Late intestinal fistula formation after incisional hernia using intraperitoneal mesh

Incisional hernia repair by synthetic mesh prosthesis in patients with inflammatory bowel disease: a comparative analysis

Background

Patients with inflammatory bowel disease (IBD) have a high-life time risk undergoing abdominal surgery and are prone to develop incisional hernias (IH) in the postoperative course. Therefore, we investigated the role of IBD as perioperative risk factor in open ventral hernia repair (OVHR) as well as the impact of IBD on hernia recurrence during postoperative follow-up.

Methods

The postoperative course of 223 patients (Non-IBD (n = 199) and IBD (n = 34)) who underwent OVHR were compared by means of extensive group comparisons and binary logistic regressions. Hernia recurrence was investigated in the IBD group according to the Kaplan–Meier method and risk factors for recurrence determined by Cox regressions.

Results

General complications (≥ Clavien-Dindo I) occurred in 30.9% (72/233) and major complications (≥ Clavien-Dindo IIIb) in 7.7% (18/233) of the overall cohort with IBD being the single independent risk-factor for major complications (OR = 4.2, p = 0.007). Further, IBD patients displayed a recurrence rate of 26.5% (9/34) after a median follow-up of 36 months. Multivariable analysis revealed higher rates of recurrence in patients with ulcerative colitis (UC, 8/15, HR = 11.7) compared to patients with Crohn’s disease (CD, 1/19, HR = 1.0, p = 0.021).

Conclusion

IBD is a significant risk factor for major postoperative morbidity after OVHR. In addition, individuals with IBD show high rates of hernia recurrence over time with UC patients being more prone to recurrence than patients with CD.

Polymer Hernia Repair Materials: Adapting to Patient Needs and Surgical Techniques

Biomaterials and their applications are perhaps among the most dynamic areas of research within the field of biomedicine. Any advance in this topic translates to an improved quality of life for recipient patients. One application of a biomaterial is the repair of an abdominal wall defect whether congenital or acquired. In the great majority of cases requiring surgery, the defect takes the form of a hernia. Over the past few years, biomaterials designed with this purpose in mind have been gradually evolving in parallel with new developments in the different surgical techniques. In consequence, the classic polymer prosthetic materials have been the starting point for structural modifications or new prototypes that have always strived to accommodate patients’ needs. This evolving process has pursued both improvements in the wound repair process depending on the implant interface in the host and in the material’s mechanical properties at the repair site. This last factor is important considering that this site—the abdominal wall—is a dynamic structure subjected to considerable mechanical demands. This review aims to provide a narrative overview of the different biomaterials that have been gradually introduced over the years, along with their modifications as new surgical techniques have unfolded.

Behaviour at the peritoneal interface of next-generation prosthetic materials for hernia repair

BACKGROUND

When using a prosthetic material in hernia repair, the behaviour of the mesh at the peritoneal interface is especially important for implant success. Biomaterials developed for their intraperitoneal placement are known as composites and are made up of two different-structure materials, one is responsible for good integration within host tissue and the other is responsible to make contact with the viscera. This study examines the behaviour at the peritoneal level of two composites, the fully degradable Phasix-ST® and the partially degradable Symbotex®. A polypropylene mesh (Optilene®) served as control.

METHODS

Sequential laparoscopy from 3 to 90 days, in a preclinical model in the New Zealand white rabbit, allowed monitoring adhesion formation. Morphological studies were performed to analyse the neoperitoneum formed in the repair process. Total macrophages were identified by immunohistochemical labelling. To identify the different macrophage phenotypes, complementary DNAs were amplified by qRT-PCR using specific primers for M1 (TNF-α/CXCL9) and M2 (MRC1/IL-10) macrophages.

RESULTS

The percentage of firm and integrated adhesions remained very high in the control group over time. Both composites showed a significant decrease in adhesions at all study times and in qualitative terms were mainly loose. Significant differences were also observed from 7 days onwards between the two composites, increasing the values in Phasix over time. Neoperitoneum thickness for Phasix was significantly greater than those of the other meshes, showing mature and organized neoformed connective tissue. Immunohistochemically, a significantly higher percentage of macrophages was observed in Symbotex. mRNA expression levels for the M2 repair-type macrophages were highest for Phasix but significant differences only emerged for IL-10.

CONCLUSIONS

Fewer adhesions formed to the Symbotex than Phasix implants. Ninety days after implant, total macrophage counts were significantly higher for Symbotex, yet Phasix showed the greater expression of M2 markers related to the tissue repair process.

