Biologic versus Synthetic Mesh Reinforcement: What are the Pros and Cons?

Ventral Hernia Repair With Onlay Placement of Biosynthetic Ovine Rumen Is Noninferior to Retrorectus Placement

Background

Mesh placement impacts postoperative outcomes in ventral hernia repair (VHR). The retrorectus technique is associated with lower recurrence rates than the onlay technique. Hybrid meshes, combining synthetic and biologic benefits, have been introduced, but the effect of placement location on outcomes remains unclear.

Methods

We retrospectively analyzed 71 patients who underwent VHR with biosynthetic ovine rumen in either an onlay (n = 38) or retrorectus (n = 33) position. We compared demographics, comorbidities, complications, and recurrent rates. Multivariate logistic regression assessed associations between mesh placement and outcomes.

Results

Onlay patients were older (mean 62.9 versus 57.4 y, P = 0.03) and had larger hernias (158 versus 73.8 cm2, P < 0.001). Most patients had grade 2 or 1 hernias according to the modified ventral hernia working group classification, with no significant differences in postoperative complications. Hernia recurrence occurred in 5.41% of onlay patients and 0% of retrorectus patients.

Conclusions

No significant differences in complications or recurrence rates were observed between placement techniques. These findings suggest that hybrid mesh placement in an onlay position is a safe and durable strategy for VHR.

Evolution and innovation in urethroplasty: a comprehensive narrative review of graft types and surgical techniques

Urethroplasty has evolved over last decades, with significant improvements in surgical techniques and graft types. In this narrative review, we aimed to explore the evolution of urethroplasty techniques for bulbar urethral strictures. To do this, the review is structured into three main sections: the Historical Background section highlights the seminal contribution from early pioneers to contemporary techniques, which re-gained momentum in reconstructive urology. Starting with the early techniques in the 19th and 20th centuries, we focused on the pioneering innovations of the 1990s, ultimately leading to the most recent tissue-preserving techniques. The second part presents a literature review comparing different graft types and critically evaluating surgical outcomes from multiple original articles and meta-analysis. Specifically, similar success rates were reported for oral and preputial grafts for the treatment of anterior urethral strictures, while long-term outcomes suggest graft deterioration over time. Furthermore, data on optimal surgical techniques remain limited. Lastly, Future Perspectives address ongoing innovations, including new graft and flap combinations for complex strictures, emphasizing the continuous refinement of less invasive, tissue-preserving techniques.

Electrospun meshes for abdominal wall hernia repair: Potential and challenges

Surgical meshes are widely used in abdominal wall hernia repairs. However, consensus on mesh treatment remains elusive due to varying repair outcomes, especially with the introduction of new meshes, posing a substantial challenge for surgeons. Addressing these issues requires communicating the features of emerging candidates with a focus on clinical considerations. Electrospinning is a versatile technique for producing meshes with biomechanical architectures that closely mimic the extracellular matrix and enable incorporation of bioactive and therapeutic agents into the interconnective porous network, providing a favorable milieu for tissue integration and remodeling. Although this promising technique has drawn considerable interest in mesh fabrication and functionalization, currently developed electrospun meshes have limitations in meeting clinical requirements for hernia repair. This review summarizes the advantages and limitations of meshes prepared through electrospinning based on biomechanical, biocompatible, and bioactive properties/functions, offering interdisciplinary insights into challenges and future directions toward clinical mesh-aided hernia repair. STATEMENT OF SIGNIFICANCE: Consensus for hernia treatments using surgical meshes remains elusive based on varying repair outcomes, presenting significant challenges for researchers and surgeons. Differences in understanding mesh between specialists, particularly regarding material characteristics and clinical requirements, contribute to this issue. Electrospinning has been increasingly applied in mesh preparation through various approaches and strategies, aiming to improve abdominal wall hernia by restoring mechanical, morphological and functional integrity. However, there is no comprehensive overview of these emerging meshes regarding their features, functions, and clinical potentials, emphasizing the necessity of interdisciplinary discussions on this topic that build upon recent developments in electrospun mesh and provide insights from clinically practical prospectives.

Outcomes of synthetic and biologic mesh in abdominal wall reconstruction: A propensity-matched analysis in Centers for Disease Control and Prevention class 1 and 2 wounds

INTRODUCTION

The choice of biologic compared with synthetic mesh in abdominal wall reconstruction remains controversial, especially in Centers for Disease Control and Prevention class 1 and 2 wounds. This study evaluated wound complications and hernia recurrence with a 2:1 propensity-matched sample and extended follow-up.

METHODS AND PROCEDURES

A prospectively maintained abdominal wall reconstruction database was queried for patients undergoing open abdominal wall reconstruction using biologic or synthetic mesh in Centers for Disease Control and Prevention class 1 and 2 wounds. Patients receiving synthetic or biologic mesh were propensity score matched in a 2:1 fashion. Univariate, bivariate, and inferential analyses were conducted. Unless stated, data are reported as biologic compared with synthetic.

RESULTS

In total, 519 patients were compared, 173 with biologic and 346 with synthetic mesh. Defect size (215.2 ± 153.6 cm2 vs 251.5 ± 284.3 cm2), body mass index (33.6 ± 9 kg/m2 vs 34 ±17.7 kg/m2), and comorbidities were well matched (all P > .05). Although Centers for Disease Control and Prevention wound class was used in the match, it was significantly different between groups (Centers for Disease Control and Prevention 1:43.4% vs 81.2%, Centers for Disease Control and Prevention 2:56.6% vs 18.8%; P < .001). The rate of component separation (40.1% vs 44.2%; P = .397), fascial closure (97.7% vs 98.3%; P = .738), and panniculectomy (33.5% vs 29.2%; P = .315) were similar. Mesh size was also similar (816.4 ± 555.5 vs 892.2 ± 487.8 cm2; P = .112). Wound complications were equal, including wound breakdown (10.5% vs 7.5%; P = .315), wound cellulitis (5.2% vs 5.8%; P = .843), wound infection (7.5% vs 4.6%; P = .223), seroma requiring intervention (6.4% vs 7.8%; P = .597), and mesh infection (1.2% vs 0.9%; P > .999). The biologic group had an increased length of stay (6.8 ± 5.5 days vs 5.4 ± 2.3 days; P < .001) and greater hospital charges ($82,181 ± 50,356 vs $62,221 ± 26,817 USD; P < .001). Mean follow-up after biologic repair was longer (33.9 ± 36.6 months vs 23.3 ± 32.3 months; P < .001). Hernia recurrence between the biologic and synthetic groups was not significantly different (2.9% vs 1.4%; P = .313). On multivariable regression, wound complications were predictive of recurrence, and panniculectomy was predictive of wound complications.

