Biologic versus synthetic mesh in open ventral hernia repair: A systematic review and meta-analysis of randomized controlled trials

Published:January 07, 2023DOI:



      Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair.


      A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.


      A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II–IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76–4.31; P < .00001; I2 = 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02–2.29; P = .04; I2 = 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups.


      As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases.
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        • Poulose B.K.
        • Shelton J.
        • Phillips S.
        • et al.
        Epidemiology and cost of ventral hernia repair: making the case for hernia research.
        Hernia. 2012; 16: 179-183
        • Burger J.W.A.
        • Luijendijk R.W.
        • Hop W.C.J.
        • et al.
        Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia.
        Ann Surg. 2004; 240: 578-585
        • Shankaran V.
        • Weber D.J.
        • Reed R.L.
        • Luchette F.A.
        A review of available prosthetics for ventral hernia repair.
        Ann Surg. 2011; 253: 16-26
        • Hiles M.
        • Record Ritchie R.D.
        • Altizer A.M.
        Are biologic grafts effective for hernia repair? A systematic review of the literature.
        Surg Innov. 2009; 16: 26-37
        • Rosen M.J.
        • Krpata D.M.
        • Petro C.C.
        • et al.
        Biologic vs synthetic mesh for single-stage repair of contaminated ventral hernias: a randomized clinical trial.
        JAMA Surg. 2022; 157: 293-301
        • United States Securities and Exchange Commission
        Tela Bio Annual Report. Published 2020.
        (Available from)
        • Darehzereshki A.
        • Goldfarb M.
        • Zehetner J.
        • et al.
        Biologic versus nonbiologic mesh in ventral hernia repair: a systematic review and meta-analysis.
        World J Surg. 2014; 38: 40-50
        • Harris H.W.
        • Primus F.
        • Young C.
        • et al.
        Preventing recurrence in clean and contaminated hernias using biologic versus synthetic mesh in ventral hernia repair: the PRICE randomized clinical trial.
        Ann Surg. 2021; 273: 648-655
      1. CDC Surgical Site Infection (SSI) Event.
        (Available from)
      2. Higgins J.P. Thomas J. Chandler J. Cochrane handbook for systematic reviews of interventions. Wiley-Blackwell, Hoboken (NJ)2019
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: 332-336
        • Thorlund K.
        • Imberger G.
        • Johnston B.C.
        • et al.
        Evolution of heterogeneity (I2) estimates and their 95% confidence intervals in large meta-analyses.
        PLoS One. 2012; 7e39471
        • Higgins J.P.T.
        • Altman D.G.
        • Gøtzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Olavarria O.A.
        • Bernardi K.
        • Dhanani N.H.
        • et al.
        Synthetic versus biologic mesh for complex open ventral hernia repair: a pilot randomized controlled trial.
        Surg Infect (Larchmt). 2021; 22: 496-503
        • Miserez M.
        • Lefering R.
        • Famiglietti F.
        • et al.
        Synthetic versus biological mesh in laparoscopic and open ventral hernia repair (LAPSIS): results of a multinational, randomized, controlled, and double-blind trial.
        Ann Surg. 2021; 273: 57-65
        • Menon N.G.
        • Rodriguez E.D.
        • Byrnes C.K.
        • Girotto BcA John
        • Goldberg N.H.
        • Silverman R.P.
        Revascularization of human acellular dermis in full-thickness abdominal wall reconstruction in the rabbit model.
        Ann Plast Surg. 2003; 50: 523-527
        • Silverman R.P.
        • Li E.N.
        • Holton L.H.
        • Sawan K.T.
        • Goldberg N.H.
        Ventral hernia repair using allogenic acellular dermal matrix in a swine model.
        Hernia. 2004; 8: 336-342
        • Cole W.C.
        • Balent E.M.
        • Masella P.C.
        • Kajiura L.N.
        • Matsumoto K.W.
        • Pierce L.M.
        An experimental comparison of the effects of bacterial colonization on biologic and synthetic meshes.
        Hernia. 2015; 19: 197-205
        • Primus F.E.
        • Harris H.W.
        A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions.
        Hernia. 2013; 17: 21-30
        • Huerta S.
        • Varshney A.
        • Patel P.M.
        • Mayo H.G.
        • Livingston E.H.
        Biological mesh implants for abdominal hernia repair: US food and drug administration approval process and systematic review of its efficacy.
        JAMA Surg. 2016; 151: 374-381
        • Zhou H.
        • Shen Y.
        • Zhang Z.
        • Liu X.
        • Zhang J.
        • Chen J.
        Comparison of outcomes of ventral hernia repair using different meshes: a systematic review and network meta-analysis.
        Hernia. 2022; 26: 1561-1571
        • Novitsky Y.W.
        • Rosen M.J.
        The biology of biologics.
        Plast Reconstr Surg. 2012; 130: 9S-17S
        • Breuing K.
        • Butler C.E.
        • Ferzoco S.
        • et al.
        Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair.
        Surgery. 2010; 148: 544-558
        • Carbonell A.M.
        • Criss C.N.
        • Cobb W.S.
        • Novitsky Y.W.
        • Rosen M.J.
        Outcomes of synthetic mesh in contaminated ventral hernia repairs.
        J Am Coll Surg. 2013; 217: 991-998
      3. Rodriguez-Quintero JH, Romero-Velez G, Lima DL, Huang L-C, Sreeramoju P, Malcher F. Permanent vs absorbable mesh for ventral hernia repair in contaminated fields: a multicenter propensity matched analysis of one-year outcomes using the abdominal core health quality collaborative database [e-pub ahead of print]. J Am Coll Surg. doi: 10.1097/xcs.0000000000000433. Accessed October 20, 2022.

        • Holihan J.L.
        • Alawadi Z.
        • Martindale R.G.
        • et al.
        Adverse events after ventral hernia repair: the vicious cycle of complications abstract presented at the Abdominal Wall Reconstruction Conference, Washington, DC, June 2014.
        J Am Coll Surg. 2015; 221: 478-485
        • Warren J.A.
        • Love M.
        • Cobb W.S.
        • et al.
        Factors affecting salvage rate of infected prosthetic mesh.
        Am J Surg. 2020; 220: 751-756
        • Dipp Ramos R.
        • O’Brien W.J.
        • Gupta K.
        • Itani K.M.F.
        Incidence and risk factors for long-term mesh explantation due to infection in more than 100,000 hernia operation patients.
        J Am Coll Surg. 2021; 232: 872-880.e2
        • Fischer J.P.
        • Basta M.N.
        • Krishnan N.M.
        • Wink J.D.
        • Kovach S.J.
        A cost-utility assessment of mesh selection in clean-contaminated ventral hernia repair.
        Plast Reconstr Surg. 2016; 137: 647-659