Which mesh for hernia repair?

INTRODUCTION

The concept of using a mesh to repair hernias was introduced over 50 years ago. Mesh repair is now standard in most countries and widely accepted as superior to primary suture repair. As a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one can be difficult. This article outlines the general properties of meshes and factors to be considered when selecting one.

MATERIALS AND METHODS

We performed a search of the medical literature from 1950 to 1 May 2009, as indexed by Medline, using the PubMed search engine (<http://www.pubmed.gov>). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. We used the following terms: ‘mesh, pore size, strength, recurrence, complications, lightweight, properties’. We also hand-searched the bibliographies of relevant articles and product literature to identify additional pertinent reports.

RESULTS AND CONCLUSIONS

The most important properties of meshes were found to be the type of filament, tensile strength and porosity. These determine the weight of the mesh and its biocompatibility. The tensile strength required is much less than originally presumed and light-weight meshes are thought to be superior due to their increased flexibility and reduction in discomfort. Large pores are also associated with a reduced risk of infection and shrinkage. For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others. Finally, biomaterials such as acellular dermis have a place for use in infected fields but have yet to prove their worth in routine hernia repair.     

Primary inguinal hernia repair utilizing the mesh ‘plug’ technique

‘Tension-free’ mesh repairs, as popularised by Lichtenstein, are being used increasingly in the management of primary inguinal hernia. Introduced more recently, the mesh ‘plug’ technique may enhance further the benefits of such repairs. Twenty six males attending for unilateral, primary, inguinal hernia repair were randomised to have either a Lichtenstein ‘patch’ repair or to undergo a mesh ‘plug’ repair. Ease of technique and operating time were recorded. Patients were given a visual analogue pain-scoring sheet and were asked to record the number of analgesic tablets taken each post-operative day. Patients were reviewed in clinic at 1 and 6 weeks post-operatively, when they were asked their time to return to ‘normal’ activity and time to return to work. Any post-operative complications were noted. The tension-free mesh ‘plug’ repair requires minimal tissue dissection, no herniotomy and is technically straightforward. Patients experienced less post-operative discomfort and returned to ‘normality’ more quickly. The results suggest that the mesh ‘plug’ technique has advantages over the Lichtenstein ‘patch’ repair. A larger trial of this technique should now be undertaken to confirm the results of our pilot study and to assess long term recurrence rates.     

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.     

Inguinal hernia: mesh or no mesh in open repair?

The operative repair of inguinal hernias is the most common surgical procedure in general surgery. This review gives a survey of the current data on the "mesh or no mesh" question in open inguinal hernia surgery. The Cochrane Database Systematic Review of 2002 has the highest level of evidence. Five randomised controlled trials were published after the Cochrane analysis and in a retrospective study, 1,513,008 patients were summarised accordingly. According to these data, the incidence of postoperative complications (haematoma, seroma, wound infection and serious complications like bowel/vessel injury and bleeding) does not depend on the operative technique used. The implantation of meshes significantly decreases the overall recurrence rate, the occurrence of chronic pain and the time of return to normal activity, as compared to non-mesh techniques. The published data shows significant advantages for mesh techniques.     

Is mesh fixation necessary in abdominal hernia repair?

Background: Abdominal hernia repair with implantation of synthetic meshes using the sublay technique has resulted in low recurrence rates and high patient satisfaction. Aim: The purpose of this experimental animal study was to investigate whether mesh fixation is necessary in abdominal hernia repair using a polypropylene mesh in the sublay technique. Methods: Forty-five rats were divided into three groups after creating an abdominal wall defect (CG control group, no mesh implantation; NoFixG mesh implantation without fixation group; SG mesh with suture fixation group) with 15 animals in each group. Endpoints were clinical herniation pressure, hydroxyproline (HP) concentration, mesh shape and number of fibroblasts/collagen fibres of the anchor zone 7, 14 and 90 days after implantation. Results: Herniation pressure, HP content and number of fibroblasts were similar between NoFixG and SG, although significantly higher in these groups than in the CG (P<0.05). Both mesh groups had significantly higher counts of fibroblasts and collagen fibres than the CG. Mesh shrinking occurred in both groups but was less in the SG. Conclusion: Mesh fixation was not mandatory in abdominal hernia repair using this animal model. Received: 18 May 1998; in revised form: 11 August 1998 Accepted: 5 October 1998     

Is parastomal hernia repair with polypropylene mesh safe?