CONCLUSION

In a 2:1 matched analysis of Centers for Disease Control and Prevention 1 and 2 wounds with nearly 3-years of follow-up, biologic and synthetic mesh had similar rates of wound complications and recurrence in abdominal wall reconstruction.

Synthetic Versus Biologic Mesh for Complex Open Ventral Hernia Repair: 3-Year Follow-Up of a Pilot Randomized Controlled Trial

Background

Biologic mesh is often used in complex hernia repair, but there has been limited clinical evidence to date to support this practice. The aim of this study was to compare clinical and patient-reported outcomes of biologic versus synthetic mesh for complex open ventral hernia repair (OVHR) at 3 years.

Methods

Patients from a single center, randomized, controlled, pilot trial comparing biologic versus synthetic mesh in complex OVHR were followed for 3 years. The primary outcome focused on major complications, namely mesh infections, hernia recurrences, reoperations, and deaths. Secondary outcomes included surgical site infections, surgical site occurrences, and patient-reported outcomes. Outcomes were assessed using frequentist generalized linear models.

Results

A total of 87 patients (44 biologic mesh, 43 synthetic mesh) were randomized, and 61 patients (70%; 28 biologic and 33 synthetic) completed 3-year follow-up. Baseline demographics were similar in both groups. No significant differences were seen in major complications (50% vs 30%, P = .123), mesh infection (14% vs 3%, P = .144), recurrence (39% vs 24%, P = .214), reoperation (14% vs 9%, P = .531), or mortality (4% vs 0%, P = .459) between the 2 arms. A single death occurred as a result of bacteremia in a patient with hepatocellular carcinoma. Similarly, no significant differences were seen in secondary or patient-reported outcomes. Both groups demonstrated clinically important improvements in quality of life and pain scores at 3 years.

Conclusion

This study failed to find benefits with biologic mesh as opposed to synthetic mesh in complex OVHR at 3 years when comparing both clinical and patient-reported outcomes.

Use of Biologic and Biosynthetic Mesh for Ventral Hernia Repair in Current Practice

Importance

Originally developed for use in contaminated fields, there is growing evidence against the use of biologic and biosynthetic mesh in ventral hernia repair. However, its prevalence and patterns of use in current practice are largely unknown.

Objectives

To describe the prevalence of biologic and biosynthetic mesh use in ventral hernia repair and to identify factors associated with its use.

Design, Setting, and Participants

This retrospective cohort study used a statewide clinical registry in Michigan to identify adults who underwent mesh-based ventral hernia repair between January 1, 2021, and December 31, 2023. Data analysis was performed from February to May 2024.

Exposures

Use of biologic or biosynthetic mesh vs synthetic mesh.

Main Outcomes and Measures

The main outcome was use of biologic or biosynthetic mesh, abstracted directly from the operative report. Multivariable logistic regression was used to identify factors associated with use of biologic or biosynthetic mesh.

Results

A total of 10 838 patients (mean [SD] age, 55.7 [14.0] years; 4619 [42.6%] female) who underwent mesh-based ventral hernia repair were identified, among whom 1174 repairs (10.8%) were performed with biologic or biosynthetic mesh and 9664 (89.2%) were performed with synthetic mesh. Of the 1174 cases using biologic or biosynthetic mesh, 1023 (87.1%) had a clean wound classification and 1039 (88.5%) were performed electively. In multivariable logistic regression, wound contamination was associated with increased odds of biologic or biosynthetic mesh use (clean-contaminated: adjusted odds ratio [aOR], 2.17 [95% CI, 1.62-2.89]; contaminated: aOR, 2.95 [95% CI, 1.63-5.34]; dirty or infected: aOR, 36.22 [95% CI, 12.20-107.56]). Other operative factors associated with increased odds of biologic or biosynthetic mesh use included urgent or emergent surgical priority (aOR, 1.69 [95% CI, 1.33-2.16]), laparoscopic or robotic approach (aOR, 1.31 [95% CI, 1.15-1.50]), larger hernia width (aOR, 1.03 [95% CI, 1.01-1.04] per centimeter), and use of myofascial release (aOR, 2.10 [95% CI, 1.64-2.70]).

Conclusions and Relevance

In this large cohort of patients undergoing ventral hernia repair, 1 in 10 mesh-based repairs was performed with biologic or biosynthetic mesh. Although urgent or emergent repair and wound contamination were associated with increased odds of biologic or biosynthetic mesh use, nearly 90% of biologic and biosynthetic mesh use occurred in elective repairs with clean wound classifications. These results raise questions regarding the appropriateness of its application in current practice.

Onlay Resorbable Biosynthetic Versus Underlay Biologic Mesh Ventral Hernia Repair in Contaminated Fields

INTRODUCTION

Abdominal wall reconstruction (AWR) with ventral hernia repair (VHR) in the setting of contamination poses unique and controversial challenges. The purpose of this study was to examine the efficacy of onlay resorbable biosynthetic mesh against underlay biologic mesh in contaminated VHR with AWR.

METHODS

A single-center retrospective review from 2015 to 2021 was performed examining subjects who underwent VHR with AWR in contaminated fields (Centers for Disease Control wound class II-IV). A matched paired analysis based on age, body mass index, and Centers for Disease Control wound class was conducted among patients who utilized resorbable biosynthetic mesh in an onlay fashion and biologic mesh in an underlay fashion.

RESULTS

A total of 94 patients (47 per group) underwent VHR with AWR in contaminated fields. Patients who utilized biosynthetic mesh had an average defect size of 314.56 ± 214.65 cm2, required component separation (57.4%), and were often recurrent (61.7%). Majority of contamination were clean-contaminated (68.1%), followed by dirty/infected (19.1%), and contaminated (12.8%). Patients utilizing resorbable biosynthetic mesh experienced fewer surgical site occurrences (SSOs) (46.8% versus 72.3%, P < 0.05) and fewer SSO procedural interventions (19.1% versus 38.4%, P < 0.05). Patients with biosynthetic mesh had fewer hernia recurrences compared to biologic mesh use; however, was not statistically significant (14.9% versus 30.4%, P = 0.07), with a mean follow-up of 25.73 ± 18.66 mo.

CONCLUSIONS

Utilization of resorbable biosynthetic mesh may be preferable to biologic mesh in contaminated fields due to lower rates of SSOs and interventions, ultimately reducing the postoperative clinical and financial burden for this patient population.