[Existing and forward-looking ways to prevent adhesions in IPOM hernia repair. A research overview]

IPOM intraperitoneal hernia repair, in comparison with other abdominal wall reconstruction methods, has a number of significant advantages. Among them are a reduction in operative time, low rate of surgical site infections, quick rehabilitation, and good cosmetic results. At the same time, one of the main constraining factors for its widespread use is the rather high frequency of adhesion formation between the implant and the abdominal organs. The first way to solve this serious problem is to improve the structure of the implant itself, and in the first place, its anti-adhesive layer. The second is the search for adjuvant tools that work in «problematic» areas, prone to adhesions formation, such as the points of implant fixation, its edges, or the areas of damage to antiadhesive layer due to a violation of the operative technique. It is desirable that they could exert their effect also in other parts of the abdominal cavity, which, despite the absence of a zone of «active» intervention, can also undergo adhesions. Based on this, the purpose of this review was to summarize modern data on the anti-adhesive activity of both composite implants and specialized membranes and liquid agents.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center

BACKGROUND

Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration.

MATERIALS AND METHODS

Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted.

RESULTS

171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m². Mean defect area was 51.35 ± 45.09 cm² and mean mesh size used was 397.56 ± 208.83 cm². Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up.

CONCLUSION

e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

Computed tomography options in the evaluation of hernia repair outcomes using "titanium silk" mesh implants

BACKGROUND

According to experimental studies, mesh implants may reduce in size up to 50.8% during their integration into soft tissues. This results in impaired mobility of the anterior abdominal wall and hernia recurrences, as well as affects patients' quality of life. Due to unsatisfactory radiographic contrast of polymeric mesh implants, changes in their size can be rarely confirmed using imaging methods. Medical devices made of metal alloys have the best radiographic contrast.

OBJECTIVE

The purpose of this study was to evaluate the radiographic contrast of mesh implants made of titanium filaments and to determine the sizes and locations of the implants after the anterior abdominal wall hernia repair.

MATERIALS & METHODS

The study included 40 patients with inguinal, umbilical, and postoperative ventral hernias. Surgical hernia repair was performed using a mash implant made of titanium filaments, "titanium silk". Multislice spiral computed tomography (MSCT) was performed on Days 3 and 90 after surgery, followed by an assessment of the size and location of the mesh implant.

RESULTS

90 days after the anterior abdominal wall hernia repair, the locations of the titanium silk mesh implants in the tissues corresponded to their intraoperative setting. There were no statistically significant changes in the sizes of mesh implants on Day 90, compared with Day 3.

CONCLUSION

The titanium silk mesh implants have satisfactory radiographic contrast, which allows imaging of their location and size in the tissues using MSCT and comprehensive evaluation of hernia repair outcomes using instrumental methods of examination.

Retrorectus sublay mesh repair using polypropylene mesh: Cost-effective approach for laparoscopic treatment of ventral abdominal wall hernias

INTRODUCTION

Laparoscopic repair of ventral abdominal hernias has become a standard of care. The surgery involves placement of a composite mesh with 3-5 cm overlap at the edges of the defect. The disadvantage of this repair is one, the composite mesh used for intraperitoneal placement is quite costly and two, it leaves a foreign body inside the peritoneal cavity, with the potential to cause problems in the future. To circumvent both these issues, we have developed a new approach, called the retrorectus sublay Mesh (RRSM) repair, which allows placement of a plain polypropylene mesh in an extraperitoneal plane.

PATIENTS AND METHODS

Patients with paraumbilical hernia and lower midline incisional hernias were included in this pilot study performed at a single centre by the same surgeon. The steps of the technique are described in detail.

RESULTS

Since 2016, a total of 52 patients were operated by this technique, including both male and female patients. It included patients with para-umbilical hernias as well as incisional hernias. The RRSM repair could be successfully carried out in all the patients. In six of the patients, transversus abdominis release was added as the defect size was large to allow closure of the defect. The results were satisfactory with a low morbidity and no mortality.

CONCLUSION

In our opinion, the RRSM technique is an important tool in the armamentarium of the laparoscopic surgeon dealing with ventral abdominal hernias, allowing placement of polypropylene mesh in an extraperitoneal space. It allows significant cost savings as compared to the prevalent intraperitoneal onlay mesh repair.

Comparative study of four different types of intraperitoneal mesh prostheses in rats

Purpose:

To compare four types of mesh regarding visceral adhesions, inflammatory response and incorporation.

Methods:

Sixty Wistar rats were divided into four groups, with different meshes implanted intraperitoneally: polytetrafluoroethylene (ePTFE group); polypropylene with polydioxanone and oxidized cellulose (PCD); polypropylene (PM) and polypropylene with silicone (PMS). The variables analyzed were: area covered by adhesions, incorporation of the mesh and inflammatory reaction (evaluated histologically and by COX2 immunochemistry).

