Hernia, mesh, microbes, and phage promise: Mapping 35 years of evidence through a systematic review

Prosthetic mesh is the standard of care for hernia repair; however, mesh-related infections remain a significant biological challenge, with pooled data showing significant morbidity, recurrence, and elevated explantation risk. This study summarises microbiological trends documented over three decades of research, characterises the microbial landscape associated with mesh infections, and investigates how various mesh materials are associated with pathogen colonisation.

The objectives are to (i) analyse the aetiology and microbial distribution in mesh-associated infections, (ii) assess the frequency of infection-related events, including mesh removal and postoperative complications, across mesh types and surgical approaches, (iii) describe study population characteristics and procedural contexts where infections occurred, (iv) identify temporal patterns in published reports, and (v) evaluate variables associated with infection-related outcomes as reported in the literature.

Following PRISMA guidelines, systematic searches (1990-2025) yielded 4000 records; 584 studies met inclusion criteria, and 32 were eligible for meta-analysis, with uniform groupings by mesh type (polypropylene, biologic, composite, biosynthetic) and period (1990-2007, 2008-2025). Analytical outcomes included incisional hernia rates, surgical site infections (SSIs), explantations, and relevant patient factors, using random-effects modelling.

Of the 1213 studies screened, 584 met the inclusion criteria, and 32 were included in the meta-analysis. Mesh use did not correlate with a consistent reduction of surgical site infections (HR: 0.90; p = 0.396). Mesh explantation was significantly correlated with chronic infections (HR: 6.11; p < 0.0001). Polypropylene meshes are most commonly associated with polymicrobial infections, mostly caused by S. aureus, E. coli, and P. aeruginosa. This trend may be a reporting bias, as polypropylene meshes are the most commonly used meshes worldwide. No clinical studies were found for phage-coated meshes. Preclinical evidence demonstrates the strong antimicrobial potential of phage therapy on mesh materials, but clinical efficacy has not been studied yet.

The review summarises over 3 decades of hernia mesh research covering the use of mesh composition and materials, associated complications and infection management. With the rise of antibiotic resistance, bacteriophages are becoming a promising alternative for the treatment of mesh infections.