Association Between Mesh Placement and Recurrence and Chronic Pain After Incisional Hernia Repair: A Systematic Review and Network Meta‐Analysis

BACKGROUND: Recurrence and chronic pain remain significant challenges in incisional hernia repair, and evidence on the optimal mesh placement is limited. This review aimed to determine whether there is a difference in the risk of recurrence and chronic pain based on mesh placement in patients undergoing incisional hernia repair. METHODS: Studies with adults undergoing elective incisional hernia repair for defects < 10 cm were included. PubMed, Embase Ovid, and Cochrane CENTRAL were searched on August 18, 2025. RCTs were assessed with Cochrane's Risk of Bias tool, version 2. Cohort studies were evaluated with Cochrane's Risk Of Bias In Non-randomized Studies of Interventions, version 2. Meta-analyses and a network meta-analysis were conducted to compare recurrence rates across placements. The protocol was pre-registered in PROSPERO (CRD420251148033). RESULTS: Twenty-two studies with 10,832 patients were included. Crude recurrence rates were highest for preperitoneal (12.8%) and lowest for retromuscular (3.0%) mesh positions. In the network meta-analysis, retromuscular (RR 0.3, 95% CI 0.1-0.8) and intraperitoneal (RR 0.4, 95% CI 0.2-0.9) placements were significantly associated with a lower risk of recurrence compared with onlay. However, the certainty of evidence was very low due to high risk of bias and heterogeneity, limiting confidence in these estimates. Four studies reported chronic pain, but substantial heterogeneity precluded meta-analysis. CONCLUSION: Retromuscular mesh placement may reduce recurrence compared with onlay mesh. However, these findings were limited by clinical and statistical heterogeneity across studies. Reports on chronic pain were few and heterogeneous, needing further research on the link between chronic pain and mesh placement.