Results:

The PMS group had the lowest adhesion area (63.1%) and grade 1 adhesions. The ePTFE and PM groups presented almost the total area of their surface covered by adherences (99.8% and 97.7% respectively) The group ePTFE had the highest percentage of area without incorporation (42%; p <0.001) with no difference between the other meshes. The PMS group had the best incorporation rate. And the histological analysis revealed that the inflammation scores were significantly different.

Conclusions:

The PM mesh had higher density of adherences, larger area of adherences, adherences to organs and percentage of incorporation. ePTFE had the higher area of adherences and lower incorporation. The PMS mesh performed best in the inflammation score, had a higher incorporation and lower area of adherences, and it was considered the best type of mesh.

Severe complications after mesh migration following abdominal hernial repair: report of two cases and review of literature

Background: Migration of mesh after ventral and incisional hernia repair is a rare but well described complication. The aim of our work is to present two cases of mesh migration after incisional hernia repair and to review the current literature.

Methods: We describe the two cases of mesh migration that occurred at our department. Additionally, we performed a systematic literature search.

Results: In both cases we observed a mesh migration with formation of an entero-cutaneous fistula that required surgical therapy. In the literature search we found a total of 16 publications dealing with mesh migration after incisional (n=14) and ventral hernia (n=2) repair in adult patients (15 case reports and one retrospective study). In 9 out of 15 patients (54%) who presented with mesh migration or erosion, a polypropylene mesh was responsible for this complication.

Conclusions: Mesh migration after abdominal hernia repair is rare, the only available retrospective study reports a rate of 2.7%. The ability of polypropylene mesh to migrate into hollow viscera is well known and confirmed both by our data and the results of the literature review. As the incidence of mesh erosion/migration is significantly lower than the recurrence rate after hernia repair without mesh, up to now, no better alternative exists for the treatment of abdominal wall hernia than mesh augmentation.

Evaluation of synthetic reticular hybrid meshes designed for intraperitoneal abdominal wall repair: Preclinical and in vitro behavior

Introduction

Reticular hybrid meshes represent an alternative material for intraperitoneal repair of abdominal hernias. These consist of a reticular mesh coated or interwoven/knitted with inert materials. This study assesses the performance of two reticular polypropylene-containing hybrid meshes, TiMESH (coated with titanium) and DynaMesh (interwoven with polyvinylidene fluoride), in vitro, as well as their efficiency in adhesion prevention and tissue incorporation in an intraperitoneal model.

Methods

The mesothelialization capacity of TiMESH and DynaMesh was evaluated in vitro and compared to that of Surgipro (reticular bare polypropylene) and Preclude (laminar expanded polytetrafluoroethylene). Mesh fragments were placed on the intact parietal peritoneum of New Zealand white rabbits (n = 24), and laparoscopy performed 7 days post-surgery. Fourteen days post-implantation, adhesions were evaluated and host tissue incorporation, macrophage response, collagen expression (immunohistochemistry/RT-PCR) and neoperitoneum formation assessed. Adhesions and omental tissue were also examined.

Results

Mesh pores in reticular meshes were devoid of cells in the in vitro study. TiMESH, DynaMesh and Surgipro showed similar adhesion rates at 7/14 days and optimal tissue integration, with significant differences in comparison to Preclude. The greatest presence of macrophages was observed for TiMESH and was significant versus that for Preclude. Hybrid meshes revealed significantly higher collagen 1 mRNA expression in implants, with no differences in the levels of collagen 3. Omental samples from animals with a reticular mesh showed significantly greater collagen 1 mRNA levels.

Conclusions

The reticular structure of a mesh limits the formation of a continuous mesothelial monolayer in vitro, regardless of its composition. The presence of titanium as a coating or polyvinylidene fluoride interwoven with polypropylene in a reticular structure did not prevent adhesions. The hybrid meshes showed proper integration and an increase in the mRNA Col 1 levels in the implant area compared to Surgipro or Preclude.

Biomaterial Implants in Abdominal Wall Hernia Repair: A Review on the Importance of the Peritoneal Interface

Biomaterials have long been used to repair defects in the clinical setting, which has led to the development of a wide variety of new materials tailored to specific therapeutic purposes. The efficiency in the repair of the defect and the safety of the different materials employed are determined not only by the nature and structure of their components, but also by the anatomical site where they will be located. Biomaterial implantation into the abdominal cavity in the form of a surgical mesh, such as in the case of abdominal hernia repair, involves the contact between the foreign material and the peritoneum. This review summarizes the different biomaterials currently available in hernia mesh repair and provides insights into a series of peculiarities that must be addressed when designing the optimal mesh to be used in this interface.