Cardiovascular patches applied in congenital cardiac surgery: Current materials and prospects

Congenital Heart Defects (CHDs) are the most common congenital anomalies, affecting between 4 and 75 per 1000 live births. Cardiovascular patches (CVPs) are frequently used as part of the surgical armamentarium to reconstruct cardiovascular structures to correct CHDs in pediatric patients. This review aims to evaluate the history of cardiovascular patches, currently available options, clinical applications, and important features of these patches. Performance and outcomes of different patch materials are assessed to provide reference points for clinicians. The target audience includes clinicians seeking data on clinical performance as they make choices between different patch products, as well as scientists and engineers working to develop patches or synthesize new patch materials.

Size Does Matter: Mastectomy Flap Thickness as an Independent Decisional Factor for the Peri-Prosthetic Device Choice in Prepectoral Breast Reconstruction

Background. In alloplastic breast reconstruction, the choice of implant positioning and the selection of periprosthetic devices is a critical and challenging decision. Surgeons must navigate between various biologic and synthetic meshes, including acellular dermal matrices (ADM). This study aimed to propose a simple selection tool for periprosthetic devices in prepectoral breast reconstruction. Methods. Patients scheduled for mastectomy followed by implant-based breast reconstruction between September 2019 and December 2023 were included. Preoperative risk assessments were performed using the Pre-Bra Score, and only those deemed suitable for prepectoral implant placement were selected. Mastectomy flap thickness was used as an independent criterion, and only cases with flap thicknesses less than 1 cm were included. Results. A total of 70 cases with an average flap thickness of 0.7 cm (range, 0.4-0.9 cm), as measured by preoperative contrast-enhanced spectral mammography (CESM), underwent prepectoral reconstruction with ADM covering the implant. Of these, 25 patients (35%) received direct-to-implant reconstruction, while 45 (65%) underwent two-stage reconstruction with a temporary tissue expander. Postoperative complications were recorded during a minimum follow-up period of 6 months. Over an average follow-up duration of 17.5 months (range 6-36 months), no major complications were observed. Minor complications occurred in seven patients: infection (1.28%), seroma (3.85%), and superficial skin necrosis (1.28%). Additionally, 21 patients (30%) experienced rippling, and secondary lipofilling was scheduled. Conclusions. The incidence of rippling was reduced by 40% through ADM in this patient subgroup, reducing the need for secondary aesthetic refinements.

A systematic review and meta-analysis of randomized controlled trials for the management of ventral hernia: biologic versus synthetic mesh

An abdominal wall hernia near the location of a prior surgical incision is referred to as an incisional hernia. A midline incisional hernia is the most prevalent form. The management of incisional hernia includes many options, from conservative to surgical. The surgeon might consider using a synthetic or biological mesh when discussing surgical options with patients. Our aim through this study is to comprehensively compare synthetic and biological mesh in terms of complication and infection rates for managing elective incisional hernia. This systematic review was designed and conducted using PRISMA guidelines. The literature was systematically searched in January 2023 using the following databases: MEDLINE, Cochrane, and EMBASE. Among the terms used to aid the search were the following: incisional hernia, ventral hernia, ventral herniorrhaphy, biologic mesh, polypropylene mesh, absorbable mesh, permanent mesh, biomaterial mesh, biological mesh, and synthetic mesh. The review of the literature resulted in a total of 3115 publications. By applying our criteria, six articles were included in this study, with 949 participants. Our meta-analysis showed the overall complication incidence displaying a significant difference favouring the synthetic mesh group (IV = 1.25, 95% CI 1.11-1.42, P = 0.0002). The operation failure rate, defined as hernia recurrence, also significantly favoured synthetic mesh (IV = 2.42, 95% CI 1.66-3.52, P < 0.00001). In conclusion, the present study found that the synthetic mesh proved superior in overall complication rate and operation failure compared to biologic mesh. However, it had no significant differences in other complications.

Use of prophylactic mesh to prevent parastomal hernia formation: a systematic review, meta-analysis and network meta-analysis

PURPOSE

To evaluate the effectiveness of prophylactic mesh placement in reducing the incidence of parastomal hernias following colostomy, ileostomy, and ileal conduit formation.

METHODS

A systematic review identified relevant studies evaluating parastomal hernia incidence with prophylactic mesh use during stoma formation. Pairwise meta-analysis and network meta-analysis using Bayesian modeling were performed.

RESULTS

25 studies, consisting of 16 randomized control trials (RCT), 6 follow up studies, and 3 retrospective cohort studies, were included. Prophylactic mesh led to significantly fewer parastomal hernias beyond 6 months follow-up (OR 0.43, 95% CI 0.33-0.58). Hernias were reduced with mesh for both ileal conduits and colostomies. When analyzing hazard ratios (HRs), only 6 studies were included, and a statistically significant difference was observed among both randomized controlled trials (RCTs) (HR 0.75 [0.53, 0.92], p = 0.01) and non-RCTs (HR 0.57 [0.36, 0.92], p = 0.02). Network meta-analysis found the retromuscular approach with mesh had the lowest hernia rate. Regression was non-significant for variations between study types.

CONCLUSION

This meta-analysis demonstrated prophylactic mesh placement during ostomy creation significantly reduced parastomal hernia risk, more prominently beyond 6 months, consistently across randomized trials and observational studies for urologic and gastrointestinal ostomies. The retromuscular technique was most effective.

Comparative anatomic and symptomatic recurrence outcomes of diaphragmatic suture cruroplasty versus biosynthetic mesh reinforcement in robotic hiatal and paraesophageal hernia repair

BACKGROUND

Hiatal and paraesophageal hernia (HH/PEH) recurrence is the most common cause of failure after gastroesophageal anti-reflux surgery. Crural reinforcement with mesh has been suggested to address this issue, but its efficacy remains debated. In this study, we aimed to determine the impact of biosynthetic mesh reinforcement compared to suture cruroplasty on anatomic and symptomatic hernia recurrence.

METHOD

Data of patients who underwent robotic HH/PEH repair with suture cruroplasty with or without biosynthetic mesh reinforcement between January 2012 and April 2024 were retrospectively reviewed. Gastroesophageal reflux disease symptoms and anatomic hernia recurrence were assessed at short-term (3 months to 1 year) and longer-term (≥ 1 year) follow-up. Symptomatic hernia recurrence was defined as having both anatomic recurrence and symptoms.

RESULTS

Out of the 503 patients in the study, 308 had undergone biosynthetic mesh repair, while 195 had suture-only repair. After the surgery, both groups demonstrated comparable improvements in symptoms. Short-term anatomic hernia recurrence rates were 11.8% and 15.6% for mesh and suture groups, respectively (p = 0.609), while longer-term rates were 24.7% and 44.9% (p = 0.015). The rates of symptomatic hernia recurrence in the same group were 8.8% and 14.6% in the short-term (p = 0.256), and 17.2% and 42.2% in longer-term follow-ups (p = 0.003). In the repair of medium and large-size hernias, mesh reinforcement resulted in a 50.0% relative risk reduction in anatomic hernia recurrences and a 59.2% reduction in symptomatic hernia recurrences at ≥ 1-year follow-up.

