Comparison of a lightweight polypropylene mesh (Optilene® LP) and a large-pore knitted PTFE mesh (GORE® INFINIT® mesh)—Biocompatibility in a standardized endoscopic extraperitoneal hernia model

Purpose  

The use of a mesh with good biocompatibility properties is of decisive importance for the avoidance of recurrences and chronic pain in endoscopic hernia repair surgery. As we know from numerous experiments and clinical experience, large-pore, lightweight polypropylene meshes possess the best biocompatibility. However, large-pore meshes of different polymers may be used as well and might be an alternative solution.     

Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair

Background  

The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair.     

Evaluation of new prosthetic meshes for ventral hernia repair

Background In hernia repair, particularly laparoscopic hernia repair, direct contact between mesh and abdominal organs cannot always be avoided. Several mesh materials and composite meshes have been developed to decrease subsequent adhesion formation. Recently, new meshes have been introduced. In an experimental rat study, their value was established and compared with that of meshes already available on the market. Methods In 200 rats, eight different meshes were placed intraperitoneally and in direct contact with abdominal viscera. The following meshes were tested: polypropylene (Prolene), e-PTFE (Dualmesh), polypropylene– polyglecaprone composite (Ultrapro), titanium–polypropylene composite (Timesh), polypropylene with carboxymethylcellulose–sodium hyaluronate coating (Sepramesh), polyester with collagen-polyethylene glycol–glycerol coating (Parietex Composite), polypropylene–polydioxanone composite with oxidized cellulose coating (Proceed), and bovine pericardium (Tutomesh). At 7 and then at 30 days postoperatively, adhesion formation, mesh incorporation, tensile strength, shrinkage, and infection were scored by two independent observers. Results Parietex Composite, Sepramesh, and Tutomesh resulted in decreased surface coverage with adhesions, whereas Prolene, Dualmesh, Ultrapro, Timesh, and Proceed resulted in increased adhesion coverage. Parietex Composite, Prolene, Ultrapro, and Sepramesh resulted in the most mesh incorporation. Dualmesh and Tutomesh resulted in significantly increased shrinkage. There were no differences in mesh infection. Parietex Composite and Dualmesh resulted in a moderate inflammatory reaction, as compared with the mild reaction the other meshes exhibited. Conclusion Parietex Composite and Sepramesh combine minimal adhesion formation with maximum mesh incorporation and tensile strength. The authors recommend the use of these meshes for hernia repair in which direct contact with the abdominal viscera cannot be avoided.     

不同材质补片固定大鼠膈肌后的炎症反应、粘连及补片皱缩情况对比研究

背景与目的：食管裂孔疝是外科常见病症，临床上多采用补片以无张力修补的方式进行治疗。食管裂孔疝的补片修补中补片的选择及其应用效果方面的实验数据仍相对缺乏。因此，本研究通过在大鼠食道裂孔处膈肌组织上分别固定聚丙烯补片和复合补片，比较两种材质补片对周围组织的影响，以及自身皱缩情况，为临床食管裂孔疝补片的选择提供参考。方法：雄性SD大鼠在分离胃部与肝脏相连接组织显露胃食道裂孔后，分别用单丝缝线将轻量聚丙烯补片（聚丙烯补片组）或复合补片（复合补片组）固定于食道裂孔处膈肌组织，或不进行补片固定（假手术组）。分别在术后7、15、30 d时记录每组每只大鼠的体质量和饮食量。观察30 d后处死大鼠，分析补片皱缩程度、粘连强度以及膈肌组织的病理学变化。结果：各组大鼠手术前后的体质量及每天进食量均无明显的变化（均P>0.05）。复合补片组膈肌组织与补片的粘连范围及粘连程度分值均明显低于聚丙烯补片组（均P<0.05）；两组补片均出现皱缩，但复合补片组术后补片面积明显大于聚丙烯补片组，皱缩率明显低于聚丙烯补片组（均P<0.05）；与假手术组比较，聚丙烯补片组和复合补片组膈肌组织出现局部肌纤维萎...     

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     

Netzschrumpfung in der Hernienchirurgie

Objectives

According to an estimated mesh shrinkage following hernia repair of up to 40% a current dogma in hernia surgery requires a mesh overlap of 5 cm around the hernia. However, no valid data addressing this problem of mesh shrinkage are available at present.

Patients and methods

Within the framework of a prospective randomized double-blinded clinical trial, 50 patients were operated on for a ventral abdominal hernia with the open sublay technique using specially prepared radio-opaque polypropylene (PP) meshes. Of the patients 27 received a conventional heavyweight mesh (P group) and 23 a new lightweight mesh construction (NK group). Follow-up for at least 2 years after mesh repair included conventional abdominal x-rays after 7 days, 3 weeks and 4, 12 and 24 months, as well as computed tomography after 7 days and 4 and 12 months. Main criteria were mesh shrinkage, recurrence and complication rates and quality of life comparing groups P and NK.

