One-year outcome after repair of giant incisional hernia using synthetic mesh or full-thickness skin graft: a randomised controlled trial

Gelatin Multiwalled Carbon Nanotube Composite 3D Printed Semi Biological Mesh for Abdominal Hernia Treatment

Hernia is characterized by the protrusion of organs or tissue through weakened areas in the abdominal cavity wall. A common treatment for hernia involves the implantation of a mesh which promotes the growth of new tissue around or within the implanted material in the damaged area. The mesh is typically made from synthetic materials like polypropylene. However, such meshes have safety concerns like biofilm and scar tissue formation, foreign body reactions, and chronic pain. These concerns gave rise to the development of biological meshes. Owing to mechanical weakness, biological meshes fail due to migration and rapid degradation. This study is aimed to develop a mechanically viable biopolymer-based composite degradable mesh. A gelatin-MWCNT composite 3D printed mesh has been developed with different pore sizes and filament sizes. Adding MWCNTs improved the composite's ductility, printability, hydrophilicity, and modulus, and reduced its degradation rate. The 3D-printed mesh also showed signs of cell attachment and proliferation representing non-toxicity of MWCNTs within the composite materials. The data showed improved cell adherence due to the incorporation of MWCNTs within the composite materials. Among the various material compositions tested, the composite material with gelatin with 0.01 g MWCNTs gave the optimum mechanical strength and biocompatibility results.

Autologous full-thickness skin in the repair of complex ventral hernias: an innovative step into the future of complex hernia repair?

The repair of complex ventral hernias, such as giant incisional or parastomal hernia, is associated with a high risk for complications and recurrence. Some serious complications are related to implantation of synthetic mesh as reinforcement material. Autologous full-thickness skin graft (FTSG) as reinforcement material in the repair of these complex hernias may offer a safe alternative. This is a review of the history of FTSG use in hernia surgery and the experiences of our research group regarding its application over the last decade. The results of FTSG used in the repair of giant ventral hernias are promising, and this method may already be recommended in selected cases. We have also conducted a translational chain of preclinical studies, based on a murine model, to gain a greater understanding of the behaviour of FTSG implanted in various positions in the abdominal wall. The use of intraperitoneal FTSG as reinforcement material in parastomal hernia repair is currently being evaluated in a randomised, controlled, multicentre study.

Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study

PURPOSE

Autologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response.

METHODS

ECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation.

RESULTS

At 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V.

CONCLUSION

This preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.

Designing Double-Layer Multi-Material Composite Patch Scaffold with Adhesion Resistance for Hernia Repair

Hernia repair mesh is associated with a number of complications, including adhesions and limited mobility, due to insufficient mechanical strength and non-resorbability. Among them, visceral adhesions are one of the most serious complications of patch repair. In this study, a degradable patch with an anti-adhesive layer was prepared for hernia repair by 3D printing and electrospinning techniques using polycaprolactone (PCL), polyvinyl alcohol (PVA), and soybean peptide (SP). The study into the physicochemical properties of the patch was found that it had adequate mechanical strength requirements (16 N cm^-1 ) and large elongation at break, which were superior than commercial polypropylene (PP) patches. In vivo and in vitro experiments showed that human umbilical vein endothelial cells (HUVECs) proliferated well on composite patches, and showed excellent biocompatibility with the host and little adhesion through a rat abdominal wall defect model. In conclusion, the results of this study show that composite patch can effectively reduce the occurrence of adhesions, while the addition of SP in the patch further enhances its biocompatibility. We believe that a regenerative biological patch with great potential in hernia repair provides a new strategy for the development of new biomimetic biodegradable patches. This article is protected by copyright. All rights reserved.

Full-thickness skin grafts to reinforce the abdominal wall: a cross-sectional histological study comparing intra- and extraperitoneal onlay positions in mice

INTRODUCTION

In the repair of complex abdominal wall hernia, there can be a strong preference to avoid synthetic or biological implants as reinforcement material. Autologous full-thickness skin grafts (FTSG) have shown promising results. However, there are few clinical data on the use of FTSG in an intraperitoneal position and rudimentary knowledge about postoperative histological appearance of tissue remodelling and repair.

OBJECTIVE

To investigate the histological appearance of FTSG in the intraperitoneal onlay mesh (IPOM) position.

