Routine Prophylactic Mesh at Midline Closure After AAA Repair Shows Improved Results Versus Suture

van den Berg R, Den Hartog FPJ, Baart SJ, et al. 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). Ann Surg. January 2026.

This individual patient data meta-analysis combined five randomized trials (n = 493) comparing prophylactic mesh augmentation with primary suture closure for midline laparotomy after open abdominal aortic aneurysm repair. 

Over a median follow-up of 24 months, mesh placement lowered the risk of incisional hernia, with an adjusted hazard ratio of 0.25 (95% CI, 0.12–0.50). At 3 years follow up, hernia rates were 13.2% with mesh versus 39.6% with suture, an absolute reduction of 27% and a number needed to treat of 3.7. Onlay and retro-rectus positions performed similarly for hernia prevention. Mesh increased operative time and was associated with more seromas, particularly with onlay placement, but did not increase surgical site infection and was linked to fewer subsequent hernia repairs.

For vascular and general surgeons performing open AAA, routine prophylactic mesh at midline closure is reasonable in appropriate candidates. When selecting the plane of reinforcement, retro-rectus mesh placement may lessen seroma risk where technical expertise is available, while onlay mesh placement is acceptable when retro-rectus dissection is not practical. 

The magnitude of hernia reduction, coupled with no infection penalty, supports standardizing mesh reinforcement with clear plans for technique, overlap, and fixation, while acknowledging the added operative time.