A randomised, multi-centre, prospective, observer and patient blind study to evaluate a non-absorbable polypropylene mesh vs. a partly absorbable mesh in incisional hernia repair

Background

The implantation of a polymer mesh is considered as the standard treatment for incisional hernia. It leads to lower recurrence rates compared to suture techniques without mesh implantation; however, there are also some drawbacks to mesh repair. The operation is more complex and peri-operative infectious complications are increased. Yet it is not clear to what extent a mesh implantation influences quality of life or leads to chronic pain or discomfort. The influence of the material, textile structure and size of the mesh remain unclear. The aim of this study was to evaluate if a non-absorbable, large pore-sized, lightweight polypropylene (PP) mesh leads to a better health outcome compared to a partly absorbable mesh.

Methods/design

In this randomised, double-blinded study, 80 patients with incisional hernia after a median laparotomy received in sublay technique either a non-absorbable mesh (Optilene? Mesh Elastic) or a partly absorbable mesh (Ultrapro? Mesh). Primary endpoint was the physical health score from the SF-36 questionnaire 21?days post-operatively. Secondary variables were patients' daily activity score, pain score, wound assessment and post-surgical complications until 6?months post-operatively.

Results

SF-36, daily activity and pain scores were similar in both groups after 21?days and 6?months, respectively. No hernia recurrence was observed during the observation period. Post-operative complication rates also showed no difference between the groups.

Conclusion

The implantation of a non-absorbable, large pore-sized, lightweight PP mesh for incisional hernia leads to similar patient-related outcome parameters, recurrence and complication rates as a partly absorbable mesh.     

Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair

BACKGROUND: Almost half the patients who undergo hernia repair with mesh report a feeling of stiffness and a foreign body in the groin. This study evaluated whether patients noticed any difference between lightweight and standard polypropylene mesh for the repair of inguinal hernia. METHODS: Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100-110 g/m(2)) or a lightweight composite multifilament mesh (polypropylene 27-30 g/m(2)). Quality of life was assessed using Short Form 36 before operation and 6 months after surgery. Pain was assessed by means of a visual analogue scale 2 days and 6 months after surgery. The primary outcome measure was the feeling of a foreign body in the groin at 6 months. RESULTS: Some 122 hernias were randomized; 117 were included in the analysis of perioperative data, and 106 were re-examined after 6 months. There were no differences between the treatment groups with respect to early and late surgical complications. Use of lightweight mesh was associated with significantly less pain on exercise after 6 months (P = 0.042). In addition, fewer patients reported the feeling of a foreign body after repair with lightweight mesh (17.2 versus 43.8 per cent with conventional mesh; P = 0.003). Quality of life was improved significantly at 6 months compared with the preoperative assessment, and there were no differences between the treatment groups. CONCLUSION: Lightweight polypropylene mesh may be preferable for Lichtenstein repair of inguinal hernia. Larger cohorts with longer follow-up are needed before it can be recommended for routine use.     

Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh

Background

The use of lightweight meshes in incisional hernia repair could have beneficial effects on quality of life. This study aimed to compare a new titanium-coated lightweight mesh with a standard composite mesh after laparoscopic incisional hernia repair.

Methods

A randomized controlled single-center clinical trial was designed using the basic principle of one unit, one surgeon, one technique (midline incisional hernia with a laparoscopic approach), and two meshes: a lightweight titanium-coated mesh (group 1) and a medium-weight collagen-polyester composite mesh (group 2) used in 102 patients. The primary end points were pain and recurrence. The secondary end points were morbidity and patient outcomes (analgesic consumption, return to everyday activities).

Results

The postoperative complication rates were similar for the two meshes. Pain was significantly less common in group 1 than in group 2 at 1 month (P = 0.029) but was similar for the two groups at 6 months and 1 year. There was a significant difference between the two groups in the average use of analgesics: 6.1 days in group 1 versus 1.6 days in group 2 (P < 0.001). The lightweight group returned to everyday activities after 6.9 days versus 9.7 days for the composite group (P < 0.001). The rate of recurrence did not differ between the two groups at the 2-year follow-up evaluation.

Conclusions

The light titanium-covered polypropylene mesh was associated with less postoperative pain in the short term, lower analgesic consumption, and a quicker return to everyday activities than the Parietex composite medium-weight mesh. The recurrence rates at 2 years showed no difference between the two groups.     

