Frailty index as a predictive tool for poor outcomes after ventral hernia repair - systematic review and meta-analysis.

introductionFrailty, characterized by reduced physiologic reserve and heightened vulnerability to surgical stress, has emerged as a key predictor of adverse postoperative outcomes. The modified 5-factor frailty index (mFI-5) offers a simplified yet validated tool for quantifying frailty. While its predictive utility is established in multiple surgical specialties, its role in ventral hernia repair (VHR) has not been comprehensively synthesized. This systematic review and meta-analysis aims to evaluate the clinical utility and discriminative performance of the mFI-5 in VHR by analyzing postoperative outcome patterns among frail and non-frail patients.

methodsFollowing PRISMA guidelines, the authors searched PubMed, EMBASE, LILACS, and Cochrane databases from inception up to April 2025. Adult patients undergoing elective VHR were included if outcomes were stratified by mFI-5 frailty status. Data on demographics, hernia characteristics, complications, readmissions, reoperations, length of stay (LOS), and mortality were extracted. Random-effects meta-analyses assessed pooled risk ratios (RR) for key outcomes. Study quality and risk of bias were evaluated using ROBINS-I.

resultsFour studies were included in the final analysis, representing 27,312 patients (17,760 non/pre-frail, 9,552 frail/severely frail). Frail patients were older, more comorbid, and more likely to have larger hernias. Meta-analysis demonstrated that frailty was significantly associated with higher 30-day reoperation (RR 1.55; 95% CI 1.22–1.99; p < 0.001). Although absolute mortality rates were low (< 1%) in both groups, the reduction observed in non/pre-frail patients remains clinically relevant in the setting of elective benign surgery. No significant differences were found in pooled rates of surgical site infections or readmissions. Recurrence was only reported in the studies when it was a cause of 30-day reoperation.

conclusionThe mFI-5 is a pragmatic and validated tool for stratifying physiologic risk in ventral hernia repair. Even small absolute reductions in postoperative mortality are clinically meaningful in a benign elective operation, underscoring the value of frailty assessment for patient selection and perioperative counseling. Incorporating frailty screening into routine practice may support safer and more personalized hernia care. Future research should refine composite risk models and test interventions to mitigate frailty-related risk while preserving the functional benefits of repair.