Permanent prophylactic mesh reinforcement in elective and emergency midline laparotomy: a registry-based comparative analysis

Background Prophylactic mesh reinforcement reduces the incidence of incisional hernia (IH) after midline laparotomy and is recommended for high-risk patients. However, concerns regarding contamination, mesh infection, and prosthetic-related morbidity have limited its implementation in emergency surgery. Whether emergency indication is associated with worse outcomes among mesh-treated patients remains uncertain. Methods A retrospective registry-based cohort study used data from the Spanish National Incisional Hernia Registry (EVEREG) from 2020 to 2025 (17 hospitals). Adults undergoing midline laparotomy with permanent prophylactic mesh reinforcement were stratified by elective or emergency indication. In-hospital outcomes included overall and general complications (cardiac, respiratory or renal failure), surgical-site occurrence (SSO), mesh infection, mesh removal, abdominal complications during the index stay and mortality at 30 days. Analyses used 204 patients with completed in-hospital data and clinically specified multivariable logistic regression models. Results The registered cohort included 234 patients: 104 elective and 130 emergency procedures. Among 204 patients with completed in-hospital modules (85 elective, 119 emergency), overall complications occurred in 38.8% versus 62.2% and general complications in 21.2% versus 48.7%, respectively; both remained significant after multiplicity correction. No statistically detectable differences were observed in SSO, mesh infection, mesh removal, abdominal complications or mortality (10.6% versus 11.8%). Recorded Clavien–Dindo categories were higher after emergency surgery (P = 0.006). After adjustment, emergency indication was associated with general complications (OR 2.13, 95% CI 1.01–4.47), but not mortality (OR 1.00, 95% CI 0.39–2.57). Renal disease and contamination were associated with overall complications, and contamination with abdominal complications. Older age and higher body mass index (BMI) were associated with mortality (BMI: OR 1.64 per 5 kg/m 2 , 95% CI 1.06–2.53). Conclusion In this selected registry cohort, emergency indication was associated with greater early general morbidity, whereas no statistically detectable increase in short-term wound- or mesh-related events was observed, with considerable uncertainty. As a cautious implication requiring confirmation, emergency indication per se might not be an absolute contraindication to prophylactic mesh in selected patients. The small number of mesh-related events, the absence of a non-mesh control group and the loss to follow-up preclude conclusions on equivalent safety or effectiveness in preventing incisional hernia.