Bahiana School of Medicine and Public Health, Dom João VI Avenue, 275, Brotas, BA, 40290-000, Brazil.
Department of Surgery, Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY, 10461, USA.
Hernia. 2024 Dec;28(6):2069-2078. doi: 10.1007/s10029-024-03106-9. Epub 2024 Jul 13.
Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR.
We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%.
2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay.
The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs.
A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).
最近的指南表明，对于大于 1 厘米的缺陷，UHR 中使用网片可减少复发，其复发率为 10%，而原发性闭合的复发率高达 54.5%。然而，Nguyen 等人表明，原发性闭合在 UHR 中仍广泛应用，特别是对于小缺陷（1-2 厘米），目前尚无发表的数据来确定最佳方法。此外，Madsen 等人之前的荟萃分析比较了 UHR 中网片修复与原发性闭合，并未排除急诊和复发性疝；也未报告疝缺陷大小的亚组分析。因此，我们旨在进行一项系统评价和荟萃分析，比较 UHR 中开放性原发性疝的网片修复与原发性缝合修复的效果。
我们在 PubMed、Scopus、Cochrane、Scielo 和 Lilacs 中检索了比较 UHR 中网片与缝线的研究，从开始到 2023 年 10 月。排除≤ 18 岁的患者、复发性或急诊条件的研究。结果包括复发、血清肿、血肿、伤口感染和住院时间。进行了亚组分析：（1）仅随机对照试验，（2）疝缺陷小于 2 厘米。我们使用 RevMan 5.4 进行统计分析。使用 I² 统计评估异质性，如果 I²>25%，则使用随机效应。
筛选了 2895 项研究，回顾了 56 项研究。共纳入 12 项研究，包括 4 项随机对照试验、1 项前瞻性队列研究和 7 项回顾性队列研究，共纳入 2926 例患者（网片组 47.6%，缝线组 52.4%）。总体分析显示，网片修复的复发率较低（RR 0.50；95%CI 0.31-0.79；P=0.003；I=24%），疝缺陷小于 2 厘米的复发率较低（RR 0.56；95%CI 0.34-0.93；P=0.03；I=0%）。缝线修复的血清肿（RR 1.88；95%CI 1.07-3.32；P=0.03；I=0%）和伤口感染（RR 1.65；95%CI 1.12-2.43；P=0.01；I=15%）的发生率较低，而随机对照试验的亚组分析没有差异。在血肿和住院时间方面没有差异。
与缝线修复相比，UHR 中使用网片在长期随访中显著降低了复发率，这强化了指南的先前指征。此外，尽管总体分析显示网片修复的血清肿和伤口感染风险较高，但随机对照试验的亚组分析没有差异。
该系统评价和荟萃分析的综述方案在 PROSPERO 中进行了注册（CRD42024476854）。
