Prophylactic Mesh Reinforcement More Effective Than Just Primary Suture in Reducing Midline Incisional Hernias

An incisional hernia is an opening on your abdominal wall that develops at the site of a prior surgical incision. Midline incisional hernias happen more frequently than other sites. An aortic aneurysm originating from the abdomen and a high body mass index (BMI) are the two most common risk factors, raising the probability by 40%.

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Surgical mesh

Surgical Mesh Credit: Doctoroftcm

Surgeons have proposed that using a prophylactic mesh to strengthen the incision or closing the fascia of the abdomen with the proper suturing technique can greatly reduce the likelihood of developing a midline incisional hernia. Nevertheless, the placement of these meshes has not yielded many long-term results, and the majority of the research that has been done is flawed. Thus far, it is thought that the use of a preventative onlay and sublay mesh would be advantageous and significantly lower the risk of midline incisional hernia. Onlay and sublay meshes are positioned in front and behind the defects, respectively.

Mesh proves to be better

A group of surgeons in the Netherlands carried out a long-term study called PRIMA, involving 480 participants who had a higher risk of developing an incisional hernia, to compare the outcome of applying mesh and using the small bite suturing technique. The recruitment and the surgeries were between 2009 and 2012, and a long-term follow-up was instituted. They accessed the outcome using CT scans, ultrasound, and physical examination of the incision sites.

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Looking at the results over the period of follow-up, the use of prophylactic mesh significantly reduced the incidence of hernias by half when compared to primary sutures. Reducing the risk of incisional hernias appeared to be equally effective with onlay and sublay mesh reinforcement. However, they suggested that the onlay mesh type could predispose individuals to infections, though it is less technical and easier to apply than sublay mesh.

The surgeons still debate whether a prophylactic mesh prevents long-term complications because so many patients were lost to follow-up and some died in the course of the study. Even though mesh reinforcement is a very effective technique, its results could be further enhanced if it were combined with the small bite technique used for fascia closure.

Clinical significance

Having a mesh in you to prevent a hernia after abdominal surgery is better than not having any at all. It is beneficial, especially if you are a high-risk patient. It reduces the incidence of incisional hernia, hastens recovery, and improves quality of life.

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Using mesh can greatly reduce the risk of a hernia occurrence, especially in high-risk patients such as the overly obese. However, if you have just had surgery and you feel something protruding from your abdomen, inform your doctor immediately.


Van den Dop, L. M., Sneiders, D., Yurtkap, Y., Werba, A., van Klaveren, D., Pierik, R. E. G. J. M., Reim, D., Timmermans, L., Fortelny, R. H., Mihaljevic, A. L., Kleinrensink, G.-J., Tanis, P. J., Lange, J. F., Jeekel, J., Grotelüschen, R., Roumen, R., van Baardewijk, L., van Brussel, J., van den Berg, M., Boomsma, M., … Eker, H. H. (2023). Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement vs. primary suture only in midline laparotomies (PRIMA): Long-term outcomes of a multicentre, double-blind, randomised controlled trial. The Lancet Regional Health – Europe.



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