Incisional hernia: challenge of re-operations after mesh repair

Background and aims The widespread use of meshes for the repair of incisional hernia is currently followed by an increasing number of re-operations. The incidence of incisional hernia recurrence after mesh repair varies between 3 and 32%. The problem of mesh failure and options for another surgical intervention seem rather unattended. Methods We present our experience of 77 re-operations after previous mesh repair that were performed between 1995 and 2004 out of a total of 1,070 operations for incisional hernia. The retrospective analysis focused on recurrence in relation to location, material of the previous mesh repair and the surgical procedure to resolve the problem. Results The locations of the preceding meshes were epifascial as onlays (n=23), retromuscular as sublays (n=46), within the defect as inlays (n=6) or intraperitoneally (n=2). The direction of the incision was vertical medial (n=41) or horizontal crossing the linea semilunaris (n=36). Recurrences after median incisional hernia mesh repair mainly occurred at the cranial border of the mesh subxiphoidal. Except for two patients, all recurrences manifested at the margin of the enclosed mesh. Conclusions Re-operation after previous mesh repair is a surgical challenge. The type of revision procedure has to consider the position and material of the previous mesh. In our clinic recurrences, heavyweight polypropylene meshes were mostly treated with mesh exchange and lightweight polypropylene meshes could be treated by extension with a second mesh. In contrast to suture techniques, deficient mesh repairs are more evidently related to technical problems.     

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia

BACKGROUND: This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair. METHODS: Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery. RESULTS: Of the 590 men who had surgery, 243 (82.7 percent) of 294 in the standard mesh group and 251 (84.8 percent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3.7 percent with standard mesh and 3.6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh. CONCLUSION: Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.     

Intraperitoneal polypropylene mesh repair of incisional hernia is not associated with enterocutaneous fistula

BACKGROUND: Incisional hernia repair with prosthetic material is followed by fewer recurrences than primary repair. Polypropylene is the most commonly used prosthetic material but may cause entero- cutaneous fistulas. The aim of this study was to determine whether enterocutaneous fistulas developed after incisional hernia repair with polypropylene mesh and to evaluate clinical outcome after incisional hernia repair. METHODS: A retrospective analysis of the outcome of incisional hernia repair with polypropylene mesh between 1982 and 1998 was conducted. Follow-up data were obtained from medical records and questionnaires. RESULTS: Polypropylene incisional hernia repair was performed in 136 patients. Median follow-up was 34 months. No enterocutaneous fistulas developed. Wound infection occurred in 6 per cent. Wound sinus formation occurred in two patients. No mesh was removed because of infection and no persisting infection of the mesh occurred. CONCLUSION: Enterocutaneous fistula formation appears to be very rare after incisional hernia repair with polypropylene mesh, regardless of intraperitoneal placement, omental coverage or closing of the peritoneum.     

Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia

BACKGROUND: Since conventional suture repair for incisional hernia is associated with high recurrence rates, alloplastic and autoplastic prosthetic techniques have been suggested. METHODS: In a randomized trial, 160 patients with simple or complex hernias underwent either suture repair, autodermal skin graft or onlay polypropylene mesh repair. Suture repair was not done in complex hernias. This report concerns a planned interim analysis. RESULTS: At mean follow-up of 16 months, there were 17 hernia recurrences that were distributed similarly between the surgical techniques. There were fewer infectious complications after suture repair (three of 33 patients) than after skin graft or mesh repair (seven of 39 and five of 28 for simple hernias; seven of 31 and ten of 29 respectively for complex hernias) (P not significant). The severity of infections after polypropylene mesh implantation prompted the trial committee to discontinue the study. No differences were noted in duration of stay in hospital and quality of life. However, pain was significantly more frequent after polypropylene mesh repair (pooled risk ratio 2.9 and 1.8 at 6 weeks and 1 year respectively). CONCLUSION: Suture repair was safe for small incisional hernias. Both autoplastic and alloplastic hernia repair yielded comparably low recurrence rates, but led to a high rate of wound infection.     

An unusual cause of chronic anemia and abdominal pain caused by transmural mesh migration in the small bowel after laparoscopic incisional hernia repair

Mesh repair of incisional hernia is recommended to reduce recurrence. Recognized complications include mesh infection and fistula. Composite meshes with antiadhesive barriers were designed for intraperitoneal placement to reduce adhesion formation and fistulization to the viscera. Transmural mesh migration is a rare complication of hernia repair with composite mesh and can be present with a variety of symptoms. We report an interesting case of transmural mesh migration into the small bowel presenting with chronic microcytic anemia and abdominal pain 5 years after laparoscopic incisional hernia repair with a composite polypropylene/ePTFE mesh.     