CONCLUSION

After more than a year of follow-up, it has been found that using biosynthetic mesh for medium and large hiatal or paraesophageal hernia repair significantly reduces the likelihood of both anatomic and symptomatic recurrence compared to using only suture cruroplasty. These findings strongly support the use of biosynthetic mesh to manage larger hernias. However, further long-term multicenter randomized studies are needed to provide more conclusive evidence.

Scaffold-based tissue engineering strategies for urethral repair and reconstruction

Urethral strictures are common in urology; however, the reconstruction of long urethral strictures remains challenging. There are still unavoidable limitations in the clinical application of grafts for urethral injuries, which has facilitated the advancement of urethral tissue engineering. Tissue-engineered urethral scaffolds that combine cells or bioactive factors with a biomaterial to mimic the native microenvironment of the urethra, offer a promising approach to urethral reconstruction. Despite the recent rapid development of tissue engineering materials and techniques, a consensus on the optimal strategy for urethral repair and reconstruction is still lacking. This review aims to collect the achievements of urethral tissue engineering in recent years and to categorize and summarize them to shed new light on their design. Finally, we visualize several important future directions for urethral repair and reconstruction.

Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery

INTRODUCTION

Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty.

METHODS

A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized.

RESULTS

Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement.

DISCUSSION

The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Emerging materials and technologies for advancing bioresorbable surgical meshes

Surgical meshes play a significant role in the treatment of various medical conditions, such as hernias, pelvic floor issues, guided bone regeneration, and wound healing. To date, commercial surgical meshes are typically made of non-absorbable synthetic polymers, notably polypropylene and polytetrafluoroethylene, which are associated with postoperative complications, such as infections. Biological meshes, based on native tissues, have been employed to overcome such complications, though mechanical strength has been a main disadvantage. The right balance in mechanical and biological performances has been achieved by the advent of bioresorbable meshes. Despite improvements, recurrence of clinical complications associated with surgical meshes raises significant concerns regarding the technical adequacy of current materials and designs, pointing to a crucial need for further development. To this end, current research focuses on the design of meshes capable of biomimicking native tissue and facilitating the healing process without post-operative complications. Researchers are actively investigating advanced bioresorbable materials, both synthetic polymers and natural biopolymers, while also exploring the performance of therapeutic agents, surface modification methods and advanced manufacturing technologies such as 4D printing. This review seeks to evaluate emerging biomaterials and technologies for enhancing the performance and clinical applicability of the next-generation surgical meshes. STATEMENT OF SIGNIFICANCE: In the ever-transforming landscape of regenerative medicine, the embracing of engineered bioabsorbable surgical meshes stands as a key milestone in addressing persistent challenges and complications associated with existing treatments. The urgency to move beyond conventional non-absorbable meshes, fraught with post-surgery complications, emphasises the necessity of using advanced biomaterials for engineered tissue regeneration. This review critically examines the growing field of absorbable surgical meshes, considering their potential to transform clinical practice. By strategically combining mechanical strength with bioresorbable characteristics, these innovative meshes hold the promise of mitigating complications and improving patient outcomes across diverse medical applications. As we navigate the complexities of modern medicine, this exploration of engineered absorbable meshes emerges as a promising approach, offering an overall perspective on biomaterials, technologies, and strategies adopted to redefine the future of surgical meshes.

Maximizing mesh mileage: evaluating the long-term performance of a novel hybrid mesh for ventral hernia repair

PURPOSE

The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR).

METHODS

This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI).

RESULTS

278 patients were identified. Mean follow-up was 24.1 (0.2-87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05).

CONCLUSION

Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations.

Omentoplasty in Surgical Interventions: A Comprehensive Review of Techniques and Outcomes

Omentoplasty, a surgical technique utilizing the omentum's unique properties, has become a pivotal intervention across various surgical fields. This comprehensive review explores the historical evolution, techniques, applications, outcomes, and complications associated with omentoplasty. With its rich vascular supply, lymphatic tissue, and remarkable immunological properties, the omentum has proven invaluable in enhancing wound healing, controlling infections, and providing mechanical support in complex surgical scenarios. The review delves into the anatomy and physiology of the omentum, elucidating its role in promoting angiogenesis and combating infections. Different omentoplasty techniques, including open, laparoscopic, and robotic-assisted approaches, are compared with regard to indications, procedural steps, and outcomes. The applications of omentoplasty span general surgery, cardiothoracic surgery, neurosurgery, gynecologic surgery, and urologic surgery, highlighting its versatility and broad clinical relevance. Short-term and long-term outcomes of omentoplasty, including postoperative recovery, complication rates, recurrence rates, and quality of life, are thoroughly analyzed. The review addresses common and rare complications, emphasizing prevention and management strategies to optimize patient outcomes. Innovations in surgical techniques, the use of biomaterials, and the potential for synthetic or bioengineered omentum are discussed, underscoring the future directions and research opportunities in this field. By providing a detailed examination of omentoplasty, this review aims to enhance understanding, guide clinical practice, and inspire future research to further improve surgical outcomes and patient care.

From Meshes to Minimally Invasive Techniques: A Comprehensive Review of Modern Hernia Repair Approaches

Hernias are a common medical condition characterized by the protrusion of organs or tissues through weakened muscle walls, affecting millions worldwide annually. Historically, from being treated with open surgeries using tension-free mesh repairs, the landscape of hernia repair has evolved significantly. This evolution has been marked by the advent and refinement of minimally invasive techniques, including laparoscopic and robotic-assisted approaches, which offer reduced postoperative pain, shorter recovery times, and improved patient outcomes compared to traditional methods. This comprehensive review aims to elucidate the evolution of hernia repair techniques, emphasizing the transition from conventional mesh repairs to advanced minimally invasive methodologies. By examining the historical progression and current state of hernia surgery, this review thoroughly analyzes the advancements in surgical techniques, materials, and technologies. Furthermore, it explores emerging trends such as biological meshes, ultrasound-guided procedures, and 3D printing applications in hernia repair. The clinical significance of these advancements lies in their potential to enhance the patient's quality of life, minimize complications, and optimize healthcare resource utilization. Insights gained from this review will inform clinicians and researchers about the efficacy, safety, and comparative effectiveness of various hernia repair approaches, guiding future directions in hernia management and fostering innovation in surgical practice.