BACKGROUND: Concern over the safety of polypropylene mesh in parastomal hernia repairs has led some to avoid its use. We reviewed our rate of complications and outcomes with polypropylene mesh. METHODS: From January 1988 through May 2002, 58 patients underwent parastomal hernia repair with polypropylene mesh. After closure of the fascia, the stoma was pulled through the center of the mesh, which was placed either above or below the fascia. Multivariate analysis was performed to determine independent predictors for the development of complications. RESULTS: There were 31 end colostomies, 24 end ileostomies, and 3 loop transverse colostomies. Mean follow-up with 50.6 months. Overall complications related to the polypropylene mesh was 36% (recurrence 26%, surgical bowel obstruction 9%, prolapse 3%, wound infection 3%, fistula 3%, and mesh erosion 2%). None of the patients had extirpation of their mesh. Complications were significantly associated with younger age (59.6 versus 67 years, P = 0.04). Cancer patients with stomas had fewer complications (P = 0.02, odds ratio 0.34). Inflammatory bowel disease, stomal type, mesh location, urgent procedures, steroid use, and surgical approaches were not significantly associated with an increased complication rate. Of the 15 patients with recurrence, 7 underwent successful repair for an overall success rate of 86%. CONCLUSIONS: Parastomal hernia repair with polypropylene mesh is safe and effective.     

Groin hernia repair in young males: mesh or sutured repair?

Background  

Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair.     

Laparoscopic ventral hernia repair: Does primary repair in addition to placement of mesh decrease recurrence?

Background  

The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repair but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant.     

Polyester-based mesh for ventral hernia repair: is it safe?

Introduction

The ideal prosthetic material for ventral hernia repair has yet to be described. Each prosthetic material has unique advantages and disadvantages in terms of tissue ingrowth, adhesion formation, and shrinkage profiles. Polyester-based mesh has shown minimal shrinkage and excellent tissue ingrowth in animal models. However, the macroporous, braided nature of this material has raised several concerns regarding the incidence of infections, fistulas, and bowel obstructions. We have reviewed our experience with polyester-based mesh for the repair of ventral hernias.

Methods

All patients undergoing ventral hernia repair at the Case Comprehensive Hernia Center at University Hospitals of Cleveland from December 2005 to April 2008 were included. Laparoscopic cases underwent intraperitoneal placement of a polyester-based mesh with a collagen hydrogel anti-adhesive barrier. The mesh was sized for at least 4 cm of fascial overlap, and transfascial fixation sutures and titanium spiral tacks were used routinely to secure the mesh to the abdominal wall. Those cases deemed inappropriate for laparoscopic ventral hernia repair underwent open repair. Open ventral hernia repairs were performed using a retrorectus repair, placing the mesh in an extraperitoneal position. Unprotected polyester mesh was used in these cases. Pertinent data included patient demographics, surgical details, postoperative outcomes, and long-term follow-up evaluation.

Results

During the study period 109 patients underwent ventral hernia repair with polyester mesh. Seventy-nine patients had a laparoscopic repair, and 30 patients had an open repair. The mean age was 57 years, with a mean body mass index of 33 kg/m², and American Society of Anesthesia score of 2.6. The patients had undergone 2.1 prior abdominal surgical procedures, and 42 patients had recurrent hernias. Surgical details for the laparoscopic repair and open repair were as follows: mean defect size, 116 versus 403 cm²; mesh size, 367 versus 1,055 cm²; and surgical times, 132 versus 170 minutes, respectively. The average hospital stay was 4.2 days for the laparoscopic repair and 5.8 days for the open repair groups. With a mean follow-up period of 14 months (range, 2-28 mo) in the laparoscopic repair group, 1 patient (1.4%) developed a mesh infection (with a history of a prior methicillin-resistant Staphylococcus aureus mesh infection), 1 patient (1.4%) developed a small-bowel obstruction remote to the mesh on re-exploration, and there were no fistulas. With a mean follow-up period of 11 months (range, 2-21 mo) in the open repair group, 3 wound infections (13%) occurred, 2 involved the mesh, which was salvaged with local wound care in 1, and required partial mesh resection in the other, and there were no bowel obstructions or fistulas during the follow-up evaluation.

Conclusions

This study shows that in this complex group of patients, polyester mesh placed during ventral hernia repair results in acceptable infection rates, and no direct bowel complications or fistulas. Given the macroporous nature of the mesh, each case of infection was treated successfully with local wound measures or partial mesh resection. Polyester-based meshes with an anti-adhesive barrier appear safe for intraperitoneal placement.     