Incisional herniorrhaphy with intraperitoneal composite mesh: a report of 95 cases

Incisional herniorrhaphy remains a formidable challenge to the general surgeon. Recurrence rates after primary repair are reported between 31-54 per cent while tension-free repairs with prosthetic mesh have lowered this rate to 10 per cent. Repairs with composite mesh (polypropylene/ePTFE) have been gaining in popularity due to the ease of mesh placement in the intraperitoneal location. This paper reviews our experience with composite repairs at a teaching community hospital. A retrospective chart review was performed which evaluated all patients undergoing abdominal incisional hernia repairs over a 4(1/2)-year period. The data were analyzed for mortality, recurrence, infection, subsequent bowel obstruction, and fistula formation. Two hundred twenty-one incisional herniorrhaphies were identified in the resident database of which 95 were repaired with Composix mesh (Bard Surgical, Cranston, RI) in the intraperitoneal position. There were two (2%) recurrences and eight (8%) infections. Fistulization to the small bowel from exposed polypropylene occurred in one patient. There were no bowel obstructions. One postoperative death occurred secondary to pulmonary embolus. Mesh removal was required in all infected cases, and there was a high incidence (63%) of methicillin-resistant Staphylococcus aureus (MRSA). Our findings parallel the low recurrence rate following prosthetic repair. We have reported a higher than expected infection rate particularly with MRSA. Although repairs with Composix mesh are highly successful in regard to recurrence, the high infection rate and resulting morbidity needs to be further evaluated.     

Incisional hernioplasty with extraperitoneal onlay polyester mesh

Recurrent incisional hernia remains a major problem for the general surgeon. The high recurrence rate of incisional hernias after primary closure by tissue approximation led to the development of tension-free procedures using prosthetic materials. The goal of this study is to present the results of an extraperitoneal tension-free technique using a polyester mesh (Mersilene). A total of 43 patients with incisional hernias were surgically treated during a 9-year period in our department. Twenty-four patients (56%) had recurrent incisional hernias, 21 had primary repair by tissue approximation, and 3 had prolene mesh tension-free repair with wound infection. Patients' mean age was 68.2 years, and the mean postoperative follow-up was 54.4 months. Immediate postoperative complications were noticed in 9 patients (21%) subcutaneous seroma in 6 (14%) and wound infection in 3 (7%). Recurrence was noticed in 4 patients (9%) during the first 9 postoperative months. Late minor complications such as restriction of abdominal wall motility and chronic pain was noticed in 3 (7%) patients. In conclusion, the extraperitoneal onlay tension-free incisional hernia repair using polyester mesh is an easy and safe procedure with no major morbidity or recurrence rate.     

Incisional hernia—comparison of mesh repair with Cardiff repair: an university hospital experience

Background: Incisional hernia is a frequent complication of abdominal surgery. Various types of repair are recommended for incisional hernia. Suture and mesh repair are compared in the present study. Method: One hundred seventy one patients with incisional hernia underwent Cardiff repair (far and near sutures with reinforcement sutures) which was used as an open suture repair while onlay polypropylene mesh was used in the mesh repair technique. Result: Cardiff repair was performed in 116 patients with no mortality with recurrence in two patients with mean follow up of 7.1 years. Both these patients with recurrence had a defect measuring more than 10 cm in width. Mesh repair was carried out in 55 patients with no recurrence in mean follow up of 37 months. Seroma formation was noted in 7 (12.72%) with mesh repair as compared to 4 (3.44%) patients with Cardiff repair. Conclusion: We recommend Cardiff repair for primary and small to medium size incisional hernias. Onlay polypropylene mesh is ideal for tension-free hernia repair, recurrent incisional hernia and hernia defects wider than 10 cm.     