METHODS

Isogeneic FTSG was positioned in the IPOM (10 mice) and the onlay position (10 mice). After eight weeks, tissues were harvested for histological analysis. Tissue structure, inflammation and cell survival were investigated with histological and immunohistochemical staining.

RESULTS

Morphology was similar in both positions. Luciferase staining indicated both onlay and IPOM graft cell survival, with microvascular networks present. In both positions, FTSG showed ongoing tissue remodelling processes and cystic formations containing hair and epidermis. Low-grade acute phase and chronic inflammation were present. Integration was observed in 50% of the mice with similar appearances in IPOM and onlay grafts.

CONCLUSION

FTSG is tolerated, with comparable results either inside or outside the abdominal cavity, and in line with historic histological evaluations. The results suggest further research on FTSG as a potential future reinforcement material in selected cases of complex abdominal wall hernia repair.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ. Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications. Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005). Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial

Purpose

Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia.

Methods

Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL).

Results

Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups.

Conclusion

The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM.

Trial Registration

The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a randomised controlled trial

Background

Parastomal hernia is a common complication of an enterostomy and can have a significant impact on health-related quality of life. Currently used methods of repair have high recurrence rates and considerable risk for complications. We have developed a new technique for parastomal hernia repair that uses full-thickness skin graft as reinforcement.

Methods

This study protocol describes a multicentre randomised controlled trial on parastomal hernia repair comparing a new full-thickness skin graft technique with conventional synthetic composite mesh as reinforcement of the abdominal wall. Patients with a symptomatic parastomal hernia will be included and followed up at 3, 12 and 36 months, with surgical complication as the primary outcome. Secondary outcomes will be recurrence rate and health-related quality of life assessed with VHPQ, EORTC C30 and CR29. Tissue biology and collagen metabolism will be investigated pre- and postoperatively using biopsies of the abdominal wall fascia and blood samples.

Discussion

Parastomal hernia constitutes a major clinical problem where the prospects of a good result after hernia repair are presently poor. This new method of repair with full-thickness skin grafting could be a new alternative in our surgical toolbox, but before then, it must be evaluated properly.

Trial registration

ClinicalTrials.gov NCT03667287. Registered on September 12, 2018

Complex giant incisional hernia repair with intraperitoneal mesh: A case report

Introduction and importance

An incisional hernia is one of the most frequent complications after abdominal surgery, with an estimated incidence of 2-20% after midline laparotomy. They are often caused by poor wound healing. We present the case of a complex giant incisional hernia that was repaired by implanting an intraperitoneal mesh.

Case presentation

A 63-year-old man with obesity, hypertension, and multiple previous laparotomies, who developed a complex giant incisional hernia (xipho-pubic > 10 cm wide). An open technique repair was decided with the introduction of a large mesh (Parietex ™ Composite) in an intraperitoneal position, covering a 25 × 16 cm hernial ring. After two years, the patient continues to be followed due to a low-output distal enterocutaneous fistula.

Clinical discussion

Currently, there is no technique or approach that has become a gold standard for ventral incisional hernia repair. The introduction of an intraperitoneal mesh with two surfaces by laparotomy is recommended when there are contraindications for laparoscopic surgery, for example in obese patients, and patients with multiple previous laparotomies. However, it has been reported to be a complex technique with an enterocutaneous fistula rate of 0.3-4%.

Conclusion

The introduction of a composite mesh represents an alternative surgical technique for the repair of giant incisional hernias.

The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia

A parastomal hernia is a common complication following stoma surgery. Due to the large number of hernial relapses and other complications, such as infections, adhesion to the intestines, or the formation of adhesions, the treatment of hernias is still a surgical challenge. The current standard for the preventive and causal treatment of parastomal hernias is to perform a procedure with the use of a mesh implant. Researchers are currently focusing on the analysis of many relevant options, including the type of mesh (synthetic, composite, or biological), the available surgical techniques (Sugarbaker’s, “keyhole”, or “sandwich”), the surgical approach used (open or laparoscopic), and the implant position (onlay, sublay, or intraperitoneal onlay mesh). Current surface modification methods and combinations of different materials are actively explored areas for the creation of biocompatible mesh implants with different properties on the visceral and parietal peritoneal side. It has been shown that placing the implant in the sublay and intraperitoneal onlay mesh positions and the use of a specially developed implant with a 3D structure are associated with a lower frequency of recurrences. It has been shown that the prophylactic use of a mesh during stoma formation significantly reduces the incidence of parastomal hernias and is becoming a standard method in medical practice.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a feasibility study