* The New Zealand White Rabbit as a Model for Preclinical Studies Addressing Tissue Repair at the Level of the Abdominal Wall

In this report, we review the use of the New Zealand White rabbit as the experimental animal for several models of abdominal wall repair. For the repair of an abdominal wall defect, such as a hernia in clinical practice, multiple types of prosthetic material exist. Before their marketing, each of these biomaterials needs to be tested in a preclinical setting to confirm its biocompatibility and appropriate behavior at the different tissue interfaces. For preclinical trials, we have always used the New Zealand White rabbit as the model owing to its ease of handling and suitable size. This size allows for laparoscopic studies designed to follow the behavior in real time of a biomaterial implanted at the peritoneal interface, a delicate interface that often gives rise to complications in human practice. The size of the rabbit also offers a sufficiently large number of implant samples to be harvested for a complete battery of tests at several time points postimplant. In this review, we first describe the models established and then provide the results obtained so far using these models to test the different types of biomaterial. We end our review with a discussion of the clinical implications of these results.

Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients

Laparoscopic transabdominal preperitoneal inguinal hernia repair is a safe and effective technique. In this study we tested the hypothesis that self-gripping mesh used with the laparoscopic approach is comparable to polypropylene mesh in terms of perioperative complications, against a lower overall cost of the procedure. We carried out a prospective randomized trial comparing a group of 30 patients who underwent laparoscopic inguinal hernia repair with self-gripping mesh versus a group of 30 patients who received polypropylene mesh with fibrin glue fixation. There were no statistically significant differences between the two groups with regard to intraoperative variables, early or late intraoperative complications, chronic pain or recurrence. Self-gripping mesh in transabdominal hernia repair was found to be a valid alternative to polypropylene mesh in terms of complications, recurrence and postoperative pain. The cost analysis and comparability of outcomes support the preferential use of self-gripping mesh.

No enterocutaneous fistula development in a cohort of 695 patients after incisional hernia repair using intraperitoneal uncoated polyproylene mesh

PURPOSE

To determine the incidence of enterocutaneous fistulas (ECFs) developed after elective incisional hernia (IH) repair using intraperitoneal uncoated polypropylene (PPE) mesh.

METHODS

This is a retrospective descriptive study of a prospective cohort of patients undergoing elective IH repair using intraperitoneal uncoated PPE mesh at the Department of General Surgery of a high complexity University Hospital.

RESULTS

Between January 1992 and December 2013, 695 IH repairs were performed using intraperitoneal uncoated PPE mesh. The omentum was placed between the mesh and bowel in 507 patients (73 %). In 188 patients (27 %) it was not possible to place the omentum between the mesh and bowel; therefore, in 69 patients (9.92 %) the PPE mesh was placed over the bowel, whereas in 119 patients (17.12 %) a Vicryl® mesh was placed between the bowel and PPE mesh. Six hundred and seventy-eight (97.5 %) IH repairs were open whereas 17 (2.5 %) were laparoscopic. Postoperative complications consisted of seroma (5.9 %), hematoma (4.3 %), wound infection (4.8 %), and mesh infection (4.0 %). Recurrence of IH occurred in 52 patients (7.4 %) after a mean follow-up of 59 months. Four (0.5 %) patients required additional surgery due to intestinal occlusion. Neither acute nor chronic ECFs were encountered during follow-up in 695 patients.

CONCLUSION

Based on these results, the placement of intraperitoneal uncoated PPE mesh for elective IH repair might be a safe procedure that is not associated with ECF formation.

Outcomes of Retromuscular Approach for Abdominal Wall Reconstruction in Patients with Inflammatory Bowel Disease

Ventral hernia repair (VHR) in patients with inflammatory bowel disease (IBD) presents unique surgical challenges including impaired wound healing, concomitant intestinal operations, along with likely future abdominal surgeries. Appropriate techniques and mesh choices in these patients remain under active debate. Herein we report our experience with using a retromuscular approach for major VHR in a consecutive cohort of IBD patients. We identified all patients with IBD undergoing open VHR with retrorectus mesh placement between 2007 and 2013 in our prospectively maintained database. Main outcomes included patient and hernia characteristics, perioperative details, wound complications, and hernia recurrence. A total of 38 patients with IBD met inclusion criteria. Mean hernia defect size was 338 cm2. Synthetic mesh was used in 16 patients and biologic mesh was used in 22 of patients. A surgical site occurrence (SSO) occurred in 13 (34.2%) patients, 7 (18.4%) of which were surgical site infections (SSIs). There were no instances of postoperative intestinal complications or enterocutaneous fistulae. At the mean follow-up 37 months, there were 3 (9.4%) recurrences. Our retromuscular repairs were associated with a low rate of wound morbidity and no intestinal complications. Furthermore, we report a relatively low rate of recurrences, especially in this series of complex multiply recurrent hernias. Overall, our retromuscular approach seems to be safe and effective in hernia patients with IBD.

