Published online Mar 18, 2026. doi: 10.13105/wjma.v14.i1.113251
Revised: October 8, 2025
Accepted: December 11, 2025
Published online: March 18, 2026
Processing time: 202 Days and 16.6 Hours
Incisional hernia (IH) is a common late complication following orthotopic liver transplantation, with reported incidences up to 46%. Incision type, particularly the use of the Mercedes incision, has been implicated as a modifiable risk factor due to its midline component and associated fascial disruption.
To determine whether the Mercedes incision increases the risk of IH compared with Chevron and J-shaped incisions in adult liver transplant recipients.
We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines (PROSPERO: CRD42020161632). PubMed, MEDLINE, EMBASE, Google Scholar, and Cochrane Library were searched up to June 2025 for studies reporting IH incidence stratified by incision type. Observational studies with ≥ 12 months follow-up in adults were included. Random-effects meta-analysis was performed to estimate pooled odds ratios (OR) with 95%CI. Heterogeneity was assessed using the I² statistic. Exploratory subgroup analyses examined closure technique, incision closure approach, and suture material.
Eight observational studies (n = 2965) met the inclusion criteria. Pooled analysis showed the Mercedes incision was associated with a higher IH risk compared with Chevron or J-shaped incisions (OR = 1.93, 95%CI: 1.06–3.51; I² = 76%). Sensitivity analysis excluding a zero-event study reduced the OR to 1.79 (95%CI: 0.99–3.25). Single-layer closure (OR = 3.75, 95%CI: 2.22–6.35) and absorbable sutures (OR = 3.06, 95%CI: 1.18–7.93) were associated with increased IH rates in exploratory analyses.
The Mercedes incision is likely associated with a higher risk of IH after liver transplantation compared with Chevron or J-shaped incisions. Surgical planning should consider incision type alongside patient and technical factors to reduce long-term abdominal wall morbidity.
Core Tip: This systematic review and meta-analysis of 2965 liver transplant recipients demonstrates that the Mercedes incision increases the risk of incisional hernia compared with Chevron or J-shaped incisions. The midline extension inherent to the Mercedes approach may contribute to fascial weakness. Technical factors such as two-layer closure and use of non-absorbable sutures may reduce this risk. Incision choice should be individualized to balance optimal surgical exposure with preservation of long-term abdominal wall integrity.