.-G. and S.S.F.) using Microsoft Excel spreadsheets (Microsoft Corp, Redmond, WA). Each article underwent a critical review by both authors separately, after which key study information was extracted and analyzed. The collected data included the first author’s name, year of publication, country of origin, intervention types and methods, sample size, demographic characteristics of the study population, and reported outcomes. Any discrepancies in data extraction were resolved by consensus, in cases where disagreement persisted, they were resolved by a third reviewer (A.I.-R.).
Outcome measures
The primary outcome was the occurrence of an incisional hernia, as the main purpose of placing a prophylactic mesh is to prevent incisional hernias. The secondary outcomes were surgical site infection.
Risk of bias and quality control
Quality assessment was conducted using the Joanna Briggs Institute (JBI) Critical Appraisal Tools, selecting the appropriate checklist based on the study design [12, 13]. The percentage of positive responses out of the total items was evaluated. Two authors (L.C.-D. and S.S.F.).independently assessed the quality of the studies, and any discrepancies were resolved by a third reviewer (A.I.-R.).
Statistical analysis
We conducted the network meta-analysis using a frequentist approach with a random-effects model based on the DerSimonian-Laird estimator. Odds ratios (ORs) with 95% confidence intervals (95% CI) were used as effect estimates and were summarized in forest plots. The network geometry was illustrated and evaluated using a network plot. We assessed the proportion of direct and indirect evidence contributing to each estimate. To rank treatments, we used P-scores, which measure the certainty that a given treatment is superior to another, averaged across all comparisons. P-scores range from 0 (worst) to 1 (best). Heterogeneity and inconsistency were assessed using Q statistics, with heterogeneity further quantified by the I2 statistic.
To assess the robustness and consistency of our findings, a sensitivity analysis was conducted using a Bayesian approach with a random-effects model. Posterior samples were generated via Markov Chain Monte Carlo simulation, running the analysis in four parallel chains. To ensure convergence, we performed 5000 burn-in simulations, followed by 100,000 additional simulations to produce the final estimates. The Brooks-Gelman-Rubin method was applied to assess model convergence, with a Potential Scale Reduction Factor (PSRF) below 1.05 considered acceptable. A rankogram was generated to visualize the probability of each treatment being the best, second-best, third-best option, and so on. Treatments were ranked according to the Surface Under the Cumulative Ranking Curve (SUCRA), ranging from 0 to 1, where higher values indicate a greater likelihood of being the most effective treatment.
Finally, we conducted a meta-regression analysis to assess the potential relationship between the anatomical plane in which the mesh was placed in the abdominal wall and the type of mesh used for each outcome. The meta-regression model was specified as follows: first, the effect size was defined as the proportion; thus, for each study, at least two effect measures were obtained—one proportion for each intervention group. A mixed-effects model was employed, incorporating a random effect associated with each study to account for variability between studies while reporting the proportions for each intervention. Fixed effects were specified using a regression model, which included the anatomical plane of mesh placement and the type of mesh as covariates.
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Publication bias was assessed using a comparison-adjusted funnel plot.
All analyses were performed using Rstudio® (version 2023.12.1 + 402) [14].
Results
Study selection and characteristics of included studies
After removing duplicates, we identified 1817 records. Titles and abstracts were screened, followed by a full-text review of 7 newly identified articles and 11 studies included in the previous version of the review, of which 11 met inclusion criteria (Fig. 1) (Supplement 3 shows reasons for exclusion).
Fig. 1
Flowchart representing information flow in each different stage of this systematic revision using PRISMA
The 11 included studies comprised a total of 2,148 patients (median: 94; interquartile range: 140). Among them, three were randomized controlled trials, while eight were non-randomized comparative studies, including six retrospective and two ambispective studies. All studies were published between 2013 and 2024.
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A summary of the characteristics of the included studies is presented in Table 1.
The use of prosthetic mesh (OR = 0.137, 95%CI 0.056–0.335), bioprosthetic mesh (OR = 0.171, 95%CI 0.061–0.473), and biological mesh (OR = 0.528, 95%CI 0.336–0.828) was associated with a lower risk of incisional hernia compared to no mesh use. However, no statistically significant superiority was observed among the different mesh types (Fig. 2A). The network plot illustrating the eligible comparisons between mesh types and incisional hernia is shown in Fig. 2B. Based on the P-score, prosthetic mesh was the most likely to result in the lowest incisional hernia rate, followed by bioprosthetic mesh (Table 2). There was no significant heterogeneity within the network (I2 = 1.4%, Cochran’s Q test = 3.75, p = 0.586), and no inconsistency was detected between direct and indirect comparisons (Cochran’s Q test = 3.35, p = 0.187). The proportion of direct and indirect evidence used in each comparison is provided in Supplement 4, where the mean path length for bioprosthetic versus prosthetic mesh and biological versus bioprosthetic mesh exceeds 2.
