From deployment to durability: Mesh positioning systems in minimally invasive intraperitoneal underlay ventral hernia repair and association with patient-reported recurrence.

Abstract

Background: Mesh positioning systems may facilitate deployment/centering during minimally invasive intraperitoneal underlay mesh ventral hernia repair, but multicenter comparative data are limited. We evaluated associations between mesh positioning system use, operative time, and clinical outcomes.

Methods: We retrospectively analyzed Abdominal Core Health Quality Collaborative data for adults undergoing elective, clean minimally invasive intraperitoneal underlay mesh for midline hernias between 2016 and 2025. Patients were categorized by mesh positioning system use. One-to-one propensity matching balanced patient, hernia, mesh, closure, fixation, and operative approach variables. Balance was assessed with standardized mean differences. Outcomes included operative time, morbidity, patient-reported outcomes, and recurrence. Recurrence-specific balance and calendar-year sensitivity analyses were performed.

Results: Of 154,582 registry patients, 3,951 met analytic criteria, 3,898 entered the propensity cohort, and 1,570 were matched. Operative time did not differ (P = .928). Among 210 patients with patient-reported recurrence data, recurrence was lower with mesh positioning systems (15.7% vs 3.6%; P = .012); surgeon-reported and pragmatic recurrence did not differ. Recurrence-subset balance demonstrated residual imbalance. Calendar-year adjusted Cox analysis for pragmatic recurrence showed mesh positioning systems (hazard ratio, 0.60; 95% confidence interval, 0.37-0.98; P = .042) and year (hazard ratio, 1.28; 95% confidence interval, 1.12-1.47; P < .001).

Conclusion: Mesh positioning systems were associated with lower patient-reported recurrence among patients with available follow-up. Within the constraints of limited follow-up, recurrence-subset imbalance, discordant recurrence definitions, and temporal confounding, the findings are hypothesis generating rather than evidence that mesh positioning systems reduce anatomic recurrence, and further prospective evaluation is needed.