Comparison of facial defect closure and non-fascial closure in ventral hernia repair: A systematic review and Meta-analysis of randomized controlled trials with trial sequential analysis.

Abstract

<h4>Background</h4>Laparoscopic ventral hernia repair (LVHR) is widely used due to its minimally invasive benefits. However, traditional IPOM without fascial defect closure (FDC) has been associated with variable complications, prompting interest in techniques incorporating FDC, such as IPOM-plus and hybrid approaches. Ventral hernia repair remains a common surgical procedure, yet the optimal management of the FDC versus non-FDC remains controversial. We conducted this systematic review and meta-analysis to compare the safety and efficacy of these methods.<h4>Methods</h4>We searched PubMed, Web of Science, SCOPUS, CENTRAL, and Clinicaltrials.gov up to September 2025. Randomized controlled trials (RCT) comparing fascial defect closure versus non-closure in LVHR were eligible. Pooled effect was calculated by Random-effect model with 95%CI. Heterogeneity was assessed using the I² tool. Sensitivity, subgroup analyses, and trial sequential analysis were performed to assess the robustness of the results.PROSPERO ID: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251231261 .<h4>Results</h4>Thirteen RCTs, comprising a total of 1482 patients, were included. No significant difference was found between the FDC and the non-FDC in terms of diagnosis of recurrence radiologically (OR:0.69,95%CI: [0.33; 1.42], p = 0.3103) or clinically (OR:0.70,95%CI: [0.39; 1.26], p = 0.2357), or in diagnosis of seroma radiologically (OR:0.68,[0.33; 1.40], p = 0.2987) or clinically (OR:0.79, 95%CI: [0.49; 1.26], p = 0.3205). FDC was associated with longer operative time (MD:7.64,95%CI: [2.33; 12.95], p = 0.0048) and slightly higher postoperative pain (at day-1:SMD:0.36,95%CI: [0.07; 0.65]) and at day-2:SMD:0.31,95%CI: [0.05; 0.57], p = 0.0175). Secondary outcomes, including infection, mesh bulging, reoperation for recurrence, chronic pain, and quality of life, were also found to be statistically insignificant. Trial sequential analysis reinforced the inconclusiveness of the evidence and that additional trials are needed.<h4>Limitation</h4>Despite we included only RCTs, the available evidence is limited by inadequate reporting of hernia defect size and insufficient follow-up durations, which restrict definitive recommendations for routine FDC.<h4>Conclusion</h4>FDC and non-FDC were comparable in terms of LVHR in recurrence and seroma rates. FDC was associated with longer operative time and post-operative pain. The current available evidence is insufficient to support the routine use of FDC, and further randomized trials are needed to explore its role and accurately identify patients who would benefit the most.