A Systematic Review and Independent Patient Data Meta-Analysis of Prophylactic Mesh Augmentation for Incisional Hernia Prevention after Abdominal Aortic Aneurysm Surgery (I-PREVENT-AAA) A Collaborative European Hernia Society Project

Objective: To analyze the effectiveness of prophylactic mesh augmentation (PMA) of the abdominal wall following open aortic aneurysm repair as compared to primary sutured closure in preventing incisional hernia (IH) formation by performing an individual patient-data meta-analysis (IPDMA). Summary Background Data: IH is a prevalent complication after abdominal surgery, especially in high-risk groups. PMA of the abdominal wall has been studied as a preventive measure for IH-formation, but strong recommendations are lacking. Methods: A systematic literature search was conducted till 23 September 2024 to identify randomized controlled trials (RCTs) that compared PMA with PS after open AAA surgery. Lead authors of eligible studies were asked to share individual patient-data. A one-stage analysis was performed, and Cox-regression analyses were used to assess time-to-event outcomes. Results: Five randomized trials with a total of 493 patients were included. Intention to treat analysis revealed that PMA was associated with significantly lower risk of IH (hazard ratio of 0.25 (95% CI 0.12-0.50)) as compared to PS closure. Three-year incisional hernia rates were 13.2% and 39.6%, respectively, with a number needed to treat of 3.7. The effect was similar for onlay and retro-rectus PMA. PMA resulted in longer operative time (mean 27 minutes) and more seroma formation (especially onlay PMA) but did not increase the risk of surgical site infection. Conclusions: PMA after elective open abdominal aortic aneurysm surgery is proven to be an effective measure to reduce IH formation and should be considered in future guidelines as standard of care.