Mesh Infection and Hernia Repair: A Review

BACKGROUND

The use of a prosthetic mesh to repair a tissue defect may produce a series of post-operative complications, among which infection is the most feared and one of the most devastating. When occurring, bacterial adherence and biofilm formation on the mesh surface affect the implant's tissue integration and host tissue regeneration, making preventive measures to control prosthetic infection a major goal of prosthetic mesh improvement.

METHODS

This article reviews the literature on the infection of prosthetic meshes used in hernia repair to describe the in vitro and in vivo models used to examine bacterial adherence and biofilm formation on the surface of different biomaterials. Also discussed are the prophylactic measures used to control implant infection ranging from meshes soaked in antibiotics to mesh coatings that release antimicrobial agents in a controlled manner.

RESULTS

Prosthetic architecture has a direct effect on bacterial adherence and biofilm formation. Absorbable synthetic materials are more prone to bacterial colonization than non-absorbable materials. The reported behavior of collagen biomeshes, also called xenografts, in a contaminated environment has been contradictory, and their use in this setting needs further clinical investigation. New prophylactic mesh designs include surface modifications with an anti-adhesive substance or pre-treatment with antibacterial agents or metal coatings.

CONCLUSIONS

The use of polymer coatings that slowly release non-antibiotic drugs seems to be a good strategy to prevent implant contamination and reduce the onset of resistant bacterial strains. Even though the prophylactic designs described in this review are mainly focused on hernia repair meshes, these strategies can be extrapolated to other implantable devices, regardless of their design, shape or dimension.

Repair of Small and Medium Size Umbilical Hernias with the "Proceed Ventral Patch" in the Preperitoneal Position

Small- and medium-sized ventral hernias including umbilical hernias can be repaired using prosthetic patches placed in the peritoneum. However, bowel-associated complications secondary to intraperitoneally placed hernia patches have been reported. Herein, we report the outcome of small and medium umbilical hernia closure with prosthetic hernia patches in the preperitoneal space. Prospectively collected data of patients undergoing repair of small- and medium-sized umbilical hernias with the proceed ventral patch in a primary care hospital in Germany was retrospectively analyzed. A total of 39 cases, including 11 female and 28 male patients, were managed with prosthetic patches in the preperitoneal position. Small-sized patches were implantated in 16 cases, whereas medium-sized patches were used in 23 cases. The median duration of surgery was 40 minutes. The median length of hospital stay was four days. Four minor complications were recorded (10.3%) and the rate of recurrence was 2.6 per cent within a follow-up period of up to 30 months. Small and medium size umbilical hernias can be effectively closed with prosthetic patches placed in the preperitoneal space without risk of serious bowel associated complications.

Tissue integration and inflammatory reaction in full-thickness abdominal wall repair using an innovative composite mesh

PURPOSE

When composite meshes are used in abdominal wall repair, seroma formation may persist and delay the desired integration leading to recurrence. This study compares tissue integration and inflammatory response in abdominal wall repair with composites with different absorbable synthetic barriers.

METHODS

Full-thickness defects created in the abdominal wall of rabbits were repaired using polypropylene prosthesis or the following composites: Physiomesh™ (Phy); Ventralight™ (Vent) and "new composite mesh" (Ncm) not yet used clinically in humans. The collected seroma was evaluated for IFN-γ/IL-4 by ELISA. Tissue integration, anti- (IL-13/TGFβ-1/IL-10/IL-4) and pro-inflammatory (TNF-α/IL-6/IFN-γ/VEGF) cytokine mRNA expression and TGFβ/VEGF immunolabeling were evaluated at 14 and 90 days post-implant.

RESULTS

Seroma was observed in 10 of 12 Phy/Vent and 4 of 12 Ncm. Wound fluid IFN-γ showed a time-dependent significant increase in Vent and tendency to decrease in Ncm, while all composites exhibited IL-4 upward trend. Prostheses were fully infiltrated by an organized connective tissue at end time although the area had shown prior seroma. A stable mesothelium was developed, except in adhesion areas. Vent/Phy displayed a significant increase in TNF-α/IFN-γ-mRNA over time. Significant decrease in VEGF mRNA was observed in Phy/Ncm, while a significant increase of TGFβ-1 mRNA was evident in all composites over time. Ncm exhibited the highest TGFβ protein expression area at short term and the greatest percentage of VEGF positive vessels at end time.