Rives-Stoppa Repair Versus Bilateral Inguinal Hernioplasty: A Comprehensive Review of Surgical Techniques and Patient Outcomes

Hernia repair surgery is a common procedure to address the protrusion of organs or tissues through weakened muscles or connective tissue. This review compares two prominent surgical techniques for hernia repair: the Rives-Stoppa repair and bilateral inguinal hernioplasty. The Rives-Stoppa repair involves a posterior approach with extensive mesh placement suitable for complex and recurrent hernias. In contrast, bilateral inguinal hernioplasty focuses on simultaneously repairing bilateral hernias, potentially reducing operative time and enhancing recovery. This review examines each approach's technical aspects, including incision methods, mesh placement, and closure techniques. Patient outcomes, such as postoperative pain, recovery time, recurrence rates, and quality of life, are critically analyzed based on current research and clinical data. Economic considerations are also evaluated, encompassing each technique's cost-effectiveness and economic impact. By synthesizing these findings, this review aims to provide valuable insights for surgeons, healthcare providers, and policymakers in optimizing hernia repair strategies. The evolving landscape of surgical techniques and materials underscores the importance of ongoing research to refine practices and improve outcomes for patients undergoing hernia repair surgery.

Ibuprofen-loaded bilayer electrospun mesh modulates host response toward promoting full-thickness abdominal wall defect repair

Pro-inflammatory response impairs the constructive repair of abdominal wall defects after mesh implantation. Electrospinning-aid functionalization has the potential to improve the highly orchestrated response by attenuating the over-activation of foreign body reactions. Herein, we combined poly(L-lactic acid-co-caprolactone) (PLLA-CL) with gelatin proportionally via electrospinning, with Ibuprofen (IBU) incorporation to fabricate a bilayer mesh for the repair improvement. The PLLA-CL/gelatin/IBU (PGI) mesh was characterized in vitro and implanted into the rat model with a full-thickness defect for a comprehensive evaluation in comparison to the PLLA-CL/gelatin (PG) and off-the-shelf small intestinal submucosa (SIS) meshes. The bilayer PGI mesh presented a sustained release of IBU over 21 days with degradation in vitro and developed less-intensive intraperitoneal adhesion along with a histologically weaker inflammatory response than the PG mesh after 28 days. It elicited an M2 macrophage-dominant foreign body reaction within the process, leading to a pro-remodeling response similar to the biological SIS mesh, which was superior to the PG mesh. The PGI mesh provided preponderant mechanical supports over the SIS mesh and the native abdominal wall with similar compliance. Collectively, the newly developed mesh advances the intraperitoneal applicability of electrospun meshes by guiding a pro-remodeling response and offers a feasible functionalization approach upon immunomodulation.

In vivo comparison of mesh fixation solutions in open and laparoscopic procedures for inguinal hernia repair: A meta-analysis

Background

Abdominal hernia repair surgeries involve the fixation of a surgical mesh to the abdominal wall with different means such as suture, tacks, and glues. Currently, the most effective mesh fixation system is still debated. This review compares outcomes of mesh fixation in different surgical procedures, aiding surgeons in identifying the optimal technique.

Methods

A meta-analysis was conducted according to PRISMA guidelines. Articles published between January 2003 and January 2023 were searched in electronic databases. Randomized controlled trials (RCTs) comparing mesh fixation with cyanoacrylate-based or fibrin glues with classical fixation techniques (sutures, tacks) in open and laparoscopic procedures were included.

Results

17 RCTs were identified; the cumulative study population included 3919 patients and a total of 3976 inguinal hernias. Cyanoacrylate-based and fibrin glues were used in 1639 different defects, suture and tacks in 1912 defects, self-gripping mesh in 404 cases, and no mesh fixation in 21 defects. Glue fixation resulted in lower early postoperative pain, and chronic pain occurred less frequently. The incidence of hematoma was lower with glue fixation than with mechanical fixation. Recurrence rate, seroma formation, operative and hospitalization time showed no significant differences; but significantly, a higher number of people in the glue group returned to work by 15- and 30-days after surgery when compared to the tacker and suture groups in the same time frame.

Conclusion

Cyanoacrylate and fibrin glue may be effective in reducing early and chronic pain and hematoma incidence without increasing the recurrence rate, the seroma formation, or the operative and hospitalization time.

Quality of life measures and cost analysis of biologic versus synthetic mesh for ventral hernia repair: The Preventing Recurrence in Clean and Contaminated Hernias randomized clinical trial

BACKGROUND

Although the most durable method for ventral hernia repairs involves using mesh, whether to use biologic mesh versus synthetic mesh remains controversial. This study aimed to compare synthetic and biologic meshes with respect to patient-reported quality of life scores and costs after ventral hernia repair surgeries.

METHODS

This study is part of the Preventing Recurrence in Clean and Contaminated Hernias (PRICE) pragmatic randomized control trial conducted from March 2014 through October 2018. Patients were randomized 1:1 to undergo ventral hernia repair using either a biologic or synthetic mesh. The coprimary outcomes were 2-year changes in Visual Analog Scale, Activities Assessment Scale, Hernia-Related Quality-of-Life Survey, and Short-Form 36 Health Survey (SF-36) quality-of-life scores from repair. The secondary outcome was the overall cost per patient.

RESULTS

Among the 165 patients included in the study, 82 were randomized to biologic meshes and 83 to synthetic meshes. There were no significant differences in the performance between the 2 mesh types with regard to quality-of-life measures using a mixed model approach. This result was consistent even when performing subgroup analysis based on wound contamination. However, nonparametric tests comparing the differences in quality-of-life measures from preoperative to 24-month postoperative timepoints revealed that the synthetic mesh group showed a greater reduction in disability than biologic mesh for the SF-36 (median [interquartile range] of 20 [5-30] vs 6 [1-20], P = .025). This difference was due to reductions in the physical role limitations (62 [0-100] vs 0 [0-50], P = .018) and the pain (38 [12-50] vs 12 [0-25], P = .012) domains of the SF-36. Overall cost per patient was greater for biologic meshes (mean [95% confidence interval] of $80,420 [$66,485-$94,355] vs $61,036 [$48,946-$73,125], P = .038), regardless of insurance type.

CONCLUSION

In this randomized clinical trial, there were no differences in changes in quality-of-life scores at the 2-year timepoint except for the SF-36, where the synthetic mesh may be associated with less pain and physical role limitations than the biologic mesh. Overall costs per patient were less for synthetic than biologic mesh.

Ventral hernia repair using bioresorbable poly-4-hydroxybutyrate mesh in clean and contaminated surgical fields: a systematic review and meta-analysis

PURPOSE

Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings.

