A systematic review and meta-analysis of subcutaneous onlay laparoscopic (SCOLA) approach for diastasis recti with or without mesh reinforcement

Purpose: SCOLA represents a minimally invasive approach to combined diastasis recti and ventral hernia repair. This systematic review investigates the clinical efficacy and safety implications of mesh placement within this technique. Methods: We followed PRISMA 2020 guidelines to search MEDLINE and EMBASE for studies reporting SCOLA outcomes in adult patients with midline hernias and/or diastasis recti. Additionally, we retrospectively identified six institutional SCOLA cases from January 2023 to March 2025. Extracted variables included patient demographics, hernia location and size, mesh use, follow-up duration, and rates of seroma, surgical-site infection (SSI), and recurrence. We calculated pooled complication rates and performed stratified meta-analyses, estimating risk ratios (RRs) and 95% confidence intervals (CIs) for mesh vs. no-mesh cohorts. Results: Six eligible studies (1 prospective, 5 retrospective) involving 247 patients were included after systematic screening. Among all patients (99.2% laparoscopic SCOLA; mean defect size 2.77 cm; mean follow-up 9.5 months; mesh used in 72.5%), seroma occurred in 19.0% overall (21.8% vs. 11.8%; RR 1.85, 95% CI 0.88–3.89; p ≈ 0.104). Infections were seen only in the mesh group (5.0% vs. 0%; RR undefined, 95% CI 0.89–∞; p ≈ 0.058), and recurrence rates were low (1.7% vs. 0%; RR undefined, 95% CI 0.14–∞; p ≈ 0.318). Studies quality was moderate, limited by non-randomized designs and small observational cohorts. Conclusions: Available data suggest that SCOLA may achieve low recurrence rates, although high-quality evidence is limited. Mesh reinforcement may offer modest reduction in recurrence at the expense of an increased SSI risk. Seroma formation appears more influenced by extent of dissection than by mesh presence.