CONCLUSION

Ncm could be an appropriate candidate to improve clinical outcome showing the lower development of seroma and optimal tissue integration with minimal pro-inflammatory cytokine response over time and consistent pro-wound healing cytokine expression.

Behaviour of a new composite mesh for the repair of full-thickness abdominal wall defects in a rabbit model

Introduction

Composite biomaterials designed for the repair of abdominal wall defects are composed of a mesh component and a laminar barrier in contact with the visceral peritoneum. This study assesses the behaviour of a new composite mesh by comparing it with two latest-generation composites currently used in clinical practice.

Methods

Defects (7x5cm) created in the anterior abdominal wall of New Zealand White rabbits were repaired using a polypropylene mesh and the composites: Physiomesh^TM; Ventralight^TM and a new composite mesh with a three-dimensional macroporous polyester structure and an oxidized collagen/chitosan barrier. Animals were sacrificed on days 14 and 90 postimplant. Specimens were processed to determine host tissue incorporation, gene/protein expression of neo-collagens (RT-PCR/immunofluorescence), macrophage response (RAM-11-immunolabelling) and biomechanical resistance. On postoperative days 7/14, each animal was examined laparoscopically to quantify adhesions between the visceral peritoneum and implant.

Results

The new composite mesh showed the lowest incidence of seroma in the short term. At each time point, the mesh surface covered with adhesions was greater in controls than composites. By day 14, the implants were fully infiltrated by a loose connective tissue that became denser over time. At 90 days, the peritoneal mesh surface was lined with a stable mesothelium. The new composite mesh induced more rapid tissue maturation than Physiomesh^TM, giving rise to a neoformed tissue containing more type I collagen. In Ventralight^TM the macrophage reaction was intense and significantly greater than the other composites at both follow-up times. Tensile strengths were similar for each biomaterial.

Conclusions

All composites showed optimal peritoneal behaviour, inducing good peritoneal regeneration and scarce postoperative adhesion formation. A greater foreign body reaction was observed for Ventralight^TM. All composites induced good collagen deposition accompanied by optimal tensile strength. The three-dimensional macroporous structure of the new composite mesh may promote rapid tissue regeneration within the mesh.

Postimplantation host tissue response and biodegradation of biologic versus polymer meshes implanted in an intraperitoneal position

BACKGROUND

This study compared the in vitro and in vivo behaviors at the peritoneal interface of a new polymer material (Bio-A) and of two biologic non-cross-linked materials (Tutomesh [Tuto] and Strattice [St]), all biodegradable.

METHODS

Omentum mesothelial cells from rabbits were seeded onto the three prosthetic materials tested. At 1, 4, 8, 16, and 24 h after implantation, mesothelial cover was performed using a scanning electron microscope (SEM). In the in vivo study, 3 × 3 cm mesh fragments were placed on the parietal peritoneum of the same rabbits and fixed at the four corners with individual stitches. The implants were randomized such that six fragments of each material were implanted in nine animals (2 per animal). Adhesion formation was quantified by sequential laparoscopy and image analysis 3, 7, and 14 days after implantation. The animals were killed at 90 days, and the meshes were subjected to microscopy and immunohistochemistry.

RESULTS

The in vitro mesothelial cover was significantly greater for St than for Bio-A at each time point. The percentage of cover for St was also higher than for Tuto 16 and 24 h after seeding and higher for Tuto than for Bio-A at all time points. Compared with the biologic meshes, significantly higher adhesion percentages were recorded for Bio-A. At 90 days after implantation, differences in absorption measured as percentage of reduction in mesh thickness were detected among all the meshes. The least absorbed was St. The neoperitoneum thickness was significantly greater for the biologic meshes than for the polymer mesh, although this variable also differed significantly between St and Tuto. Macrophage counts were higher for Bio-A than for the biologic meshes.

CONCLUSIONS

Greater mesothelial cover was observed in vitro for St. In vivo, adhesion formation and the macrophage response induced by Bio-A were greater than those elicited by the biologic materials. Bio-A and Tuto showed substantial biodegradation compared with St.

A defect of the abdominal wall with intestinal fistulas after the repair of incisional hernia using Composix Kugel Patch

INTRODUCTION

In the present paper, we show a rare case of the large abdominal wall defect and enterocutaneous fistulas after the tension free repair using prostheses for incisional hernia.

PRESENTATION OF CASE

The patient, a 70-year-old man, had a history of a hemicolectomy for a perforating colon cancer, complicated by a large incisional hernia that was closed primarily but recurred. Three years later, the hernia was repaired at the time of a second colectomy using a Composix Kugel Patch. His course was complicated by a chronic postoperative wound infection with eventual development of enterocutaneous fistulas. The patient was successfully treated with extirpation of the prosthesis, resection of the fistulized bowel, and placement of a tensor fasciae latae myocutaneous flap.

