Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Major mesh-related complications following hernia repair

Mesh material affects complications following hernia repair. Medical device reports on the use of surgical mesh for hernia repair were reviewed from the Food and Drug Administration’s (FDA) Manufacturer User Facility Device Experience Database from January 1996 to September 2004. We analyzed 252 adverse event reports related to the use of surgical mesh for hernia repair. Adverse events included infection (42%, 107 reports), mechanical failure (18%, 46), pain (9%, 23), reaction (8%, 20), intestinal complications (7%, 18), adhesions (6%, 14), seroma (4%, 9), erosion (2%, 6), and other (4%, 9). Compared to all other mesh types, Sepra/polypropylene mesh had more mechanical failures (80 vs 14%, p < 0.05), biomaterial mesh had more reactions (57 vs 7%, p < 0.05), polytetrafluoroethylene (PTFE)/polypropylene mesh had more intestinal complications (14 vs 7%, p < 0.05), and PTFE mesh tended to have more infections (75 vs 41% all other, p = 0.07). Death occurred in 2% (5). We conclude that specific mesh materials are related to specific complications.     

Comparison of biomaterials in the early postoperative period

Background: Laparoscopic hernia repair necessitates the use of biocompatible materials. A prospective, double-blind study was conducted to compare two different polypropylene meshes. Methods: The study included 40 men with primary inguinal hernia undergoing transabdominal preperitoneal polypropylene mesh repair. In 20 of these men, a monofile, heavy-weight, rigid mesh was implanted (group A), and in the remaining 20 men, a smooth, heavy-weight variant of polypropylene mesh was implanted (group B). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented. Results: Reconvalescence in group A was slower than in group B. In group A, the postoperative values of the visual scales for pain development were higher; inability to work was 7.3 days longer; urologic disorders were worse; activities of everyday life were more reduced; and SF-36 data showed a significant reduction of physical problems (p < 0.05). Conclusions: The polypropylene mesh variant seems to be more compatible with the human organism than conventional mesh. Not only the material, but also the structure seems to influence the comfort of the mesh.     

Laparoscopic evaluation of abdominal adhesions with different prosthetic meshes in rabbits.

BACKGROUND: The use of prosthetic materials to reinforce the abdominal wall is associated with a low index of recurrence; however, intraperitoneal placement of a foreign body may lead to adhesions. The present investigation was designed to determine adhesion formation with commercially available meshes implanted laparoscopically in rabbits. METHODS: Three different meshes were implanted laparoscopically in 24 rabbits: polypropylene (mesh A), polypropylene and sodium hyaluronate-carboxymethylcellulose (mesh B), and polypropylene and expanded polytetrafluoroethylene (mesh C). Sites of implantation for each mesh (the left lower quadrant, right lower quadrant, and lower midline) were randomly determined so that every rabbit had all 3 meshes implanted. All animals underwent diagnostic laparoscopy after 28 days to grade adhesions and histological analysis of inflammation. RESULTS: Adhesions were noticed in 46 of the 72 meshes implanted (64%). The number of adhesions was higher for mesh C (87.5%) compared with meshes A (62.5%) and B (41.6%). The severity of adhesions was also higher for mesh C (grade I in 14, II in 6, and III in 1) compared with mesh A (grade I in 10, II in 4, and III in 1 case) and B (all of them grade II). Histological inflammatory reaction was classified as mild in 23 cases of mesh A, 15 of mesh B, and 23 of mesh C. A moderate reaction was found in 1 case of mesh A, 4 cases of mesh B, and 1 case of mesh C. Severe reaction was induced in 5 cases of mesh B. Mesh B induced a higher inflammatory reaction compared with the other meshes. CONCLUSIONS: All meshes induced adhesions of different grades. Mesh B had fewer adhesions and more intense inflammation them did the others.     

Open mesh-plug repair for primary inguinal hernia (826 cases)

Summary The authors report their experience with open mesh-plug repair in the treatment of adult primary inguinal hernias from 1992 to 1998. Eight hundred and twenty-six cases, i.e.: 71% of all repairs for primary hernias, were operated using this procedure. 65.3% of all this operations were performed under local anesthesia (LA). The following complications were observed: wound infection 1.7%, haematoma 1.6%; orchitis 0.9%, recurrence 0.8%. The results were consistent with those of large series in the literature. Complications increased when anesthesia other than LA was used, in obese and in elderly patients. No patients required prosthesis removal due to pain or infection. We also discuss the various prostheses and our results favour polypropylene as opposed to Dacron. Several types of polypropylene mesh are discussed, comparing thickness, thread and pore size and their physical properties. The results suggest that a single thread close knit with controlled memory stiffness for the mesh and a looser and thinner version for the plug give the best results.     