Fig. 2
Type of mesh and incisional hernia. A. Forest plot. B. Network graph
P-score and SUCRA according to type of mesh and wall plane for incisional hernia and surgical site infection
Type of mesh and incisional hernia
P-score
SUCRA
Prosthetic
0.8740
0.8521
Bioprosthetic
0.7855
0.7753
Biological
0.3394
0.3480
No mesh
0.0010
0.0244
Type of mesh and surgical site infection
Bioprosthetic
0.7600
0.7084
No mesh
0.5149
0.4899
Prosthetic
0.4917
0.4951
Biological
0.2334
0.3064
Wall plane for the mesh and incisional hernia
Retromuscular
0.9928
0.9702
Onlay
0.6641
0.6211
Intraperitoneal
0.3414
0.3430
No mesh
0.0017
0.0656
Wall plane for the mesh and surgical site infection
Retromuscular
0.6543
0.6327
Onlay
0.5119
0.5193
No mesh
0.4891
0.4992
Intraperitoneal
0.3448
0.3486
In the Bayesian sensitivity analysis, SUCRA rankings and the rankogram plot were consistent with the findings from the frequentist approach (Table 2 and Fig. 3A). Assessment of model convergence indicated adequate convergence, with a PSRF < 1.05 (Gelman-Rubin plot: Supplement 5).
Fig. 3
Rankogram plot according to type of mesh and wall plane for incisional hernia and surgical site infection
Funnel plots suggested no apparent publication bias among the included studies (Supplement 6).
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Type of mesh and surgical site infection
The use of prosthetic mesh (OR = 1.004, 95%CI 0.551–1.831), bioprosthetic mesh (OR = 0.637, 95%CI 0.163–2.489), and biological mesh (OR = 1.243, 95%CI 0.714–2.164) was not associated with a lower risk of surgical site infection compared to no mesh use (Fig. 4A). The network plot illustrating the eligible comparisons between mesh types and incisional hernia is shown in Fig. 4B. Based on the P-score, bioprosthetic mesh was the most likely to result in the lowest surgical site infection (Table 2). There was no significant heterogeneity within the network (I2 = 6.1%, Cochran’s Q test = 7.18, p = 0.304), and no inconsistency was detected between direct and indirect comparisons (Cochran’s Q test = 0.27, p = 0.600). The proportion of direct and indirect evidence used in each comparison is provided in Supplement 4, where the mean path length for bioprosthetic versus prosthetic mesh and biological versus bioprosthetic mesh exceeds 2.
Fig. 4
Type of mesh and surgical site infection. A. Forest plot. B. Network graph
In the Bayesian sensitivity analysis, the SUCRA rankings and the rankogram plot were consistent with the findings from the frequentist approach. However, a slight difference was observed between the second and third rankings compared to the P-score (Table 2 and Fig. 3B). Assessment of model convergence indicated adequate convergence, with a PSRF < 1.05 (Gelman-Rubin plot: Supplement 5).
Funnel plots suggested no apparent publication bias among the included studies (Supplement 6).
Wall plane for the mesh and incisional hernia
The placement of the mesh in a retromuscular position (OR = 0.068, 95% CI 0.024–0.189), onlay position (OR = 0.224, 95% CI 0.095–0.524), and intraperitoneal position (OR = 0.564, 95% CI 0.366–0.869) was associated with a lower risk of incisional hernia compared to no mesh use (Fig. 5A). The network plot illustrating the eligible comparisons between mesh positions and incisional hernia is shown in Fig. 5B. Based on the P-score, the retromuscular position was the most likely to result in the lowest incidence of incisional hernia (Table 2). There was no significant heterogeneity within the network (I2 = 0%, Cochran’s Q test = 5.78, p = 0.328), and no inconsistency was detected between direct and indirect comparisons (Cochran’s Q test = 0.00, p = 0.986). The proportion of direct and indirect evidence used in each comparison is provided in Supplement 4, where the mean path length for retromuscular versus intraperitoneal and onlay versus intraperitoneal exceeds 2.