DISCUSSION

Enterocutaneous fistulas are a known complication of incisional hernia repairs using prostheses. Additional clinical data are required to confirm the safety and efficacy of this procedure as it becomes more widely adopted.

CONCLUSION

Extirpation of the prosthesis should be performed without delay to prevent serious complications. Reconstruction with a tensor fasciae latae myocutaneous flap was useful for the large abdominal wall defect.

Desarda versus Lichtenstein technique for primary inguinal hernia treatment: 3-year results of a randomized clinical trial

BACKGROUND

The Shouldice method and other tissue-based techniques are still acknowledged to be acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda's technique, presented in 2001, is an original hernia repair method using an undetached strip of external oblique aponeurosis. This randomized trial compared outcomes after hernia repair with Desarda (D) and mesh-based Lichtenstein (L) techniques.

METHODS

A total of 208 male patients were randomly assigned to the D or L group (105 vs. 103, respectively). The primary outcomes measured were recurrence and chronic pain. Additionally, early and late complications, foreign body sensation, and return to everyday activity were examined in hospital and at 7, 30 days, and 6, 12, 24, and 36 months after surgery.

RESULTS

During the follow-up, two recurrences were observed in each group (p = 1.000). Chronic pain was experienced by 4.8 and 2.9% of patients from groups D and L, respectively (p = 0.464). Foreign body sensation and return to activity were not different between the groups. There was significantly less seroma production in the D group (p = 0.004).

CONCLUSIONS

The results of primary inguinal hernia repair with the Desarda and Lichtenstein techniques are comparable at the 3-year follow-up. The technique may potentially increase the number of tissue-based methods available for treating groin hernias.

Outcomes of the open mesh repair of large incisional hernias using an intraperitoneal composite mesh: our experience with 100 cases

Incisional hernia repair sometimes requires intraperitoneal implantation of a mesh. This becomes necessary when the hernia opening is large, in particular, in patients with a low abdominal wall surface/wall defect surface (AWS/WDS) ratio, in large boundary incisional hernias where the proximity to bone structures or cartilage often complicates retromuscular mesh implantation and in multi-recurrent incisional hernias that are sometimes characterised by an actual loss of abdominal wall tissue. The authors report on the results of a series of 100 incisional hernias treated between 1999 and 2006 using the open technique to implant an intraperitoneal mesh (Parietex Composite). Mean follow-up time was 42 months (range 12-96 months). The mean wall defect surface was 95 cm(2) (range 60-210 cm(2)). Twelve percent of patients suffered minor complications: 5 seromas (5%), 3 haematomas (3%) and 4 parietal suppurations (4%). No mesh had to be removed. The recurrence rate was 6%. At 6 months after surgery, no patient lamented pain or discomfort due to foreign body sensation. None of these patients presented intestinal occlusion or enterocutaneous fistulae. In conclusion, it is our opinion that the mesh should be implanted in direct contact with the viscera only where absolutely necessary, i.e., when it cannot be implanted in the retromuscular area without creating excessive parietal tension. Our experience with PC mesh, over the short-to-medium term, was positive. Naturally, further studies are required to evaluate long-term biocompatibility.

Spontaneous mesh evacuation per rectum after incisional ventral hernia repair

We present a case of a 58-year-old man who was admitted to our hospital because of abdominal pain. He underwent incisional ventral hernia repair with intraabdominal mesh (ePTFE). On the day of admission, physical examination included the discovery of a foreign body in the rectum. There were no signs of acute abdomen. We induced stool, and the mesh came out with it. His further course was uneventful. Gastrografin series showed persisting fistula between the small intestine and colon, but without extralumination into the peritoneal cavity. The patient was discharged in good health and without signs of incisional ventral hernia.

Gas gangrene of the abdominal wall due to late-onset enteric fistula after polyester mesh repair of an incisional hernia

The occurrence of enteric fistulae after wall repair using a prosthetic mesh is a serious but, fortunately, rare complication. We report the case of a 66-year-old diabetic man who presented with gas gangrene of the abdominal wall due to an intra-abdominal abscess caused by intestinal erosion six years after an incisional hernia repair using a polyester mesh. The aim of this case report is to illustrate the seriousness of enteric fistula after parietal repair using a synthetic material.

Prosthetic material in ventral hernia repair: how do I choose?

