Onlay and retrorectus synthetic nonabsorbable mesh-augmented fascia closure during midline laparotomy: A systematic review and updated meta-analysis using trial sequential analysis

Abstract

Introduction: Randomized clinical trials (RCTs) and meta-analyses have confirmed the efficacy of prophylactic mesh placement. This study aimed to update evidence on IH prophylaxis using onlay (OM) or retrorectus (RM) mesh-augmented fascia closure and assess the certainty of evidence using trial sequential analysis (TSA). Methods: Scopus and Medline databases were searched to identify new studies on prophylactic OM and RM (2019–2022). Studies were eligible if they were RCTs and had investigated nonabsorbable mesh efficacy in midline laparotomy. Two independent reviewers extracted data and assessed the risk of bias. Relative risk (RR) of IH, with 95% confidence interval (CI), was estimated from a meta-analysis. Heterogeneities were explored using meta-regression, and publication bias was assessed. Required information size (RIS) was calculated using control event rate (CER) and relative risk reduction (RRR), and accumulated Z-scores were compared with adjusted significance boundary in TSA. Results: Nine RCTs were included for analysis. RR (95% CI) of IH compared to primary suture closure (PSC) was 0.28 (0.15, 0.50) for OM and 0.33 (0.17, 0.65) for RM. TSA indicated that evidence from meta-analyses for OM versus PSC and RM versus PSC was certain. However, uncertainty was observed in RM versus PSC meta-analysis when sensitivity TSA was performed using 40% RRR. Conclusions: Both OM and RM significantly lowered IH incidence, and TSA indicated that evidence from meta-analysis for OM versus PSC was certain. Evidence from RM versus PSC was less certain than that of OM versus PSC, especially when the results from sensitivity analysis were considered. Highlights