Systematic review and meta-analysis of mesh versus suture repairs of small umbilical hernias (≤ 2 cm)

Updated guidelines of approaches to small umbilical hernia repairs (UHRs) ≤ 2 cm defect size are inconclusive. Operations to resolve small UHRs remain high heterogeneous depending upon local guidelines and surgical expertise, therefore there is no clear optimal approach nor guideline. This systematic review and meta-analysis aims to evaluate mesh versus suture methodological approaches in small UHR.

Systematic search of four databases (EMBASE, PubMed, OVID, MEDLINE) retrieved relevant studies after screening, de-duplication, eligibility assessment and full-text analyses were conducted. Descriptive and numerical analysis was achieved for each included study in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias assessment was achieved using Cochrane risk of bias methodologies (Risk of bias in non-randomised studies, ROBINS-I; Risk of bias tool, RoB-2). Primary outcome assessed was recurrence; secondary outcomes included haematoma, bleeding, infection, systemic complications and patient-reported pain scores.

Mesh approaches to UHRs resulted in fewer recurrence rates postoperatively in variable follow-up periods (RR 0.46 (95% CI 0.38-0.55, I² = 0%, p < 0.00001). Limited intra-group meta-analysis of mesh techniques demonstrated improved recurrence rates associated with onlay mesh compared with inlay/plug, intraperitoneal and sublay approaches (p = 0.00162). Suture approaches were superior for haematoma/ bleeding (RR 1.74 95% CI 1.16-2.75, I² = 0%, p = 0.0009); infection risk (RR 1.75, 95% CI 1.18-2.59, I² = 0%, p = 0.007); however, did not reach statistical significance for pain scores postoperatively (RR = 1.20, 95% CI 0.98-1.47, I² = 0%, p = 0.07).

Mesh-based small UHRs offers superior outcomes for short and long-term recurrence rates, although increased risk of bleeding and infection. Subgroup analyses of mesh repairs revealed merit for onlay approaches for recurrence although analysis is limited by heterogeneous study design. No significant difference in recurrence risk with choice of suture material was found. Symptomatic burden and quality-of-life detriments were not significantly higher in mesh group therefore authors contend for greater adoption of mesh-based approaches in small UHRs. Further RCTs specifically investigating small UHRs are encouraged to establish long-term adverse consequences, and longitudinal patient-reported outcome measures.