Critical Under-Reporting of Hernia Mesh Properties and Development of a Novel Package Label

Primary ventral and incisional hernias: comprehensive review

BACKGROUND

Primary ventral and incisional hernias are frequent conditions that impact the quality of life of patients. Surgical techniques for ventral hernia repair are constantly evolving and abdominal wall surgery has turned into a highly specialized field.

METHODS

This is a narrative review of the most recent and relevant literature on the treatment of primary ventral and incisional hernias performed by eight experts in ventral hernia surgery from across the world and includes review of classification systems, preoperative measures, descriptions of surgical techniques, and postoperative complications.

RESULTS

Repairs of primary ventral and incisional hernias range from simple open procedures in healthy patients with small defects to complex procedures when patients are co-morbid and have large defects. Optimizing patient-related risk factors before surgery is important to decrease complication rates. Surgical repair techniques from open repairs to minimally invasive procedures are described in detail in the review. Minimally invasive techniques are technically more demanding and take longer, but decrease the risk of surgical-site infections and shorten the duration of hospital stay.

CONCLUSION

Treatment of ventral hernias aims to improve the quality of life of patients. The risks and benefits of procedures should be weighed against patients' complaints and co-morbidities. Optimizing patient-related risk factors before surgery is important.

The development, implementation, and evaluation of a pre-rotation quiz to improve resident preparedness for an abdominal wall reconstruction surgical rotation

INTRODUCTION

Although hernia repair constitutes a significant portion of surgical training, education around more complex hernia concepts such as abdominal wall reconstruction (AWR) or paraesophageal hernia repair may be lacking. We developed and implemented a pre-rotation quiz for residents on an AWR and minimally invasive surgery service. We also investigated the staff and resident perception of resident knowledge and experience of the rotation before and after quiz implementation.

METHODS

The multiple-choice quiz questions were written by clinical and research fellows, validated by four staff, two fellows, and two senior residents and implemented in June 2023. Questions assessed knowledge of anatomy, operative steps, mesh materials, clinical trials, and postoperative management specific to ventral, inguinal, and paraesophageal hernia repairs. Residents were notified of the summative quiz three weeks prior and provided with reference materials specific to quiz questions. Anonymous Likert-type surveys were distributed to staff and residents between 3/2023 and 3/2024. Responses were assessed based on the overall score as well as individual domains and then compared based on whether they were completed before or after implementation of the quiz.

RESULTS

17 seniors and 29 juniors rotated on service and all completed the pre-rotation quiz between 7/1/2023-3/4/2024. The mean first attempt score was 72%(± 12.4%) for junior residents and 88.4%(± 9.6%) for senior residents. Staff reported overall resident knowledge improved after quiz implementation (maximum 90, mean(SD): 46.25(± 8.58) vs. 75.5(± 11.24),p = 0.05). Sixteen(45.7%) residents responded to the survey before quiz implementation and 23(50%) after. Residents only reported improved knowledge regarding current literature (maximum 5, mean(SD):3.2 ± 0.98 vs. 3.8 ± 0.78,p = 0.04).

CONCLUSION

Implementing a pre-rotation quiz effectively improves staff perception of resident knowledge and preparation.

Are Surgeons Going to Be Left Holding the Bag? Incisional Hernia Repair and Intra-Peritoneal Non-Absorbable Mesh Implant Complications

Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.

Primary and Recurrent Repair of Incisional Hernia Based on Biomechanical Considerations to Avoid Mesh-Related Complications

Aim: Mechanical principles successfully guide the construction of polymer material composites in engineering. Since the abdominal wall is a polymer composite augmented with a textile during incisional hernia repair we ask: can incisional hernia be repaired safely and durably based on biomechanical principles?

Material and Methods: Repair materials were assessed on a self-built bench test using pulse loads to elude influences on the reconstruction of the abdominal wall. Tissue elasticity was analyzed preoperatively as needed with computed tomography at rest and during Valsalva's maneuver. Preoperatively, the critical retention force of the reconstruction to pulse loads was calculated and a biomechanically durable repair was designed based on the needs of the individual patient. Intraoperatively, the design was adjusted as needed. Hernia meshes with high grip factors (Progrip^®, Dahlhausen^® Cicat) were used for the repairs. Mesh sizes, fixation elements and reconstructive details were oriented on the biomechanical design. All patients recieved single-shot antibiosis. Patients were discharged after full ambulation was achieved.