Does every hernia demand a mesh repair? A critical review

Conclusion  In accordance with the experiences gained in other surgical fields the use of implants should be restricted to those patients, where there is an unequivocal indication. The indiscriminate use of biomaterials in every case of hernia at every age disregards the certain and usually severe complications of the extended contact of the body with alloplastic materials.To minimise future risks in hernia repair we favour at this point of time the following concept:

Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia?

Background: Giant prosthetic reinforcement of the visceral sac (GPRVS), an open preperitoneal mesh repair, is a very effective groin hernia repair. Laparoscopic transabdominal preperitoneal repair (TAPP), based on the same principle, is expected to combine low recurrence rates with minimal postoperation morbidity. Methods: Seventy-nine patients with 93 recurrent and 15 concomitant primary inguinal hernias were randomized between GPRVS (37 patients) and TAPP (42 patients). Operating time, complications, pain, analgesia use, disability period, and recurrences were recorded. Results: Mean operating time was 56 min with GPRVS versus 79 min with TAPP (p < 0.001). Most complications were minor, except for a pulmonary embolus and an ileus, both after GPRVS. Patients experienced less pain after a laparoscopic repair. Average disability period was 23 days with GPRVS versus 13 days with TAPP (p= 0.03) for work, and 29 versus 21 days, respectively (p= 0.07) for physical activities. Recurrence rates at a mean follow-up of 34 months were 1 in 52 (1.9%) for GPRVS versus 7 in 56 (12.5%) for TAPP (p= 0.04). Hospital costs in U.S. dollars were comparable, with GPRVS at $1,150 and TAPP at $1,179. Conclusions: Laparoscopic repair of recurrent inguinal hernia has a lower morbidity than GPRVS. However, laparoscopic repair is a difficult operation, and the potential technical failure rate is higher. With regard to recurrence rates, the open preperitoneal prosthetic mesh repair remains the best repair. Received: 14 April 1998/Accepted: 28 May 1998     

Inguinal hernia repair: Where to next?

Background: Hernia repair is one of the most frequently performed operations in general surgery ? a total of 39 000 elective inguinal hernia repairs were performed in public and private hospitals in Australia between July 1998 and June 1999 ? and, as such, even minor alterations in outcome and resource use have appreciable impact. However, decisions regarding choice of operation for hernia repair remain controversial. The purpose of the present paper is to critically evaluate the evidence available regarding recently introduced open mesh repair techniques and to try to identify meaningful directions for future hernia research. Methods: A thorough search of all published surgical literature was undertaken. Medline, EMBASE and the Cochrane databases were searched by title, by key words and by author. References in review articles and in textbooks were pursued. The manufacturing companies were contacted for trials evaluating their product. Results: Eight original articles evaluating either the Kugel Patch, the PerFix Plug or the Prolene Hernia System were located. None of these trials directly compared two or more of these repair systems. To date, there has been no published review of the evidence regarding the newer mesh repair techniques. With one exception, all of these articles qualify as Level IV evidence. Highlighted is the lack of evidence regarding chronic significant posthernioplasty pain ? this has an incidence of 6?12%. This complication is 3?5 times more common than recurrence after open repair, is clinically relevant, is poorly understood and has been poorly studied. Arguably it is a more important end point than recurrence. Conclusion: Only one study comparing the newer techniques of open hernia repair (PerFix Plug) constitutes Level II evidence. The PerFix Plug appears to be quicker to insert and uses a smaller incision. Chronic significant posthernioplasty pain is a more important endpoint in hernia research than is recurrence, and this review concludes with a proposal for a multicentre, randomized, controlled trial evaluating the incidence of chronic significant posthernioplasty pain following elective mesh repair of primary, unilateral ­hernias.     

Which repair in umbilical hernia of adults: primary or mesh?

In classic literature, knowing that small defects can be repaired primarily in umbilical hernias of adults, mesh repair should be reserved for larger defects. Conventional repair methods have resulted in high rates of recurrence. Therefore, this prospective study investigated the repair techniques in umbilical hernias of adults. The patients who underwent primary umbilical hernia operation between 1998 and 2003 were reviewed. Primary repair was conducted in defects less than 3 cm, whereas larger defects were repaired with polypropylene mesh. Postoperative complications, the length of hospital stay, and recurrence in follow-up were recorded. Of 111 patients, primary repair was carried out on 63 patients, and 48 underwent polypropylene mesh repair. Recurrence rate was significantly higher in the primary repair group (14%) compared with polypropylene mesh repair group (2%). In conclusion, contrary to the general tendency that small defects can be repaired primarily, polypropylene mesh should be used in all umbilical hernias regardless of the size of the defect.     