Fig. 5
Wall plane and surgical site infection. A. Forest plot. B. Network graph
In the Bayesian sensitivity analysis, SUCRA rankings and the rankogram plot were consistent with the findings from the frequentist approach (Table 2 and Fig. 3C). Assessment of model convergence indicated adequate convergence, with a PSRF < 1.05 (Gelman-Rubin plot: Supplement 5).
Funnel plots suggested no apparent publication bias among the included studies (Supplement 6).
Wall plane for the mesh and surgical site infection
The placement of the mesh in a retromuscular position (OR = 0.787, 95% CI 0.251–2.465), onlay position (OR = 0.974, 95% CI 0.272–3.488), and intraperitoneal position (OR = 1.294, 95% CI 0.324–5.159) was not associated with a lower risk of surgical site infection compared to no mesh use (Fig. 6A). The network plot illustrating the eligible comparisons between mesh positions and incisional hernia is shown in Fig. 6B. Based on the P-score, the retromuscular position was the most likely to result in the lowest incidence of incisional hernia (Table 2). There was moderate heterogeneity within the network (I2 = 31.1%, Cochran’s Q test = 7.28, p = 0.200). The proportion of direct and indirect evidence used in each comparison is provided in Supplement 4, where the mean path length for retromuscular versus onlay, intraperitoneal versus onlay and intraperitoneal versus onaly exceeds 2.
Fig. 6
Wall plane and surgical site infection. A. Forest plot. B. Network graph
In the Bayesian sensitivity analysis, SUCRA rankings and the rankogram plot were consistent with the findings from the frequentist approach (Table 2 and Fig. 3D). Assessment of model convergence indicated adequate convergence, with a PSRF < 1.05 (Gelman-Rubin plot: Supplement 5).
Funnel plots suggested no apparent publication bias among the included studies (Supplement 6).
Meta-regression
The meta-regression analysis for incisional hernia, assessing the interaction between mesh type and wall plane for the mesh, found that the bioprosthetic-onlay combination (OR = 0.259, 95%CI 0.033–2.110) and the biological-onlay combination (OR = 0.894, 95%CI 0.160–4.995) did not show a statistically significant difference compared to no mesh placement. However, all other evaluated combinations demonstrated superiority over not placing a mesh. (Fig. 7)
Fig. 7
Forest plot of the proportion of incisional hernia according to the wall plane and the type of mesh. A. Incisional hernia. B. Surgical site infection
For the outcome of surgical site infection, the meta-regression analysis indicated that no specific combination was superior in reducing or increasing the risk of surgical site infection.
Quality assessment
The results of the JBI Critical Appraisal Tools assessment are detailed in Supplement 7. According to this evaluation, one cohort study met all criteria except for one item (90.9% compliance), two studies failed to meet two items (81.8% compliance), and the remaining cohort studies had three or more unmet criteria, with an overall compliance rate below 72.7%.
Regarding the randomized controlled trials, one study met all criteria except for one item (92.3% compliance), another failed to meet two items (84.6% compliance), and the last study did not meet three items (76.9% compliance).
Discussion
We found that placing prosthetic or bioprosthetic mesh in the retromuscular plane yields the most favorable outcomes, significantly reducing the risk of both incisional hernia and surgical site infection. Although mesh placement did not show statistically significant differences in surgical site infection rates compared to no mesh placement—regardless of the mesh type or anatomical plane—this concern remains one of the primary reservations surrounding prophylactic mesh use. Sensitivity analyses demonstrated consistent results between frequentist and Bayesian approaches, reinforcing the robustness and reliability of our findings.
Meta-regression analysis revealed that the combinations of bioprosthetic-onlay and biological-onlay meshes did not demonstrate superior protection against incisional hernia when compared to no mesh placement. Additionally, no specific combination showed a significant effect on the risk of surgical site infection. However, these results should be interpreted with caution, as the number of included studies was limited. This restricts the statistical power of the meta-regression and the ability to draw definitive conclusions regarding complex interactions between mesh type and placement plane. Therefore, these findings should be considered exploratory and hypothesis-generating.