Results: A total of 163 patients (82 males and 81 females) were treated for incisional hernia in four hospitals by ten surgeons. Primary hernia was repaired in 119 patients. Recurrent hernia was operated on in 44 cases. Recurrent hernia was significantly larger (median 161 cm² vs. 78 cm²; u-test: p = 0.00714). Re-do surgery took significantly longer (median 229 min vs. 150 min; p < 0.00001) since recurrent disease required more often transversus abdominis release (70% vs. 47%). GRIP tended to be higher in recurrent repair (p = 0.01828). Complication rates (15%) and hospital stay were the same (6 vs. 6 days; p = 0.28462). After 1 year, no recurrence was detected in either group. Pain levels were equally low in both primary and recurrent hernia repairs (median NAS = 0 in both groups at rest and under load, p = 0.88866).

Conclusion: Incisional hernia can safely and durably be repaired based on biomechanical principles both in primary and recurrent disease. The GRIP concept provides a base for the application of biomechanical principles in incisional hernia repair.

Endoscopic transposition with the hernial sac (eTHS) in ventral hernia repair - technical description

Incisional hernia is a late complication of the most frequent after abdominal surgeries, with resulting morbidity that can worsen the condition. The treatment has been done both by open techniques, using screens or not, and by laparoscopic and robotic methods, which use them systematically. However, introducing a permanent foreign body into the tissues requires more surgical time, despite not closing the parietal defect in most cases and a higher risk of infections. New technologies have been trying to improve these results, with absorbable prostheses (biological or synthetic), but their high cost and recurrences remain a severe problem. Even so, standard repair establishes reinforcement with screens, routine, and whether the approach is traditional or mini-invasive. The authors report their first case of endoscopic repair of incisional hernia, which occurred two years ago, with a Brazilian technique already fifty years old: the transposition with the hernia sac proposed by Prof. Alcino Lázaro da Silva in 1971.

Developing a Hernia Mesh Tissue Integration Index Using a Porcine Model-A Pilot Study

Introduction: With so many prosthetics available, it can be difficult for surgeons to choose the most appropriate hernia mesh. Successful hernia repair mandates an understanding of how the patient's inflammatory response influences surgical outcomes. Failure to appreciate the importance of the biological aspect of hernia repair can be very costly as emerging evidence supports that biofilm formation and reduction in effective mesh porosity gives rise to long-term mesh complications including fibrosis, chronic mesh infection, and pain. In this pilot study, we utilized a large animal (porcine) model to develop a numerical Mesh Tissue Integration (MTI) Index focused on visible tissue ingrowth, fibrosis, adhesion formation and resorption of mesh. The aim is to help surgeons adopt an evidence-based approach in selecting the most appropriate mesh according to its tissue ingrowth characteristics, matched to the patient to achieve improved surgical outcomes and optimal patient-centered care.

Methods: Two forty kg female Landrace pigs were recruited for this pilot study. A total of eight commonly used hernia mesh products and two controls measuring 5 × 5cm were surgically implanted in subrectus and intraperitoneal planes. The pigs were euthanised at 2 and 4 weeks, respectively. The abdominal wall was explanted, and the mesh specimens underwent macroscopic, histologic and biomechanical analysis, with engineering and pathology teams blinded to the mesh.

Results: Significant differences between the degrees of MTI were observed at 2 weeks and the distinctions were even more apparent at 4 weeks. One of the interesting incidental findings we observed is that mesh products placed in the subrectus plane displayed greater degrees of adhesion strength and integration than those placed intraperitoneally.

Conclusion: This pilot study is one of the first to propose a functional, biological standardized model for comparing hernia mesh products. The results are encouraging and demonstrate that this is a robust and transferrable model for assessing MTI in hernia mesh. The intention for this model is that it will be utilized synergistically with long term mesh/patient outcome registries and databases to inform improved matching of mesh to patient, particularly in the setting of the complex hernia repair and abdominal wall reconstruction.

Polypropylene mesh and systemic side effects in inguinal hernia repair: current evidence

INTRODUCTION

Increasing awareness and regulatory body attention is directed towards the insertion of synthetic material for a variety of surgical procedures. This review aims to assess current evidence regarding systemic and auto-immune effects of polypropylene mesh insertion in hernia repair.

METHODS

The electronic literature on systemic and auto-immune effects associated with mesh insertion was examined.

RESULTS

Foreign body reaction following mesh implantation initiates an acute inflammatory cellular response. Involved markers such as IL-1, IL-6, IL-10 and fibrinogen are increased in circulation in the presence of mesh but return to normal at 7 days post operatively. Oxidative degradation of implanted mesh is likely, but no evidence exists to support systemic absorption or resulting disease effects. Variable cytokine production in healthy hosts leading to unpredictable or overwhelming response to implanted biomaterial warrants further investigation. Clinical studies show no associated long-term systemic effects with mesh.

CONCLUSION

To date, there remains no evidence to link polypropylene mesh and systemic or auto-immune symptoms. Based on current evidence, the use of polypropylene mesh is supported.