Prophylactic mesh at subcostal closure cut incisional hernia in high-risk hepatobiliary patients

Design

Single-centre, double-blinded randomised clinical trial

Population

139 adults with 2 or more hernia risk factors having open right subcostal hepatobiliary surgery

Primary outcome

Radiological incisional hernia at 12 to 24 months

Effect

24 months: 8.1% (4/49) with mesh vs 37.5% (18/48) without; 12 months: 5.2% vs 21%

A double-blinded randomised trial from a single Spanish hospital (JAMA Surgery, 9 September 2026) enrolled adults with at least two risk factors for incisional hernia who were having open right subcostal hepatobiliary surgery. After intraoperative exclusions, 66 had conventional closure reinforced with a synthetic mesh and 73 had conventional closure alone.

Radiological incisional hernia at 12 months was 5.2% with mesh and 21% without. At 24 months it was 8.1% (4 of 49) with mesh and 37.5% (18 of 48) without. Wound events, complications and pain did not differ, and functional recovery was better with mesh. J-shaped incisions herniated more often than Kocher incisions.

Subcostal incisions are often assumed to be safer than midline ones, and this trial shows how often they fail in high-risk patients. The caveats are real: one centre, small numbers, and about a third of patients not imaged at two years. Even so, the size of the difference is large.

For high-risk patients having open subcostal hepatobiliary surgery, this supports considering a prophylactic synthetic mesh at closure, and preferring a Kocher incision to a J incision where exposure allows.

• Count hernia risk factors before closing a subcostal incision: obesity, smoking, diabetes, steroids and previous hernia among them.
• Consider a prophylactic synthetic mesh at closure when two or more are present.
• Prefer a Kocher incision to a J incision where exposure allows; J incisions herniated more often.
• Arrange imaging or examination for hernia at one to two years in high-risk patients.
• Avoid prophylactic mesh in contaminated or emergency fields, which this trial excluded.

Why it matters

Subcostal incisions are not the low-hernia option many assume, and a simple step at closure changed that.

Don't overread it

This is one small single-centre trial with incomplete two-year imaging, not yet guideline-level evidence.

The statistics, in plain English

At two years, about 3 in 8 patients without mesh had a hernia on imaging, against about 1 in 12 with mesh: roughly 29 fewer hernias per 100 patients. The numbers are small, so the true difference could be smaller, and losing about a third of patients before the two-year scan could bias the result in either direction.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.