METHODS

Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software.

RESULTS

Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%).

CONCLUSIONS

P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison.

Definitive Closure Using an Ovine Reinforced Tissue Matrix in Contaminated Penetrating Abdominal Trauma

BACKGROUND Cases involving penetrating abdominal trauma may be complex and often involve damage to multiple organ systems. Synthetic, biologic, and reinforced biologic matrices/reinforced tissue matrices (RBMs/RTMs) are frequently used in hernia repair and other surgical procedures requiring reinforcement, including trauma cases that require abdominal repair. CASE REPORT The first case was a 35-year-old male patient with a stab wound (SW) to the right side of the chest and the abdomen resulting in damage to the diaphragm, epicardium, liver, and duodenum. The second case was a 22-year-old male patient who suffered multiple traumas after an automated trencher accident, including a skull fracture with exposed brain and major lacerations to the shoulder and abdomen causing a large right-flank hernia. In both cases, OviTex® (TELA Bio, Inc., Malvern, PA), a reinforced tissue matrix (RTM), was used to help obtain and maintain abdominal wall closure. We also present an institutional economic analysis using data from the author's institution with average case cost and future projections for procedure volume and product usage volume through 2021. CONCLUSIONS We report favorable outcomes in a series of patients with contaminated (CDC Wound Class III) surgical fields who underwent abdominal wall closure and reinforcement with OviTex RTM. Our work adds to the growing body of literature suggesting that reinforced biologics offer a potential alternative to biological meshes in the setting of a contaminated surgical field. Additionally, in comparison to other commonly available biologic matrices, use of OviTex RTM may be a cost-effective option to achieve abdominal wall closure even in complex cases.

Wound healing and hernia after abdominal aortic aneurysm repair: Onlay self-gripping polyester mesh reinforcement compared with small bite sutured closure

BACKGROUND

Prophylactic mesh implantation following open surgical repair of abdominal aortic aneurysm is a debatable subject.

OBJECTIVE

To assess the efficacy of a self-gripping polyester mesh used in on-lay technique to prevent incisional hernia after open abdominal aortic aneurysm repair.

METHODS

We retrospectively reviewed the records of 495 patients who underwent aortic surgery between May 2017 and May 2021. Patients included in the study underwent open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with closure of the abdominal wall with either small bite suture technique or prophylactic mesh reinforcement. Primary endpoint of the study was the occurrence of incisional hernia during a two-year follow-up period. Secondary endpoints were mesh-related complications.

RESULTS

Mesh implantation with the on-lay technique was successful in all cases. No patient in the mesh group developed an incisional hernia during the 24-month follow-up period. Two patients in the non-mesh group developed a symptomatic incisional hernia during the follow-up period at 6 months. Three cases of post-operative access site complications were observed in the mesh group.

CONCLUSIONS

Application of a self-gripping polyester mesh using the on-lay technique demonstrates acceptable early-durability after open surgical repair of abdominal aortic aneurysms. However, it appears to be associated with a number of post-operative access site complications.

Reconstructive Strategies in Pediatric Patients after Oncological Chest Wall Resection: A Systematic Review

An appropriate reconstruction strategy after surgical resection of chest wall tumors in children is important to optimize outcomes, but there is no consensus on the ideal approach. The aim of this study was to provide an up-to-date systematic review of the literature for different reconstruction strategies for chest wall defects in patients less than 18 years old. A systematic literature search of the complete available literature was performed and results were analyzed. A total of 22 articles were included in the analysis, which described a total of 130 chest wall reconstructions. All were retrospective analyses, including eight case reports. Reconstructive options were divided into primary closure (n = 21 [16.2%]), use of nonautologous materials (n = 83 [63.8%]), autologous tissue repair (n = 2 [1.5%]), or a combination of the latter two (n = 24 [18.5%]). Quality of evidence was poor, and the results mostly heterogeneous. Reconstruction of chest wall defects can be divided into four major categories, with each category including its own advantages and disadvantages. There is a need for higher quality evidence and guidelines, to be able to report uniformly on treatment outcomes and assess the appropriate reconstruction strategy.

Cysteine-Silver-Polymer Systems for the Preparation of Hydrogels and Films with Potential Applications in Regenerative Medicine

Herein, the problem concerning the poorer mechanical properties of gels based on low molecular weight gelators (LMWGs)-L-cysteine and silver nitrate-was solved by the addition of various polymers-polyvinyl alcohol (PVA), polyvinyl pyrrolidone (PVP) and polyethylene glycol (PEG)-to the initial cysteine-silver sol (CSS). The physicochemical methods of analysis-viscosimetry, UV spectroscopy, DLS, and SEM-identified that cysteine-silver hydrogels (CSG) based on PVA possess the best rheological properties and porous microstructure (the average pore size is 2-10 µm) compared to gels without the polymer or with PVP or PEG. Such gels are able to form cysteine-silver cryogels (CSC) and then porous cysteine-silver films (CSF) with an average pore size of 10-20 µm and good mechanical, swelling, and adhesion to skin characteristics as long as the structure of CSS particles remains stable. In vitro experiments have shown that hydrogels are non-toxic to normal human fibroblast cells. The obtained materials could potentially be applied to regenerative medicine.

Bubble plastic use in rats hernioplasty: Uso do plástico bolha em hernioplastias de ratos

Purpose

Despite the high frequency of hernioplasties worldwide, their complications and recurrences are still a challenge to be overcome. The search for prostheses that aim to promote the correction of hernia defects has been a challenge. For this purpose, the materials used in hernioplasties must be biocompatible, promote the formation of little or no peritoneal adhesion, possess compatible texture and flexibility, providing the necessary resistance to protect the viscera and allow the movement of the abdomen.

Methods

The aim of the present study was to evaluate the effectiveness of bubble plastic (low density polyethylene, LDPE) as a material for the correction of hernia in the abdominal wall. For this, twenty male rats (Rattus norvegicus, Wistar variety) were used and divided into four groups of five animals. The animals were evaluated at 7, 15, 30 and 90 days after surgery according to clinical, thermographic and morphological parameters (macroscopic and microscopic).

Results

The results showed that the bubble plastic induced inflammatory reaction in the initial period (7 day), followed by a reduction (30 day) to increase considerably at 90 days after the operation.

Conclusion

So, bubble plastic can be used for temporary implants (up to 30 days).

Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review

OBJECTIVE

This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes.

SUMMARY BACKGROUND DATA

Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim.

METHODS

A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria.

RESULTS

After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores.

CONCLUSION

This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.