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.     

The use of three different mesh materials in the treatment of abdominal wall defects

Abstract Abstract. Various prosthetic materials have been proposed for the repair of abdominal wall defects. These materials offer tension-free repair and significantly lower recurrence rate. Their respective properties are related to such complications as seroma, infection, fistula formation, intestinal adhesions and removal. We compared the final outcome in treating abdominal wall defects in 56 patients with three different prosthetic materials: conventional polypropylene in a preperitoneal location, expanded polytetrafluoroethylene mesh, and hydrophilic membrane coated polyester mesh in an intraperitoneal location. The hydrophilic coated polyester group exhibited the lowest complication rate and the polypropylene group the highest. Electronic Publication     

Functional impairment and complaints following incisional hernia repair with different polypropylene meshes

The influence of mesh material on the clinical outcome of hernia repair has often been neglected, although recent studies have clearly demonstrated the importance of mesh properties for integration in the abdominal wall. Of particular significance are the amount of mesh material and the pore size. In the following study, patients received different mesh types with distinct amounts of polypropylene and of various pore sizes for incisional hernia repair. We investigated whether the type of material influenced the clinical and functional outcomes. Between 1991 and 1999, 235 patients received polypropylene meshes in a sublay position for incisional hernia repair: 115 patients were implanted with a Marlex heavy-weight mesh (Mhw mesh), 37 patients with an Atrium heavy-weight mesh (Ahw mesh) and 83 with a Vypro low-weight mesh (Vlw mesh). The study protocol included ultrasound examination and 3D-stereography in all patients, with a total follow-up of 24±13 months (Mhw-mesh), 11±8 months (Ahw-mesh) and 8±7 months (Vlw-mesh). Our findings demonstrate that the side effects of mesh implantation, comprising paraesthesia and restriction of abdominal wall mobility, were significantly affected by the type of material implanted. Three-dimensional stereographic examinations were well in accordance with our clinical findings. Our data support the hypothesis that the use of low-weight large-pore meshes is advantageous for abdominal wall function. Electronic Publication     

Comparison of biomaterials: three meshes and TAPP for inguinal hernia

Background In laparoscopic hernia repair the use of biocompatible materials is necessary. A prospective, double-blind study was projected to compare three different meshes. Methods Ninety male patients with primary inguinal hernia undergoing transabdominal preperitoneal (TAPP) implant procedures were included. Three different types of mesh were tested: a monofile, heavy-weight, rigid mesh (group A), a smooth, heavy-weight variant of polypropylene (group B), and a polyglactin/polypropylene compound mesh (group C). Complications, pain development, inability to work, physical conditions, testicular volume, and blood circulation were documented. Results Convalescence in group A was slower than in groups B and C: Postoperative values of visual scales for pain development were higher, inability to work was 7.3 days longer, urologic effects were more severe, activities of everyday life were more reduced, and data of the German SF-36 Health Survey Test showed a significant reduction of physical condition (p < 0.05). Conclusion The compound mesh did not create more comfort for the patients than the smooth variant of the heavy-weight polypropylene mesh.     

A lightweight,partially absorbable mesh (Ultrapro) for endoscopic hernia repair: experimental biocompatibility results obtained with a porcine model

Background A meticulous surgical technique, a mesh of adequate dimensions, and use of a mesh with good biocompatibility properties are decisively important for minimizing the development of recurrences after endoscopic hernia repair surgery. Mesh “shrinkage” is a function of the mesh’s biocompatibility, that is, the properties of the mesh. Large-pore, lightweight polypropylene meshes possess the best biocompatibility, and the newly developed meshes meet these requirements. Methods Using a totally extraperitoneal technique in an experimental animal model, 10 domestic pigs were implanted with a lightweight, large-pore polypropylene mesh containing an absorbable component consisting of poliglecaprone (Ultrapro). After a period of 91 days, diagnostic laparoscopy followed by explantation of the specimens for macroscopic, histologic, and immunohistochemical evaluation was performed. Results The mean mesh shrinkage was a mere 1.9%. The partial volume of the inflammatory cells was a low 15.8%. The markers of cell turnover, namely Ki67 and the apoptosis index, were, at 5.8 and 2.1, respectively, also very low. The extracellular matrix showed a low value of transforming growth factor-beta (TGF-beta) (50.8). The mean value of collagen 1 was 136.9. Conclusions As a result of its good biocompatibility and elastic properties, the lightweight, large-pore Ultrapo mesh showed only a very slight tendency to “shrink.” This renders it extremely well suited for clinical use in hernia repair surgery, and its minimal shrinkage characteristic should help in achieving low complication and recurrence rates.     