Several factors must be considered in deciding which mesh to use for a ventral hernia repair. Open hernia repairs with no exposure of mesh to viscera can be performed with unprotected synthetic mesh, preferably a "lightweight" option. For open repair with high risk for fascial dehiscence and visceral exposure to mesh, and for open underlay repair and laparoscopic underlay repair, recommendations call for a tissue-separating mesh that prevents ingrowth of intra-abdominal contents into the mesh. Although no long-term data are available about biologic (acellular collagen scaffold) meshes, these may have good results when used in contaminated or well-drained infected fields, and do best when used according to the principles of a high-quality synthetic mesh repair (wide mesh overlap, frequent fixation points). Evidence is still insufficient to support the use of biologic materials for primary hernia repair.

Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery

BACKGROUND

Prosthetic incisional hernia repair (PIHR) is superior to primary closure in preventing hernia recurrence. Serious complications have been associated with the use of prosthetic material. Complications of subsequent surgical interventions after prior PIHR in relation to its anatomical position were the objectives of this study.

PATIENTS AND METHODS

Patients who underwent subsequent laparotomy/laparoscopy after PIHR between January 1992 and February 2005 at our institution were evaluated. Intraperitoneal and preperitoneal mesh was related to complication rates after subsequent surgical interventions.

RESULTS

Sixty-six of 335 patients underwent re-laparotomy after PIHR. The perioperative course was complicated in 76% (30/39) of procedures with intraperitoneal placed grafts compared to 29% (8/27) of interventions with preperitoneally positioned meshes (P < 0.001). Small bowel resections were necessary in 21% of the intraperitoneal group (8/39) versus 0% in the preperitoneal group. Surgical site infection rates were higher in the intraperitoneal group (10/39, 26%, versus 1/27, 4%). Enterocutaneous fistula formation was rare and occurred in two patients after subsequent laparotomy (5%).

CONCLUSIONS

Re-laparotomy after PIHR with polypropylene meshes are associated with more preoperative and postoperative complications when the mesh is placed intraperitoneally. Therefore 0intraperitoneal positioning of polypropylene mesh at incisional hernia repair should be avoided if possible.

Laparoscopic sutured closure with mesh reinforcement of incisional hernias

BACKGROUND

This study reports medium-term outcomes of laparoscopic incisional hernia repair.

STUDY DESIGN

Laparoscopic repair was performed on 721 patients with ventral hernia. After adhesiolysis the defect was closed with no. 1 polyamide suture or loop. This was followed by reinforcement with intraperitoneal onlay repair with a bilayered mesh.

RESULTS

Laproscopic repair of ventral hernia was performed on 613 females and 108 males. Of these, 185 (25.7%) were recurrent incisional hernias of which 93 had undergone previous open hernioplasty. The remaining 92 patients had previously undergone sutured repair. The average operating time was 95 min (range 60-115 min). Conversion rate was 1%. The average hospital stay was 2 days (range 1-6 days). The commonest complication was seroma formation at the incisional hernia site. Full-thickness bowel injury occurred in two patients. The mean follow-up period was 4.2 years (range 3 months to 10 years). Recurrence was noted in four (0.55%) patients.

CONCLUSION

Laparoscopic repair is well-tolerated and can be accomplished with minimum morbidity in ventral hernias.

Mesh migration following obturator hernia repair presenting as a bezoar inducing small intestinal obstruction

This is the first report on synthetic mesh migration following obturator hernia repair. Obturator hernias have a low incidence--with fewer than 700 published case studies to date--usually occur in elderly women and are difficult to diagnose. Since 1976, there have been no more than 29 reported cases in which synthetic materials were used in obturator hernia repair. Thus, information relevant to the surgical repair of this type of hernia is based on small numbers only. The use of synthetic mesh for the repair of obturator hernias is a recent development, and to date no complications have been reported with this type of repair. We report here on the outcome of a patient with mesh migration after obturator hernia repair. This report provides a short overview of mesh migration as a complication following the use of synthetic grafts for surgical repair.

Risk factors related to recurrence in inguinal hernia repair: a retrospective analysis

The aim of this study was to analyze and evaluate the long-term recurrence rate and risk factors for inguinal hernia recurrence in patients treated by the Shouldice suture repair. A total of 293 hernias treated by Shouldice suture technique in 1992 were studied retrospectively. After a 10-year follow-up, 15 potential risk factors for recurrence were assessed in 142 patients undergoing 171 Shouldice repairs. Recurrent hernias showed a significantly higher (22.0%) recurrence rate than primary inguinal hernias (7.7%). Furthermore, an age of more than 50 years, smoking, and the presence of two or more similarly affected relatives were found to be independent risk factors for recurrence. The present study underlines the importance of patient-related risk factors for the development of a recurrent inguinal hernia. Patients at risk should preoperatively be identified in order to improve treatment by, for example, the application of mesh techniques.