Results

In 46 cases (92%) no mesh shrinkage could be detected and only 4 meshes (8%) showed a moderate shrinkage (1 of 22.2%, 2 of 8% and 1 of 3%) all from the P group. While no hernia recurrences were found, 2 surgical complications occurred with 1 seroma in the P group and 1 hematoma in the NK group. Quality of life showed a linear improvement over time up to the 2 year time point following mesh repair with advantages for the NK group. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the two groups.

Conclusions

In principle PP meshes following an uncomplicated ventral hernia repair do not shrink at all. A moderate shrinkage in isolated cases might occur following heavyweight mesh implantation. Under controlled conditions recurrence as well as complication rates are equal for heavyweight and lightweight PP meshes. Quality of life improves up to 2 years following mesh repair with a trend to a better outcome for lightweight meshes. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the lightweight and heavyweight meshes.     

Chronic Pain after Laparoscopic Transabdominal Preperitoneal Hernia Repair: A Randomized Comparison of Light and Extralight Titanized Polypropylene Mesh

Background  

The aim of this prospective, randomized, single-blinded clinical trial was to compare the incidence of chronic pain after laparoscopic transabdominal preperitoneal hernia repair (TAPP) using a 35-g/m² titanized polypropylene mesh and a 16-g/m² titanized polypropylene mesh. The reported incidence of chronic pain in patients who underwent laparoscopic hernia repair is a serious problem. The techniques of dissection, mesh fixation, and the mesh material used have all been identified as being part of the problem. Excellent biocompatibility through a unique combination of a lightweight open porous polypropylene mesh covered with a covalent-bonded titanium layer has been claimed. The aim of this study was to find out whether the titanium surface alone or the difference in material load between the two available meshes influences clinical outcomes.     

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.     

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。     

In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs

Background: Polypropylene (PP) meshes are currently being used in millions of operations for hernial repair. We tested several recently modified PP meshes to evaluate them in terms of their biocompatibility and handling characteristics during minimally invasive procedures. Methods: Four different PP meshes (a heavyweight PP, Atrium; a lightweight PP incorporating absorbable polyglactic acid, Vypro II; a lightweight PP, Parietene; and a titanium-coated lightweight PP, Ti-Mesh Extralight), all implanted using the endoscopic total extrapreperitoneal (TEP) technique, were investigated in groups comprising 11 pigs each. After 94 ± 5 days, the animals were autopsied and tissue samples were studied histologically, immunohistochemically, and electron-microscopically. Results: Whereas endoscopic handling of the Vypro II mesh proved difficult, the already good properties of the Atrium mesh were significantly improved on by Parietene and the Ti-Mesh. Clear differences were also found in the shrinkage characteristics of the implant materials. In comparison with Atrium (12%), Vypro II mesh shrinkage was significantly greater (28%), whereas Parietene (7%) and Ti-Mesh (5%) incurred less shrinkage. With regard to the chronic inflammatory reaction, the titanium-coated mesh showed a significantly lower inflammatory activity (13.1% partial volume [%PV] vs 34.1%PV and 29.0%PV) than the lightweight meshes Vypro II and Parietene, but—with the exception of the monocytic (0.2 vs 9.1, 5.1, and 7.9) and B-lymphocytic reaction (1.1 vs 18.0, 11.7, and 12.2)—no significant difference was seen in comparison with Atrium. The various mediators in the extracellular matrix (matrix metalloproteinases 1 [MMP-1 transforming growth factor beta [TGF-], urokinase plasminogen activator [uPA], and type I collagen) tended to show the highest expression with Vypro II (13.6, 113.2, 132.7, and 139.5, respectively) and the lowest expression with Ti-Mesh (11.9, 68.5, 92.8, and 75.0, respectively). With regard to cell proliferation, Parietene and Ti-Mesh appeared to have slight advantages, but no differences were observed in the apoptotic rate. Conclusion: In our opinion, despite a reduction in material, Vipro II, on account of the inflammatory reaction, does not represent a true improvement over the meshes currently used for hernia repair. In comparison, the two lightweight PP patches are characterized by a more favorable foreign body reaction, with the titanium coating of the Ti-Mesh providing an additional advantage in terms of its biocompatibility.     