Mesh repair for postoperative wound dehiscence in the presence of infection: is absorbable mesh safer than non-absorbable mesh?

Objective In patients with postoperative wound dehiscence in the presence of infection, extensive visceral oedema often necessitates mechanical containment of bowel. Prosthetic mesh is often used for this purpose. The aim of the present study was to assess the safety of the use of non-absorbable and absorbable meshes for this purpose. Method All patients that had undergone mesh repair of abdominal wound dehiscence between January 1988 and January 1998 in the presence of intra-abdominal infection were included in a retrospective cohort study. All surviving patients had physical follow-up in February 2001. Result Eighteen patients were included in the study. Meshes consisted of polyglactin (n = 6), polypropylene (n = 8), polyester (n = 1), or a combination of a polypropylene mesh with a polyglactin mesh on the visceral side (n = 3). All patients developed complications, consisting mainly of mesh infection (77%), intra-abdominal abscess (17%), enterocutaneous fistula (17%), or mesh migration through the bowel (11%). Mesh removal was necessary in eight patients (44%). Within four months postoperatively, six patients (33%) had died because of progressive abdominal sepsis. The incidence of progressive abdominal sepsis was significantly higher in the group with absorbable polyglactin mesh than in the group with nonabsorbable mesh (67 vs. 11%, p = 0.02) After a mean follow-up of 49 months, 63% of the surviving patients had developed incisional hernia. Absorbable meshes did not yield better outcomes than nonabsorbable meshes in terms of complications and mortality rate. Conclusion Synthetic graft placement in the presence of intra-abdominal infection has a high risk of complications, regardless of whether absorbable (polyglactin) or non-absorbable mesh material (polypropylene or polyester) is used, and should be avoided if possible.     

Two cases of cystic seroma following mesh incisional hernia repair

Cystic seromas, or mature fibrous cysts, are rare complications after ventral and incisional hernioplasties employing polypropylene mesh. We analyzed the medical records of patients, whose abdominal-wall hernias were surgically repaired with polypropylene mesh from November 1996 to February 2004 (N=685). Of the 162 patients, who had incisional hernias repaired with the Rives technique (preperitoneal mesh), we detected two patients who developed giant cystic seromas. Both patients underwent surgical resection of the cyst wall. As follow-up care improves for patients undergoing hernioplasties with polypropylene meshes, more cystic seromas are detected, thereby improving our knowledge of the clinical, radiological, and histopathological characteristics of this complication. However, the etiologic factors related to the appearance of this chronic cyst remain uncertain.     

Laparoscopic herniorrhaphy with porcine small intestinal submucosa: a preliminary study.

INTRODUCTION: Using mesh or a synthetic prosthesis during the laparoscopic repair of inguinal hernias has been demonstrated to be safe and effective. A new material, porcine small intestinal submucosa (SIS mesh), has been successfully used in canine and rodent animal models with excellent results. This mesh is degradable and resorbable with a marked decrease in the possibility of becoming infected. However, the amount of fibroblast ingrowth is equal to that with polypropylene mesh. METHODS: A comparison was made between this new SIS mesh to repair 15 inguinal hernias in 12 patients and polypropylene mesh used in 12 similar patients. A preperitoneal approach with balloon dissection was used in all patients. RESULTS: Demographics were similar in both groups. The results were excellent and compared equally. Complications (seroma, discomfort) were minimal in both groups and were similar. CONCLUSIONS: Porcine small intestinal submucosa, SIS mesh, can be used for laparoscopic repair of inguinal hernias. Long-term follow-up will be necessary to confirm these preliminary results.     