Comparative long-term effectiveness between ventral hernia repairs with biosynthetic and synthetic mesh

BACKGROUND

Debate exists regarding the most appropriate type of mesh to use in ventral hernia repair (VHR). Meshes are broadly categorized as synthetic or biologic, each mesh with individual advantages and disadvantages. More recently developed biosynthetic mesh has characteristics of both mesh types. The current study aims to examine long-term follow-up data and directly compare outcomes-specifically hernia recurrence-of VHR with biosynthetic versus synthetic mesh.

METHODS

With IRB approval, consecutive cases of VHR (CPT codes 49,560, 49,561, 49,565, and 49,566 with 49,568) performed between 2013 and 2018 at a single institution were reviewed. Local NSQIP data was utilized for patient demographics, perioperative characteristics, CDC Wound Class, comorbidities, and mesh type. A review of electronic medical records provided additional variables including hernia defect size, postoperative wound events to six months, duration of follow-up, and incidence of hernia recurrence. Longevity of repair was measured using Kaplan-Meier method and adjusted Cox proportional hazards regression.

RESULTS

Biosynthetic mesh was used in 101 patients (23%) and synthetic mesh in 338 (77%). On average, patients repaired using biosynthetic mesh were older than those with synthetic mesh (57 vs. 52 years; p = .008). Also, ASA Class ≥ III was more common in biosynthetic mesh cases (70.3% vs. 55.1%; p = .016). Patients repaired with biosynthetic mesh were more likely than patients with synthetic mesh to have had a prior abdominal infection (30.7% vs. 19.8%; p = .029). Using a Kaplan-Meier analysis, there was not a significant difference in hernia recurrence between the two mesh types, with both types having Kaplan Meir 5-year recurrence-free survival rates of about 72%.

CONCLUSION

Using Kaplan-Meier analysis, synthetic mesh and biosynthetic mesh result in comparable hernia recurrence rates and surgical site infection rates in abdominal wall reconstruction patients with follow-up to as long as five years.

Does bioabsorbable mesh reduce hiatal hernia recurrence rates? A meta-analysis

INTRODUCTION

The use of bioabsorbable mesh at the hiatus is controversial. Long-term data are scant. We evaluated the world literature and performed a meta-analysis to determine if these meshes were effective in reducing recurrence.

METHODS

A literature search was performed using PubMed, MEDLINE, and ClinicalKey. We evaluated articles reporting on both Bio-A™ (polyglycolic acid:trimethylene carbonate-PGA:TMC) and Phasix™ (poly-4-hydroxybutyrate-P4HB) used at the hiatus. The DerSimonian-Laird random effects model was used to estimate the overall pooled treatment effect along with a 95% confidence interval (CI). Similar analysis was conducted to compare the clinical outcomes, i.e., recurrence rate, mean surgical time, mean hospital stays and mean follow-up duration between non-Mesh and Mesh group. The I2 statistic was computed to assess the heterogeneity in effect sizes across the studies.

RESULTS

A total of 21 studies (12 mesh studies with 963 subjects and 9 non-mesh studies with 617 subjects) were included to conduct the meta-analysis. There was one article reporting outcomes on P4HB mesh (73 subjects) and 11 on PGA:TMC mesh (890 subjects). The bioabsorbable mesh group had a significantly lower recurrence rate compared to the non-mesh group (8% vs. 18%; 95%CI 0.08-0.17), pooled p-value < 0.0001. Surgery time was shorter in the mesh group compared to the non-mesh group (136.4 min vs. 150 min) but not statistically significant (p = 0.54). There tended to be a more extended follow-up period after surgery in the non-mesh group compared to the mesh group (27 vs. 25.8 months, range 10.8-54 months); but not statistically significant (ES: 27.4; 95%CI 21.6-33.3; p = 0.92).

CONCLUSIONS

Hiatal hernia repair with bioabsorbable mesh is more effective at reducing hernia recurrence rate in the mid-term than simple suture cruroplasty. Further studies investigating the long-term outcomes and P4HB mesh are needed.

Fabrication of Mechanically Enhanced, Suturable, Fibrous Hydrogel Membranes

Poly(vinyl-alcohol) hydrogels have already been successfully utilised as drug carrier systems and tissue engineering scaffolds. However, lacking mechanical strength and suturability hinders any prospects for clinical and surgical applications. The objective of this work was to fabricate mechanically robust PVA membranes, which could also withstand surgical manipulation and suturing. Electrospun membranes and control hydrogels were produced with 61 kDa PVA. Using a high-speed rotating cylindrical collector, we achieved fibre alignment (fibre diameter: 300 ± 50 nm). Subsequently, we created multilayered samples with different orientations to achieve multidirectional reinforcement. Finally, utilising glutaraldehyde as a cross-linker, we created insoluble fibrous-hydrogel membranes. Mechanical studies were performed, confirming a fourfold increase in the specific loading capacities (from 0.21 to 0.84 Nm²/g) in the case of the monolayer samples. The multilayered membranes exhibited increased resistance from both horizontal and vertical directions, which varies according to the specific arrangement. Finally, the cross-linked fibrous hydrogel samples not only exhibited specific loading capacities significantly higher than their counterpart bulk hydrogels but successfully withstood suturing. Although cross-linking optimisation and animal experiments are required, these membranes have great prospects as alternatives to current surgical meshes, while the methodology could also be applied in other systems as well.

Robotic Ventral Transabdominal Preperitoneal Repair of Uncomplicated Spigelian Hernia

Spigelian hernias are rare herniations through the Spigelian fascia, with an incidence rate of 0.12-2.0% of all hernias. Diagnosis may be difficult due to a potential lack of symptoms until complications arise. Therefore, imaging with either ultrasound or CT with oral contrast is recommended to confirm the diagnosis if a Spigelian hernia is suspected. Once the diagnosis has been established, it is essential that operative repair be performed as soon as possible because 24% of Spigelian hernias become incarcerated, and 27% of Spigelian hernias lead to strangulation. Management options include open surgery, laparoscopic surgery, and robotic surgery. This case report discusses the management of a 47-year-old man with an uncomplicated Spigelian hernia that was repaired with the robotic ventral transabdominal preperitoneal repair technique.