Inguinal hernia recurrence: classification and approach

We reviewed case reports, updated to January 2005, of 2,468 operations for groin hernia in 2,350 patients, including 277 recurrent hernias. The data obtained, following a simple anatomo-clinical classification into three types that could be used to orient surgical strategy, were: type R1—first recurrence of “high” oblique external reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; type R2—first recurrence of “low” direct reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; and type R3—all other recurrences, including femoral recurrences, recurrent groin hernia with large defect (inguinal eventration), multi-recurrent hernias, non-reducible contralateral primary or recurrent hernia, and situations compromised by aggravating factors (e.g. obesity) or otherwise not easily included in R1 or R2 after pure tissue or mesh repair.     

Biomechanical properties of lightweight versus heavyweight meshes for laparoscopic inguinal hernia repair and their impact on recurrence rates

Background  Laparoscopic inguinal hernia repair can be performed using light- or heavyweight meshes. Apart from the size of the mesh, its friction coefficient (μ₀) and flexural stiffness are of crucial importance to avoidance of hernia recurrence. Methods  In the current biomechanical study, tensile tests were performed to determine the ultimate tensile strength and modulus of elasticity of six lightweight meshes and six heavyweight meshes for laparoscopic inguinal hernia repair. To determine their friction coefficient (μ₀), the meshes were placed between a resected peritoneum and groin muscles during an autopsy. Meshes measuring 15 × 10 cm in size then were used in a hernia model with an opening size of 1.5, 3, or 5 cm. Results  The ultimate tensile strength and modulus of elasticity were significantly lower in the lightweight mesh group than in the heavyweight mesh group. The mean friction coefficient (μ₀) of the meshes was 0.4. Given an opening of 1.5 cm, all meshes remained adequately stable. At opening sizes of 3 and 5 cm, the lightweight meshes flexed on the average by 3.16 ± 0.4 mm and 10.40 ± 2.5 mm, respectively. Heavyweight meshes, on the other hand, were significantly less flexible. Their mean flexure was, respectively, 0.34 ± 0.2 mm and 3.97 ± 0.7 mm (p < 0.001). Conclusion  Stable meshes are characterized by a small degree of flexure and do not slide into the gap even when subjected to repetitive loads. Therefore, in terms of hernia recurrence, meshes with greater flexural stiffness or well-fixed lightweight meshes that adequately overlap the hernia defect can be used for laparoscopic treatment of large inguinal hernias.     

Feasibility and outcome after laparoscopic ventral hernia repair using Proceed mesh

Background  There are many different meshes available for laparoscopic repair of ventral hernias. A relatively new product is the Proceed mesh with a bioresorbable layer against the bowels and a polypropylene layer against the abdominal wall. There are, however, no human data available. The aim of this study was to evaluate the feasibility and outcome after laparoscopic ventral hernia repair using the Proceed mesh in humans. Methods  Patients presenting for laparoscopic ventral hernia repair in our department from September 2004 to October 2006 were included in the study. All patients had a standard laparoscopic ventral hernia repair using the Proceed mesh secured with tackers with a double crown technique. Patients were discharged according to standard discharge criteria, and follow-up was performed with a search in the national patient database and with manual search in the patients’ files. Results  Our study included 49 patients with a median age of 64 years (range 30–89) and body mass index of 27.8 (19.4–50.5). The dimensions of the mesh varied from 4 × 4 cm to 30 × 40 cm (median 15 × 15 cm). One patient developed an uncomplicated wound infection and none of the 49 patients developed mesh infections or postoperative seroma requiring surgical intervention. Thus, there were no mesh-related complications. During the follow-up period of 17 months (3–27), we have not seen any postoperative recurrences. The median length of stay was 1 day (range 0–63), and there was no mortality. Conclusion  Laparoscopic ventral hernia repair in humans using the Proceed mesh is feasible and has a low complication rate even in obese patients or those with pulmonary disease.     

The effects of onlay titanium-coated mesh on recurrence,foreign body sensation and chronic pain after ventral hernia repair

Background/objectiveThere are many complications of meshes in hernia repair. The aim of this study was to investigate the effects of onlay titanium-coated meshes (TCM) on recurrence, foreign body sensation and chronic pain in ventral hernia repair.MethodsIn this retrospective study, 160 patients undergone TCM or polypropylene mesh (PM) surgery for onlay repair of ventral hernia were examined between May 2014 and January 2018 at our center. Patient characteristics, type of hernia, defect size, operative time, follow-up time, surgical site occurrence (infection, seroma and hematoma), recurrence, foreign body sensation and chronic pain were analyzed. Patients were divided into two groups according to mesh used: TCM (titanium group) or PM (polypropylene group).ResultsOut of 160 patients, 63 (32.6%) had TCM and 97 (67.4%) had PM. There was no significant difference between groups in terms of recurrence (p = 0.757). Chronic pain and foreign body sensation were low in the titanium group (p = 0.047 and p = 0.029, respectively), a positive correlation was found between surgical site infection and recurrence (p = 0.020). In the polypropylene group, an increase in defect size was significantly associated with foreign body sensation and chronic pain (p < 0.001 for both comparisons).ConclusionIn onlay repair of ventral hernia, TCM led to less foreign body sensation and chronic pain then PM. The surgical site infection was associated with recurrence for these meshes. Additionally, the increase in defect size causes a risk for foreign body sensation and chronic pain in repair using PM.     