轻量型和普通聚丙烯补片在腹股沟疝修补术中的对照研究

目的：比较使用普通聚丙烯补片f普理灵）和轻量型聚丙烯补片（薇普Ⅱ）进行腹股沟疝修补术后的疗效。方法：2006年10月至2008年3月间,我院对609例腹股沟疝病人,行Lichtenstein修补术,病人分成2组,一组使用普理灵补片,另一组使用薇普Ⅱ补片。比较两组平均手术时间、术后炎症反应程度、并发症及恢复工作的时间,并根据SF-36对病人术前和术后6个月内的生活质量进行评估。使用疼痛的数字评分法（NRS）对术后第2天和6个月的疼痛情况进行评分．以此判断术后6个月腹股沟区是否仍有异物感。结果：与普理灵补片相比,使用薇普Ⅱ补片可减轻术后导致的腹壁活动受限,炎性反应和纤维组织的生成也减低;术后6个月运动时疼痛的比例也降低（P〈0．05）;腹股沟区有异物感的病人较少。结论：腹股沟疝行Lichtenstein修补术中更适宜使用轻量型聚丙烯补片。     

Use of polypropylene mesh for incisional hernia repair

Incisional hernia is an important complication of abdominal surgery. Procedures for the repair of these hernias with sutures and with mesh have been reported, but there is no consensus about which type of procedure is best. We have performed a retrospective analysis on 1014 patients operated on in our unit between 1994 and 2003 for simple or recurrent incisional hernias. The polypropylene mesh has been used in a number of 107 patients. The mesh has been placed either intraperitoneal, extraperitoneal/subfascial or onlay. Median follow-up was 36 months. There were 1 enterocutaneous fistula and 5 wound sinus developed. The mesh had to be removed in 6 cases. All of these complication developed when the mesh has been placed either extraperitoneal/subfascial or onlay. We note 5 recurrent incisional hernias after a period of up to 24 months. The recurrence rates after open mesh repair are less then after primary closure. The intraperitoneal use of polypropylene mesh with omental coverage is a good procedure with less complications.     

Preventing parastomal hernia with a prosthetic mesh

HYPOTHESIS: Parastomal hernia is a common complication following colostomy. The lowest recurrence rate has been produced when repair is with a prosthetic mesh. This study evaluated the effect on stoma complications of using a mesh during the primary operation. DESIGN: Randomized clinical study. METHODS: Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. The mesh used was a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material. RESULTS: Twenty-seven patients had a conventional stoma, and in 27 patients the mesh was used. No infection, fistula formation, or pain occurred (observation time, 12-38 months). At the 12-month follow-up, parastomal hernia was present in 13 of 26 patients without a mesh and in 1 of 21 patients in whom the mesh was used. CONCLUSIONS: A lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the stoma site is not associated with complications and significantly reduces the rate of parastomal hernia.     

Single surgeon experience with bilayer polypropylene mesh repair of inguinal hernia

Background: Open mesh repair of inguinal hernia has been shown to be an effective and safe method of hernia repair. In search of the ‘ideal’ method of open mesh hernia repair, many different methods of mesh placement have been developed. Laparoscopic hernia repair is reported to be superior to open repair in terms of postoperative pain and rehabilitation. These improved functional outcomes could be the result of placement of mesh in the preperitoneal space (underlay), rather than the laparoscopic method per se. A bilayer polypropylene mesh implant has been developed that provides onlay and underlay (preperitoneal) mesh layers. The present study reports the singular experience of a general surgeon with this bilayer polypropylene mesh implant. Methods: A retrospective audit of the first 169 consecutive inguinal hernia repairs was conducted by mailed questionnaire and telephone interview. Data was collected on patient demographics, postoperative pain scores and complications. Patients with potential recurrences at the time of follow up were invited for clinical review. Results: One hundred and three patients (71%) participated in the audit. Thirteen per cent of cases were for recurrent hernia. Median age was 60 years (range 21?99). Median length of follow up was 19 months (range 8?27). No recurrences were detected in the patients who underwent primary repair of inguinal hernia. Conclusion: Inguinal hernia repair with bilayer polypropylene mesh is safe and has low complication and recurrence rates.     

轻量型网片和普通聚丙烯补片在腹股沟疝修补术中的对比研究

目的探讨轻量型网片（强生UPP）在腹股沟疝无张力修补中的作用。方法回顾分析90例次腹股沟疝无张力修补患者的临床资料,其中47例次行普通聚丙烯材料修补,43例次行强生UPP修补。结果强生UPP修补组与普通聚丙烯材料修补组比较,早期并发症发生率（切口疼痛、切口积液、伤口感染、肺部感染、尿道损伤以及尿潴留等）和住院时间差异无统计学意义。在6个月时强生UPP修补组其局部切口疼痛、异物感的患者明显少于普通聚丙烯材料修补组,腹壁顺应性明显好于普通聚丙烯材料修补组,在6个月时两组均没有复发。结论轻量型网片在腹股沟疝无张力修补中,其后期并发症明显减少,有望成为腹股沟疝无张力修补的首选材料。     

