Incisional hernia following abdominal surgery is one of the most common late complications of major surgical practice and one of the least visible. My presentation at this year’s Milan Colorectal Congress examined three connected questions about this complication – how large is the burden, how much does it cost European health systems and does prevention pay? What follows is a synthesis of the European evidence on each of these questions.
A common complication, consistently observed
The strongest contemporary estimate of incisional hernia prevalence after midline laparotomy comes from the a recently published meta-analysis by Edgard Lozada Hernandes and his colleagues that pooled 20 studies and 790,800 patients. They found a global pooled prevalence of 10.1% (95% CI: 7.0–15.0), a European prevalence 13.4% (95% CI: 7.8–19.1) and a hazard ratio for colorectal surgery, relative to other abdominal sites, of 1.55.
Real-world repair rate data from individual European systems corroborate this meta-analytic anchor. In France, Ortega-Deballon et al analysed 710,074 patients in the PMSI national hospital discharge database and found a hazard ratio of 1.2 for colorectal surgery against other abdominal sites. In Italy, two independent cohorts – Gruppo et al and Scortichini et al – converge on roughly 11–12% of patients experiencing a clinically relevant hernia event within 4–6 years. Meanwhile, in the United Kingdom, Laurie Smith and his co-authors used NHS Hospital Episode Statistics covering 297,134 patients to show that 10.0% of colorectal patients undergo incisional hernia repair – the highest rate of any surgical specialty.
These studies use different denominators, different follow-up windows and different ascertainment methods. They are not strictly comparable. But every fragment of the evidence base points the same way: incisional hernia is not a rare event in colorectal surgical practice.
Costs rise with complexity
The cost picture across European systems can be assembled as a staircase of progressively complex episodes. At the simplest end, Ortega-Deballon’s French national data show a mean hospital cost of €4,153 per repair. Adding the indirect costs of inability to work raises this to €6,451 in Gillion et al’s multicentre French analysis, rising to €10,107 in employed patients. The Italian data of Rampado et al show direct hospital costs of €16,397 for complex repair with biological mesh – three times the cost of synthetic mesh repair. Smith et al capture the downstream burden differently again: incisional hernia patients accumulate £14,814 (€17,064) in healthcare resource use over follow-up, compared with £7,753 (€8,967) for matched non-hernia patients.
At the top of the staircase, the French study by Law-Ki et al reports a mean total cost of €29,169 per stay for complex abdominal wall reconstruction with biological prostheses – against a mean DRG reimbursement of €13,936. This means that French hospitals are losing €15,233 on every such admission. Italy faces a similar structural mismatch. Where current reimbursement systems were designed around routine repair, complex abdominal wall reconstruction has outgrown them.
Does prevention pay?
The evidence that prophylactic mesh placement reduces incisional hernia incidence has matured substantially in the last three years. The 5-year follow-up of the PRIMA trial – a three-arm randomised controlled trial of 480 high-risk midline laparotomy patients – reported incisional hernia rates of 53.4% after primary suture closure, against 24.7% with onlay mesh (HR 0.39) and 29.8% with sublay mesh (HR 0.49). PRIMA establishes the principle at the highest tier of evidence: prophylactic mesh roughly halves long-term incisional hernia risk.
That principle has now been translated into the specific context of biosynthetic mesh at ileostomy reversal. Drissi et al reported a case-matched French study of 100 patients receiving prophylactic poly-4-hydroxybutyrate (Phasix) mesh against historical controls; stoma site incisional hernia rates were 8% in the mesh group and 24% in the control group at four years (p=0.029). The Italian multicentre PRINCESS study by Roberto Peltrini and his colleagues confirmed the safety and effectiveness signal in real-world practice across 14 hospitals, with SSIH rates of 1.7% at one year and 4.3% at two.
The Italian budget impact analysis of Carla Rognoni and her colleagues, built on Drissi et al’s clinical rates and applied to Italian hospital cost structures, estimates per-patient savings of €861 from the hospital perspective, €180 from the healthcare system perspective and €328 from the societal perspective.
A question with a public-policy answer
Incisional hernia after colorectal surgery is common, costly and – for the most complex repairs – fundamentally under-reimbursed by current European reimbursement systems. The evidence chain from RCT-grade principle to real-world Italian budget impact now supports a clear policy proposition: in appropriately selected patients undergoing ileostomy reversal, prophylactic biosynthetic mesh is not only clinically effective but economically rational from every reasonable perspective.
The question for European health systems is no longer whether prophylactic mesh works, but whether they can afford not to use it.
Disclosure: this analysis draws on work commissioned by Becton, Dickinson and Company. The framing and conclusions are the author’s own.