Utility of a new soft non-woven polypropylene mesh for the transabdominal extraperitoneal laparoscopic hernia repair: preliminary results

SummaryAims Tension-free mesh reinforcement is the mainstay of laparoscopic hernia repair. Problems with current prostheses include shrinkage, migration, patient discomfort and neuralgias. We prospectively analyzed the short-term utility of a soft, non-woven mesh (Biomesh W/NK®, Cousin Biotech) in the TAPP repair.Methods During surgery, ease of insertion, unrolling, positioning and fixation of the mesh were evaluated. Postoperatively, all patients were followed up at 8 and 30 days.Results Forty-five hernias were repaired in 32 patients. Hernias were classified as Nyhus I-2; II-5; Nyhus III-33; Nyhus IV-5. Mean mesh size for unilateral hernias was 14,4 × 12.8 × 9 cm. All meshes were inserted without difficulty, and unrolled into the correct space with minimal trouble. Once in position, moving the mesh was more difficult than with a conventional woven mesh. Fixing was relatively straightforward. The mesh was noted to mould to tissues, assisting with hemostasis. At follow-up, there were no complications noted, specifically no neuralgias or seromas.Discussion Woven or knitted polypropylene mesh is commonly used for laparoscopic hernia repair, due to its ease of manipulation. However, the stiffness of such mesh probably contributes to its well-recognized complications. The Biomesh is much softer, lighter and more pliable, and can potentially reduce complications related to mesh stiffness. We have demonstrated the ease of insertion and fixation of the mesh, and the absence of short-term complications related to its use. In light of our experience, we believe that, in selected cases, the Biomesh offers an attractive alternative to traditional mesh.     

Central perineal hernia mimicking rectocele: a case report

Background A perineal hernia is a very rare clinical finding. Three forms are distinguished: anterior, posterior, and central. Diagnosis of the last one is difficult, and sometimes, it is falsely named a posterior rectocele. Aim This work presents a successfully treated case of central perineal hernia and makes a brief summary of existent literature on the problem. Presentation of the case We report of a 67-year-old female patient with a symptomatic central pelvic floor hernia. After radiological confirmation of the diagnosis, a transperitoneal approach was chosen to reposition the protruded segment of the small bowel. The hernial orifice was closed by extraperitoneal implantation of a polypropylene mesh. Discussion In the present case, the use of a laparoscopic technique seemed unsuitable due to the extension of the findings. For the repair of perineal hernia, we followed the principles of the “tension-free” concept. If there are no signs of a pelvic floor infection and if the mesh can be implanted totally extraperitoneally, we recommend the use of nonabsorbable alloplastic material (polypropylene) for reinforcement of the pelvic floor as a suitable technique for the repair of large perineal hernias.     

One-year results of a prospective,randomised clinical trial comparing four meshes in laparoscopic inguinal hernia repair (TAPP)

Background  

A low rate of chronic pain and maximum postoperative comfort are the main goals today in inguinal hernia repair. This four-arm randomised trial compares these parameters after laparoscopic hernia repair (TAPP) with a standard heavyweight mesh (HW), a pure middleweight polypropylene mesh (MW), a lightweight composite polypropylene mesh (LW), or a titanised lightweight mesh (TLW). The primary endpoint of the study was the incidence of chronic pain of any severity at the site of hernia repair at 1 year.     

Treatment of primary inguinal hernias by “held in mesh repair”: our experience related to 3,520 cases

In the last 15 years, a rapid evolution occurred from the traditional hernioplasties toward prosthetic techniques, in Italy. Outpatient procedures under local anaesthesia are now most commonly performed. We report our experience with a personal modification of the sutureless mesh repair, called “held in mesh repair”. From 1990 to 2003 we treated 3,520 cases of primary hernia with the “held in mesh repair”. 2,370 patients were affected by a unilateral hernia and 575 by a bilateral one. Local anaesthesia was used in 92% of the cases, loco-regional in 6% and general in 2%. Sixteen (0.4%) hernias recurred after 2 years, while two further recurrences (total 0.5%) were observed after 3 years; three femoral pseudo-relapses (0.08%) occurred before the first postoperative year. An overall incidence of 1.3% of major complications were observed. One mortality case (0.02%) occurred 3 days after the operation for cardiovascular complications. The favourable results of the “held in mesh repair” and the simplicity of the procedure suggest that it can be considered a safe and reliable technique for most primary inguinal hernias.     

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。