Efficacy of Biological Versus Synthetic Mesh in Ventral Hernia Repair: A Systematic Review and Meta-Analysis of Long-Term Outcomes and Recurrence Rates.

Ventral hernia repair commonly employs either biologic or synthetic mesh, yet the optimal choice remains debated. This systematic review and meta-analysis aimed to compare clinical outcomes such as infection, recurrence, and reoperation rates between biologic and synthetic mesh in ventral hernia repair.  Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search was conducted across MEDLINE, Cochrane Library, and EMBASE. Randomized controlled trials (RCTs) comparing biologic and synthetic mesh outcomes in adult ventral hernia repair were included. Risk of bias was assessed using the Risk of Bias 2 (ROBINS-II) tool. Pooled analyses used odds ratios (OR) for binary outcomes and weighted mean differences for continuous variables, with heterogeneity evaluated via I² statistics.  Four RCTs were included reporting outcomes for patients receiving biologic (n = 251-378) or synthetic mesh (n = 254-380). Recurrence rates were higher in the biologic mesh group (25.1%) compared to the synthetic group (12.7%) (OR: 2.30; 95% CI: 1.15-4.53; p = 0.01; I² = 73%). Additionally, reoperation rates were higher with biologic mesh (16.9%) versus synthetic mesh (10.4%), but this difference was not statistically significant (OR: 1.94; 95% CI: 1.06-2.44; p = 0.38; I² = 0%). Mesh infection incidence was also slightly higher with biologic mesh (4.8%) than with synthetic mesh (3.1%) (OR: 2.33; 95% CI: 0.64-3.73; p = 0.65; I² = 0%). However, no significant difference in mean patient age was observed between the groups (mean difference: -0.67; 95% CI: -2.78 to 1.44; p = 0.76; I² = 0%). Overall, biologic mesh was associated with a higher hernia recurrence compared to synthetic mesh, while differences in reoperation and mesh infection rates were not statistically significant. These findings suggest that synthetic mesh offers more durable outcomes for ventral hernia repair. Biologic mesh may still be considered selectively in contaminated or high-risk surgical scenarios, but this recommendation is based on limited evidence. Further high-quality RCTs with longer follow-up are needed to better define the optimal mesh choice for varying clinical contexts.