EFFICIENCY OF DRAIN IN ETEP RETRORECTUS RIVES STOPPA MESH REPAIR: A SYSTEMATIC REVIEW AND META ANALYSIS

Abstract

Background: Prophylactic drain placement after ventral, incisional, and retromuscular hernia repair remains one of the most persistently debated technical decisions in abdominal wall reconstruction, including in enhanced-view totally extraperitoneal (eTEP) repair. Objective: To systematically review, critically appraise, and, where the evidence permits, quantitatively synthesize the comparative outcomes of drain versus no-drain strategies following ventral/incisional and retromuscular (including eTEP) hernia repair, using PICOS-defined eligibility criteria and formal risk-of-bias assessment. review Methods: A structured search of PubMed/MEDLINE, Cochrane Library, Scopus, and Google Scholar identified 16 eligible studies spanning 2013–2025: three existing peer-reviewed meta-analyses, one Cochrane systematic review, one systematic of seroma-prevention adjuncts, four randomized controlled trials, and seven observational/registry/propensity-matched cohort studies. Risk of bias was assessed using Cochrane RoB2-informed domains for RCTs and ROBINS-I-informed domains for observational studies. Pooled effect estimates from existing meta-analyses are reported directly; an exploratory pooled summary is presented for the subset of studies with extractable 2×2 outcome data. Results: The three existing meta-analyses reached three different conclusions from overlapping literature — Marcolin et al. (2023) found drains significantly reduced seroma (OR 0.34); Mohamedahmed et al. (2023) found drains increased SSI with no wound-complication benefit; Sanha et al. (2024) found drains increased both infection risk (OR 1.89) and length of stay, with no effect on seroma. Subsequent large registry and propensity-matched studies (2024–2025) consistently found drains reduced seroma at the cost of longer hospitalization. Risk-of-bias assessment identified confounding by indication (larger, more complex defects preferentially drained) as a recurring, largely unaddressed limitation across the observational literature, most visibly in the one other published eTEP-specific study (Wilters et al. 2025), which closely parallels the source manuscript's own findings. Conclusion: The evidence indicates a genuine, unresolved, and only partially confounding-adjusted trade-off. This reinforces the source manuscript's conclusion that routine drain omission is a reasonable default in appropriately selected eTEP patients, with selective drain use reserved for higher-risk, larger defects — while highlighting that this exact question has not yet been tested in an adequately powered eTEP-specific RCT.