The choice of anatomical plane and mesh type plays a critical role in the effectiveness of prophylactic mesh placement and should not be overlooked. Each plane carries distinct advantages and limitations. For example, the onlay plane is theoretically linked to a higher risk of surgical site infection due to its proximity to the skin and the clean-contaminated nature of the surgical field. Nevertheless, our findings did not demonstrate a statistically significant increase in infection rates with onlay mesh placement. Among all anatomical planes, the retromuscular position emerged in our analysis as the most favorable option. Although technically more demanding—particularly when the fascial defect is small—this plane offers biomechanical advantages. Retromuscular placement allows for better distribution of intra-abdominal pressure and may more effectively resist fascial disruption during increases in intra-abdominal pressure, such as those caused by Valsalva maneuvers. Additionally, because the mesh is positioned away from both the skin and intra-abdominal viscera, it is associated with lower risks of wound complications and visceral injury. These characteristics likely contribute to the lower incidence of incisional hernia observed with retromuscular mesh placement. However, this technique may require additional operative time, which could be a limiting factor in certain settings or when performed by non-hernia specialists. Intraperitoneal meshes, by contrast, must possess specific properties to reduce the risk of adhesions and visceral complications, which remains a key consideration when selecting this anatomical location [4].
Regarding mesh type, it is essential that it effectively prevents hernia formation and exhibits a low infection rate. In cases where infection occurs, the mesh should allow for salvage with a high success rate [26]. In this study, both prosthetic and bioprosthetic meshes demonstrated efficacy in preventing incisional hernia while showing infection risks comparable to those observed in patients without mesh placement.
Furthermore, it is important to highlight that prosthetic and bioprosthetic meshes tend to be more cost-effective. For instance, the ROCCS trial, which compared prophylactic biological mesh placement versus no mesh following stoma closure, found the intervention to be not cost-effective—a result that may have been influenced by the higher cost of biological mesh [18, 27].
This systematic review has several limitations. First, the anatomical plane of mesh placement was often poorly reported. We recommend avoiding vague terms like"underlay"or"sublay"because they may refer to various locations such as the retromuscular, retrorectus, transversalis fascial, preperitoneal, or intraperitoneal planes [28]. Additionally, certain planes that have not yet been adequately studied—such as the inter-oblique plane (for laterally placed stomas) or the anterectus plane (for transrectal stomas)—may offer technical advantages and comparable or improved outcomes (29). Second, beyond mesh type (prosthetic, bioprosthetic, or biological), mesh characteristics such as density and pore size, which may significantly influence surgical outcomes, were not consistently reported or analyzed. Third, the overall quality of included studies—especially observational studies—was generally low.
Conclusion
Based on the findings of this study, we conclude that the prophylactic placement of prosthetic or bioprosthetic mesh in the retromuscular plane at the time of stoma closure is the most effective approach for reducing the incidence of incisional hernia and surgical site infection. This strategy offers a favorable balance between clinical outcomes.
Declarations
Conflicts of interest
All authors declare no conflicts of interest.
Ethical approval
Ethical compliance with the Helsinki Declaration and current legislation on research 008430 − 1993 and Res. 2378 − 2008 (Colombia) and the International Committee of Medical Journal Editors (ICMJE) were ensured.
All authors reviewed and approved the final version of the manuscript.
Informed consent
Informed consent was not required, as this study is a systematic review based on data extracted from previously published articles.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
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Ein chirurgischer Eingriff kann für Patienten mit primärem Hyperparathyreoidismus gegenüber dem konservativen Management metabolisch von Vorteil sein. Denn wie eine Studie zeigt, senkt die Operation das Diabetesrisiko.
Beim Ernährungsmanagement vor und nach einer Krebs-Op. im Gastrointestinaltrakt klafft offenbar eine große Lücke zwischen Leitlinienempfehlungen und klinischer Praxis. Darauf deuten die Ergebnisse einer Umfrage in 263 deutschen Zentren hin.
Seit etwa 20 Jahren ist die Ballonsinuplastik als Option für die Therapie der chronischen Rhinosinusitis verfügbar. Zwei Studien haben sich nun mit der Frage beschäftigt, ob das Verfahren adäquat angewendet wird.
Patientinnen und Patienten, die schon früh am Tag auf dem OP-Tisch zu liegen kommen, haben bessere Überlebenschancen als am Nachmittag operierte. Allerdings sind die im Zuge einer Studie ermittelten Mortalitätsraten insgesamt niedrig und die Differenzen gering – wenngleich signifikant.