Does expanded polytetrafluoroethylene mesh really shrink after laparoscopic ventral hernia repair?

Background

The shrinkage of mesh has been cited as a possible explanation for hernia recurrence. Expanded polytetrafluoroethylene (ePTFE) is unique in that it can be visualized on computed tomography (CT). Some animal studies have shown a greater than 40% rate of contraction of ePTFE; however, very few human studies have been performed.

Study design

A total of 815 laparoscopic incisional/ventral hernia (LIVH) repairs were performed by a single surgical group. DualMesh Plus (ePTFE) (WL Gore &; Associates, Newark, DE) was placed in the majority of these patients using both transfascial sutures and tack fixation. Fifty-eight patients had postoperative CTs of the abdomen and pelvis with ePTFE and known transverse diameter of the implanted mesh. The prosthesis was measured on the CT using the AquariusNet software program (TeraRecon, San Mateo, CA), which outlines the mesh and calculates the total length. Data were collected regarding the original mesh size, known linear dimension of mesh, seroma formation, and time interval since mesh implantation in months.

Results

The mean shrinkage rate was 6.7%. The duration of implantation ranged from 6?weeks to 78?months, with a median of 15?months. Seroma was seen in 8.6% (5) of patients. No relationship was identified between the percentage of shrinkage and the original mesh size (P?=?0.78), duration of time implanted (P?=?0.57), or seroma formation (P?=?0.074). In 27.5% (16) of patients, no shrinkage of mesh was identified. Of the patients who did experience mesh shrinkage, the range of shrinkage was 2.6?C25%.

Conclusions

Our results are markedly different from animal studies and show that ePTFE has minimal shrinkage after LIVH repair. The use of transfascial sutures in addition to tack fixation may have an implication on the mesh contraction rates.     

Is postoperative chronic pain syndrome higher with mesh repair of inguinal hernia?

Chronic postoperative pain has been associated with mesh repair in meta-analysis of clinical trials. We compared the incidence of early complications, recurrence, and chronic pain syndrome in anatomic and mesh repairs in 200 patients. We defined chronic pain syndrome as pain in the inguinal area more than 3 months after inguinal hernia repair, patient referral to pain management, or necessity of a secondary procedure for pain control. The mean follow-up time was 4 years and 2 months for anatomic repair and 3 years and 7 months for mesh repair. The clinical outcomes did not reveal a significant disparity between the 100 consecutive patients who had mesh repair versus the 100 patients who had anatomic repair with regard to the incidence of superficial wound infection (0 vs. 2%, P = 0.497), testicular swelling (12 vs. 7%, P = 0.335), hematoma (1 vs. 0%, P = 0.99), recurrence (3 vs. 2%, P = 0.99), or chronic postoperative pain (4 vs. 1%, P = 0.369). The anatomic procedure without mesh should continue to be offered to patients who have an initial inguinal hernia repair.     

Totally extraperitoneal repair for bilateral inguinal hernia: Does mesh configuration matter?

BACKGROUND: The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate. METHODS: Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit. RESULTS: The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups. CONCLUSIONS: Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.     

Is there a place for a biological mesh in perineal hernia repair?

Purpose

This study aimed to determine the outcome of perineal hernia repair with a biological mesh after abdominoperineal resection (APR).

Method

All consecutive patients who underwent perineal hernia repair with a porcine acellular dermal mesh between 2010 and 2014 were included. Follow-up was performed by clinical examination and MRI.

Results

Fifteen patients underwent perineal hernia repair after a median of 25 months from APR. Four patients had a concomitant contaminated perineal defect, for which a gluteal fasciocutaneous flap was added in three patients. Wound infection occurred in three patients. After a median follow-up of 17 months (IQR 12–24), a clinically recurrent perineal hernia developed in 7 patients (47 %): 6 of 11 patients after a non-cross-linked mesh and 1 of 4 patients after a cross-linked mesh (p = 0.57). Routine MRI at a median of 17 months revealed a recurrent perineal hernia in 7 of 10 evaluable patients, with clinical confirmation of recurrence in 5 of these 7 patients. No recurrent hernia was observed in the three patients with combined flap reconstruction for contaminated perineal defects.

Conclusion

A high recurrence rate was observed after biological mesh repair of a perineal hernia following APR.