Background

Parastomal hernia is a common complication of stoma formation and the methods of repair available today are unsatisfactory with high recurrence and complication rates. To improve outcome after surgical repair of parastomal hernia, a surgical method using autologous full-thickness skin grafts as intraperitoneal reinforcement has been developed. The purpose of this study was to evaluate the feasibility of this novel surgical technique in the repair of parastomal hernia.

Methods

A pilot study was conducted between January 2018 and June 2019 on four patients with symptomatic parastomal hernia. They had a laparotomy with suture reduction of the hernia and reinforcement of the abdominal wall with autologous full-thickness skin. They were then monitored for at least 1 year postoperatively for technique-related complications and recurrence.

Results

No major technique-related complications were noted during the follow-up Two patients developed a recurrent parastomal hernia at the long term follow-up. The other two had no recurrence.

Conclusions

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair is feasible and should be evaluated in a larger clinical trial.

The Tensile Strength of Full-Thickness Skin: A Laboratory Study Prior to Its Use as Reinforcement in Parastomal Hernia Repair

Purpose: Parastomal hernia is a common complication of an enterostoma. Current methods of repair have high recurrence rates and are associated with severe complications. Autologous full-thickness skin as reinforcement may reduce the recurrence and complication rates. This study aims to investigates the tensile strength of full-thickness skin; information that is essential if we are to proceed with clinical trials on humans.

Methods: Full-thickness skin samples from 12 donors were tested for tensile strength, as well as the load tolerated by a suture through the skin. Strips of skin were cut out and stretched until breaking point. Sutures were made through skin samples and traction applied until either the tissue or the suture gave way. All done while recording the forces applied using a dynamometer. Identical tests were carried out on commercially available synthetic and biologic graft material for comparison.

Results: The full-thickness skin strips had a median tensile strength of 604 N/cm. This tensile strength was significantly higher than that of the compared materials evaluated in this study. In full-thickness skin, the suture, or tissue endured a median force of 67 N before giving way, which was as high as, or higher than similar sutures through the compared materials.

Conclusions: The tensile strength of full-thickness skin vastly exceeds the physiological forces affecting the abdominal wall, and sutures through skin endure high loads before giving way. The tensile strength of a full-thickness skin graft and the strength of sutures through this material will not limit its use for reinforcement in parastomal hernia repair.

Autologous abdominal wall reconstruction using anterolateral thigh and iliotibial tract flap after extensive tumor resection: A case series study of 50 consecutive cases

BACKGROUND

The utility of anterolateral thigh (ALT) + iliotibial tract (ITT) flaps for the reconstruction of large abdominal wall defects has been reported, especially in cases with huge skin defects, surgical contamination, or a history of radiotherapy. However, previous reports have mainly described short-term results such as flap success rates or incidence of wound complications. The present study reviewed 50 consecutive cases of abdominal wall reconstruction using an ALT+ITT flap after extensive tumor resection and evaluated the durability of this approach (incidence of bulge or hernia) and the factors affecting the results.

PATIENTS AND METHODS

A detailed retrospective review of 50 consecutive cases was conducted. Computed tomography or magnetic resonance imaging findings were reviewed to assess the incidence of abdominal bulge or hernia. Items extracted as variables from patient records were subjected to univariate and multivariate logistic regression analyses to identify their relationship with postoperative abdominal bulge or hernia.

RESULTS

Forty-six cases that were followed up for more than six months were analyzed. Twenty-three patients (50.0%) developed abdominal bulge, while none (0%) developed hernia. The multivariate logistic regression analysis revealed that old age and a high body mass index were independently associated with abdominal bulge, while abdominal defect size was not.

CONCLUSIONS

Abdominal wall reconstruction using an ALT+ITT flap after extensive tumor resection was considered a reasonable option with a low risk of hernia despite a marked incidence of postoperative abdominal bulge; however, the usage of additional material may be considered depending on the situation.