Laparoscopic inguinal hernia repair using an anatomically contoured three-dimensional mesh

Background: Laparoscopic inguinal hernia repair frequently is performed with mechanical fixation of a flat polypropylene mesh. Mechanical fixation is associated with pain syndromes, and mesh migration may occur without fixation of flat prostheses. An anatomically contoured mesh (3D Max; Davol, Cranston, RI, USA) using no or minimal fixation would avoid these problems. Methods: A retrospective case study reviewed 212 transabdominal preperitoneal herniaplasties with 11 × 16-cm 3D Max mesh in 146 patients. Fixation with three helical tacks at the most was used early or with very large defects. Results: Fixation was used in 19% of the cases, but only for 1 of the last 98 patients. As reported, 94% of the patients returned to normal activities by 3 weeks, 97% returned to unrestricted sports by 6 weeks, and 92% complete recovery from surgery by 9 weeks. Fixation or bilateral repair did not alter recovery. Four patients had minor pain or numbness. Symptomatic recurrence was 0%. One asymptomatic indirect recurrence was noted on examination, during a mean follow-up period of 23 months, yielding a 0.55% hernia rate and a 0.42% patient-year recurrence risk. Conclusions: An anatomically contoured mesh for transabdominal preperitoneal hernia repair often requires no fixation, with minimal risk of neuropathy and less than a 0.5% patient-year recurrence rate. Recovery is excellent even with bilateral repair or some fixation. Financial support for this study was provided by Davol, Inc., Cranst, USA     

Ultrasound detection of visceral adhesion after intraperitoneal ventral hernia treatment: A comparative study of protected versus unprotected meshes

Intraperitoneal (IP) ventral hernia repair has been proposed with the advantages of reducing dissection, operative time, and postoperative pain. The IP position of the mesh is suspected of increasing the risk of visceral adhesion and inducing complications. To overcome these drawbacks, a mesh protected on one side by a hydrophilic resorbable film (Parietex Composite) has been validated [1]. Using a previously described ultrasound procedure [2], the purpose of this study was to compare the rate of visceral adhesion after intraperitoneal placement of a polyester mesh versus this protected mesh. Fifty-one patients who received a Parietex Composite mesh were prospectively compared to a retrospective series of 22 consecutive asymptomatic patients who received a Mersilene mesh. To objectively assess visceral adhesion toward the abdominal wall, an ultrasound (US) specific examination was firstly validated and secondly used to evaluate the adhesion incidence in both groups. Both groups were equivalent in terms of inclusion criteria and body mass index (BMI). Pre-operative US versus perioperative macroscopical findings determined the following parameters: sensitivity 83%, accuracy 78%, negative predictive value 81%. Using this procedure, 77% of the patients exhibited visceral adhesion to the mesh in the Mersilene group, against 18% in the Parietex Composite group (P<0.001, chi-square). US examination represents a suitable tool to evaluate postoperative adhesions to the abdominal wall. Using this procedure, a significant reduction of visceral adhesion in the Parietex Composite group was shown.An erratum to this article can be found at     

Sixty-month follow-up after endoscopic inguinal hernia repair with three types of mesh: a prospective randomized trial

Background  This prospective, clinical, randomized, double-blind study was intended to investigate the impact of the structure and the amount of polypropylene (PP) mesh used in laparoscopic transabdominal preperitoneal hernioplastic (TAPP) on physical function and life quality. Methods  180 male patients with primary inguinal hernia undergoing TAPP were randomized for using a heavyweight (108 g/m²), double-filament PP mesh (Prolene, 10 × 15 cm, group A, n = 60), a multifilament, heavyweight variant (116 g/m²) of PP mesh (Serapren, 10 × 15 cm, group B, n = 60), or a composite mesh (polyglactin and PP) (Vypro II, 10 × 15 cm, group C, n = 60). We compared in terms of complications (seromas, recurrence rate) and life quality (pain development, physical function). The development of life quality was documented according to the SF-36 Health Survey. The follow-up period was 60 months. Results  The recurrence rate (2.2% overall) during 60-month follow-up was not significantly different between the groups. Convalescence in group A was slower than in groups B and C: mean-term values of the visual scales for pain development were significantly (p < 0.05) higher, incapacity for work was 8.2 days longer, and urological adverse effects were stronger. The mean-term development of life quality was significantly lower in group A up to 12th week postoperatively. There were no significant differences between groups B and C. Beyond the 12th postinterventional week the differences diminished. Conclusions  The composite mesh does not provide an advantage concerning physical function or pain development in comparison to the multifilament, heavyweight, pure polypropylene mesh. Independently of which mesh was implanted 5% of patients are still suffering from discomfort after 5 years.     

Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair

Background:

The characteristics of the ideal type of mesh are still being debated. Mesh shrinkage and fixation have been associated with complications. Avoiding shrinkage and fixation would improve hernia recurrence rates and complications. To our knowledge, this is the first study of a device with a self-expanding frame for laparoscopic hernia repair.

