- Design
- Single-centre, double-blind randomised clinical trial
- Population
- 139 adults with ≥2 hernia risk factors having open right subcostal hepatobiliary surgery
- Primary outcome
- Radiological incisional hernia at 12–24 months
- Effect
- 24 months: 8.1% vs 37.5%; 12 months: 5.2% vs 21%
A double-blind randomised trial at one Spanish centre enrolled patients with two or more hernia risk factors having open right subcostal hepatobiliary surgery; 139 were analysed as allocated. Half had conventional closure, half had closure reinforced with prophylactic synthetic mesh.
At 12 months, radiological incisional hernia occurred in 5.2% with mesh and 21% without. At 24 months, it was 8.1% (4 of 49) versus 37.5% (18 of 48). Surgical site occurrences, complications and pain did not differ, and functional recovery was better with mesh. J incisions carried more hernias than Kocher incisions.
Mesh prophylaxis in midline laparotomy is already established; this extends it to the subcostal incision, where there was little evidence. For a high-risk patient having open liver or biliary surgery, mesh reinforcement is worth adding to the closure plan.
- Identify hernia risk factors pre-operatively: obesity, smoking, diabetes, previous hernia, steroid use.
- For two or more, plan mesh-reinforced subcostal closure.
- Prefer a Kocher incision over a J incision where access allows.
- Follow up with imaging if you want to know your true hernia rate — examination misses many.
Why it matters
Subcostal wounds have been treated as low-risk for hernia; in selected patients more than a third herniated by two years.
Don't overread it
One centre with substantial loss to follow-up; confirmation in a multicentre trial would firm this up.
The statistics, in plain English
An absolute fall from 37.5% to 8.1% means about one hernia prevented for every three to four patients meshed. But only about 70% of patients had 24-month imaging, and losses of that size can shift the estimate in either direction.
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