Recurrent parastomal hernia and middle incisional hernia: surgical treatment through midline incision with wide prosthetic mesh

Parastomal hernia is a frequent complication of stoma surgery. The results of parastomal hernia repair however are poor, showing an high incidence of postoperative recurrences. In the last years, hernia repair with prosthetic mesh has given better postoperative results. The parastomal hernia, however, is associated with middle incisional hernia. The authors review the problem of surgical repair of parastomal hernia and report a case of recurrent parastomal hernia associated to middle incisional hernia. The technique of surgical repair using, through midline incision, one, wide, prosthetic polypropylene mesh, in sublay position, according to Rives' technique, is described. The mesh has been incised in a trasverse direction for the stoma crossing. At 6 years follow-up the patient does not show postoperative recurrence. According literature and the authors' results, the parastomal hernia might be considered an incisional hernia and, therefore, a sing of diffuse abdominal wall disease. The Rives' surgical technique might be the gold standard for treatment of parastomal hernia, even if not associated to incisional hernia. The more complexity of Rives' technique compared to local fascial mesh repair is compensated by the result of total abdominal wall reinforcement.     

Massive incisional hernia: abdominal wall replacement with Marlex mesh

Marlex (polypropylene) mesh was used to replace the abdominal wall in massive incisional herniation in 50 patients. Seventeen unsuccessful attempts at primary repair had previously been made on nine patients. Patient follow-up ranged from 6 to 120 months (mean = 45 months). There was minor hernia recurrence in four (8 per cent) patients. In each instance it was due to partial detachment of the peripheral fixation of the patch. Complications were: wound infection, four (8 per cent); wound seroma, two (4 per cent); wound haematoma, one (2 per cent); and wound sinus, six (12 per cent). Complications did not necessitate removal of the patch in any case. Inadequate peripheral attachment of the patch has been the only cause of hernia recurrence and should be avoidable.     

轻量聚丙烯补片与自固定补片在Lichtenstein疝修补术的研究

目的对比研究轻量大网孔聚丙烯补片与自固定补片在Lichtenstein疝修补术中的应用。 方法选择2021年1-3月在吉林大学第二医院60例单侧男性腹股沟疝患者行前瞻性随机对照研究,随机分为轻量大网孔聚丙烯补片组和自固定补片组各30例,分别应用轻量大网孔聚丙烯补片和自固定补片进行Lichtenstein疝修补术;对比2组一般资料、手术相关指标、术后平均住院时间、血清肿、补片感染、术后疼痛、复发、异物感以及治疗费用等相关情况进而评价两种补片的治疗效果。 结果2组患者一般资料、手术麻醉方式、术后住院时间比较差异无统计学意义（P>0.05）,2组的平均手术时间和治疗费用差异有统计学意义（P<0.05）;术后血清肿、术后短期（7 d及1个月）疼痛和慢性疼痛、补片感染、局部不适或异物感、复发等并发症差异均无统计学意义。 结论自固定补片可明显缩短手术时间,但医疗费用明显高于轻量大网孔聚丙烯补片,在术后复发和慢性疼痛等并发症方面差异不显著。     

Peritoneal adhesions to prosthetic materials

BACKGROUND: In many cases, incisional hernia repair requires the use of prosthetic materials. The aim of this experimental study in a rat model was to assess the role of polyglactin 910 mesh and fluoropassivated polyester mesh in preventing the formation of adhesions. METHODS: In the first experiment, the formation of peritoneal adhesions was assessed after insertion of polypropylene, polypropylene combined with polyglactin 910, or no mesh. In the second experiment, adhesion formations were compared after insertion of fluoropassivated polyester, polypropylene, and no mesh. RESULTS: The first experiment showed no significant difference in adhesion formations between the polypropylene mesh and the combined mesh; however, when no mesh was used, there were significantly fewer adhesions in both experiments (p < 0.01). The second experiment showed a significantly lower degree of adhesions and a lower Adhesion Index after insertion of fluoropassivated polyester mesh than when polypropylene mesh was used (p = 0.04). CONCLUSIONS: Adding polyglactin 910 mesh to polypropylene mesh to prevent the formation of adhesions is not an effective measure. Fluoropassivated polyester meshes appear to provide a better alternative to the use of polypropylene meshes for incisional hernia repair in humans in terms of the formation of adhesions.