Methods:

Six Rebound Hernia Repair Devices were placed laparoscopically in pigs. This device is a condensed polypropylene, super-thin, lightweight, macro-porous mesh with a self-expanding Nitinol frame. The devices were assessed for adhesions, shrinkage, and histological examination. Laboratory and radiologic evaluations were also performed.

Results:

The handling properties of the devices facilitated their laparoscopic placement. They were easily identified with simple x-rays. The mesh was firmly integrated within the surrounding tissue. One device was associated with 3 small adhesions. The other 5 HRDs had no adhesions. We noted no shrinkage or folding. All devices preserved their original size and shape.

Conclusions:

At this evaluation stage, we found that the Rebound Hernia Repair Device may serve for laparoscopic hernia repair and has favorable handling properties. It prevents folding and shrinkage of the mesh. It may eliminate the need for fixation, thus preventing chronic pain. The Nitinol frame also allowed radiologic evaluation for gross movement. Further studies will be needed to evaluate its clinical application.     

The new 4DDome prosthesis: an original light and partially absorbable composite mesh for hernia repair

Introduction The use of non-absorbable meshes for the repair of inguinal hernias has become standard; however, these meshes have been associated with complications including long-term postoperative pain. To this end, a new partially absorbable composite mesh has been developed, and the aim of this study was to investigate its efficacy in animal and human trials. Materials and methods Sixty male Wistar rats were used to evaluate the behavior of the newly designed composite mesh. Composite meshes were implanted in the extra-peritoneal plane for 2, 4 and 8 weeks and compared to a standard polypropylene mesh. Forty patients with symptomatic inguinal hernias were treated using a new 4DDome designed prosthesis. Follow-up was by clinical and ultrasound examination at 1, 6 and 12 months. Results The animal study demonstrated that the inflammatory reaction associated with the new composite mesh was significantly lower than a standard polypropylene mesh, characterized by a lower macrophage infiltrate (P < 0.001). The mesh did not shrink over the 8-week period, unlike the polypropylene mesh (P < 0.05). The human study showed that there were three minor postoperative complications, no recurrences and the mesh was well tolerated. Follow-up with serial ultrasound showed that at 10 days and 1 month the dome was clearly visible in position; however, by 6 months it had flattened out, been partially absorbed and become incorporated into the repair. Conclusion These experimental and clinical studies have validated the concept of the new 4DDome composite mesh. It was well tolerated and was associated with good short-term results. The combination of the dome shape and the new composite mesh means that less polypropylene is required and represents a significant advance in anterior hernia repair.     

Late complication of open inguinal hernia repair: Small bowel obstruction caused by intraperitoneal mesh migration

We describe a case of small bowel obstruction due to prosthetic mesh migration. A 67-year-old male, who had undergone prosthetic repair of inguinal hernia 3 years before, was admitted for a mechanical small bowel obstruction. Laparotomy revealed the penultimate ileal loop choked by an adhesion drawing it towards a polypropylene mesh, firmly attached to the parietal peritoneum of the inguinal region. The intestinal loop was released; the mesh was embedded deep with continuous whip suture after folding the parietal peritoneum. The patient was dismissed on the 11th postoperative day surgically healed. The "tension-free" technique is undoubtedly the gold standard for hernia repair. However, it is not free of complications, mostly due to technical errors, of which the surgeon must be aware, both when he is responsible for correcting defects in the wall, as well as when he has to face an occlusion in a patient who has undergone plastic surgery for inguinal hernia.     

Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields

Surgisis (Cook Surgical, Bloomington, Ind., USA) is a new four-ply bioactive, prosthetic mesh for hernia repair derived from porcine small-intestinal submucosa. It is a naturally occurring extracellular matrix which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. From November 2000 through May 2002, 25 patients (11 male, 14 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 25 hernia repairs were performed in our patient population. Fourteen procedures (56%) were performed in a potentially contaminated setting (i.e. with incarcerated/strangulated bowel within the hernia or coincident with a laparoscopic cholecystectomy/colectomy). Eleven repairs (44%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis and one in which necrotic bowel was discovered within the hernial sac. Median follow-up was 15 months with a range of 1–20 months. Of the 25 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There were no mesh-related complications or recurrent hernias in our early postoperative follow-up period. Surgisis mesh appears to be a promising new prosthetic material for hernia repair, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required. Electronic Publication