Incisional hernia repair with mesh: How I choose it?

Incisional hernia is a common late complication of abdominal surgery. Treatment consists in restoring abdominal wall integrity, with prosthetic reinforcement to limit long-term recurrence. In practice, the choice of mesh is complicated by the wide variety of materials, their composition and biological behaviors, while current guidelines are broad and poorly discriminative according to indications. The aim of this review is to summarize the main criteria for selecting parietal meshes and their clinical impact, in order to propose recommendations for rational choice in each situation. Non-absorbable materials are standard in most indications, but are increasingly controversial because of long-term complications associated with a permanent foreign body: notably chronic inflammation, and environmental concerns related to micropollutants. Slowly or partially absorbable materials are a promising alternative, particularly in high-risk contexts, as they optimize tissue integration by modulating the immune response. However, further studies with high levels of evidence are needed to confirm indications. The physical characteristics of meshes, the clinical impact of which is difficult to pinpoint among other operative variables, should be re-assessed by manufacturers, in the light of newly available materials. The choice of parietal mesh is based on a combination of multiple interdependent parameters derived from preclinical and clinical studies. It should be primarily guided by clinical context and the risk of complications.