BackgroundWhether prosthetic mesh increases infection in contaminated fields remains controversial, particularly in incarcerated hernias and adult Bochdalek hernia (BH) with gastric pathology.MethodsWe combined a PRISMA-guided systematic review of adult BH with gastric pathology (14 cases, 1981-2025) with a single-center retrospective cohort of incarcerated hernias treated laparoscopically or laparoscopy-assisted (n = 313; inguinal 177, incisional 111, diaphragmatic 10 4 BH, 1 Morgagni, and hiatal 15). Pure open repairs were excluded. Intraoperative findings were stratified as clean, mild, or severe contamination. Primary endpoint: 3-month infectious outcomes (surgical site infection, intra-abdominal abscess, and mesh infection) comparing mesh vs non-mesh repair. A representative BH case with gastric antral perforation managed by one-stage gastric repair and mesh-reinforced diaphragmatic closure is presented.ResultsAmong clean cases receiving mesh, the 3-month infection rate was 1.5% (3/198). In mild contamination, mesh did not increase infection compared with non-mesh repair (10.0% 4/40 vs 6.7% 3/45; RR 1.50, 95% CI 0.36-6.30; P = .702). In severe contamination, infection rates were also similar (21.4% 3/14 vs 18.8% 3/16; RR 1.14, 95% CI 0.27-4.78; P = 1.000). The BH review showed 57.1% gastric volvulus and 42.9% perforation/necrosis; mesh was used selectively (21.4%) in staged or clean settings, and 37.5% of female cases occurred during pregnancy.ConclusionsIn this laparoscopic-dominant cohort, mesh repair after meticulous lavage was not associated with higher 3-month infection across contamination strata and appeared safe in selected severely contaminated cases. These findings support a contamination-aware, selective mesh strategy within a CT-first, laparoscopy-first pathway and warrant prospective validation, particularly for open repairs and longer follow-up.
Gao et al. (2026) studied this question.