NIR-II live imaging study on the degradation pattern of collagen in the mouse model

The degradation of collagen in different body parts is a critical point for designing collagen-based biomedical products. Here, three kinds of collagens labeled by second near-infrared (NIR-II) quantum dots (QDs), including collagen with low crosslinking degree (LC), middle crosslinking degree (MC) and high crosslinking degree (HC), were injected into the subcutaneous tissue, muscle and joints of the mouse model, respectively, in order to investigate the in vivo degradation pattern of collagen by NIR-II live imaging. The results of NIR-II imaging indicated that all tested collagens could be fully degraded after 35 days in the subcutaneous tissue, muscle and joints of the mouse model. However, the average degradation rate of subcutaneous tissue (k = 0.13) and muscle (k = 0.23) was slower than that of the joints (shoulder: k = 0.42, knee: k = 0.55). Specifically, the degradation rate of HC (k = 0.13) was slower than LC (k = 0.30) in muscle, while HC showed the fastest degradation rate in the shoulder and knee joints. In summary, NIR-II imaging could precisely identify the in vivo degradation rate of collagen. Moreover, the degradation rate of collagen was more closely related to the implanted body parts rather than the crosslinking degree of collagen, which was slower in the subcutaneous tissue and muscle compared to the joints in the mouse model.

Outcomes of Biosynthetic and Synthetic Mesh in Ventral Hernia Repair

The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care.

Methods

We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO).

Results

Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05).

Conclusion

Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.

Establishing Peer Consensus About the Use of Long-Term Biosynthetic Absorbable Mesh for Hernia (Grades 2-3) as the Standard of Care

BACKGROUND

Standard synthetic and biologic meshes, often used in hernia repair, have commonly been used and each have their strengths but associated drawbacks. Long-term biosynthetic absorbable (LTBA) mesh has been developed to combine the strengths of synthetic and biologic meshes without the associated weaknesses. As a newer type of mesh, the supporting evidence base is still growing, and their optimum use has yet to be defined. This consensus was initiated to provide insight into those situations where a LTBA might be considered the Standard of Care in ventral hernia repair grades 2-3 (original classification, 2010) of the Ventral Hernia Working Group.

METHODS

A steering group of expert surgeons identified 35 statements, based around the evidence supporting LTBA, surgical technique, patients type most suitable for LTBA, risk-benefit of LTBA, patient and surgeon considerations, LTBA value. Surgeons involved in hernia repair received an online survey to assess consensus with these statements. Consensus was defined as high if ≥ 70% and very high if ≥ 90% of respondents agreed. Statements that had not achieved consensus agreement were revised and these were then issued for a subsequent round. Finally, 34 statements were included.

RESULTS

Two hundred fifty-five surgeons were involved. Fourteen statements (41%) achieved very high consensus, 24 achieved consensuses (≥ 70-< 90%), whilst one (3%) just failed to achieve consensus with an agreement score of 69%.

CONCLUSIONS

Expert consensus opinion about the use of LTBA for hernia (Grades 2-3) as the Standard of Care was achieved. Based on the consensus scores, the steering group derived eleven keys.

The sternum reconstruction: Present and future perspectives

Sternectomy is a procedure mainly used for removing tumor masses infiltrating the sternum or treating infections. Moreover, the removal of the sternum involves the additional challenge of performing a functional reconstruction. Fortunately, various approaches have been proposed for improving the operation and outcome of reconstruction, including allograft transplantation, using novel materials, and developing innovative surgical approaches, which promise to enhance the quality of life for the patient. This review will highlight the surgical approaches to sternum reconstruction and the new perspectives in the current literature.

Extensive orbital inflammation in an anophthalmic socket: is the Bioceramic implant a bystander or a participant?

Purpose

Porous orbital implants are commonly used materials following enucleation or evisceration. Implant-associated inflammation is a rare but serious complication which may necessitate explantation.

Observations

We report a case of a patient who developed extensive orbital inflammation six months after implantation of a vicryl (polyglactin 910) mesh-wrapped Bioceramic (aluminum oxide) spherical implant. An orbital biopsy demonstrated an extensive fibroinflammatory reaction with multinucleated giant cells. Removal of the implant resulted in complete resolution of symptoms.

Conclusions and importance

We surmise that the Bioceramic implant played a significant contributory role in this patient's orbital inflammation, a complication which has not been described previously.

A biomimetic multilayered polymeric material designed for heart valve repair and replacement

Materials currently used to repair or replace a heart valve are not durable. Their limited durability related to structural degeneration or thrombus formation is attributed to their inadequate mechanical properties and biocompatibility profiles. Our hypothesis is that a biostable material that mimics the structure, mechanical and biological properties of native tissue will improve the durability of these leaflets substitutes and in fine improve the patient outcome. Here, we report the development, optimization, and testing of a biomimetic, multilayered material (BMM), designed to replicate the native valve leaflets. Polycarbonate urethane and polycaprolactone have been processed as film, foam, and aligned fibers to replicate the leaflet's architecture and anisotropy, through solution casting, lyophilization, and electrospinning. Compared to the commercialized materials, our BMMs exhibited an anisotropic behavior and a closer mechanical performance to the aortic leaflets. The material exhibited superior biostability in an accelerated oxidization environment. It also displayed better resistance to protein adsorption and calcification in vitro and in vivo. These results will pave the way for a new class of advanced synthetic material with long-term durability for surgical valve repair or replacement.

Synthetic versus Biological Patches for CDH: A Comparison of Recurrence Rates and Adverse Events, Systematic Review, and Meta-Analysis

OBJECTIVE

 Our systematic review aims to compare recurrence rates and complications of biological versus synthetic patches for the repair of congenital diaphragmatic herniae.

METHODS

 Studies from January 1, 1980 to April 25, 2020, with patients under the age of 16 years and with a minimum 6-month follow-up, were included from MEDLINE, Embase, and Cochrane databases. Funnel plots for recurrence rates were constructed for biological and synthetic patches. Subgroup analysis was performed for recurrence rate at the 1-year time-point and data were gathered on individual adverse events from relevant studies.

RESULTS

 A total of 47 studies with 986 patients (226 biological, 760 synthetic) were included. Funnel plot analysis determined overall recurrence rates of 16.7% for synthetic and 30.3% for biological patches. Subgroup analysis of 493 and 146 patients with synthetic and biological patches, respectively, showed recurrence rates of 9.9 and 26%, respectively.The most commonly used patch types-PTFE (polytetrafluoroethylene) and SIS (small intestinal submucosa)-had 11.5 and 33.3% recurrence, respectively. Adhesive bowel obstruction rates ranged from 4 to 29% in studies that systematically reported it for synthetic, and 7 to 35% for biological patches. Gastroesophageal reflux rates ranged from 25 to 48% in studies that systematically reported it for synthetic, and 21 to 42% for biological patches. Pectus deformity rates were reported as high as 80% for synthetic patches.

CONCLUSION

 Biological patches appear to have higher recurrence rates than synthetic patches, while skeletal deformities are associated more commonly with synthetic patches. Results of biological patches are mainly using SIS and this may overestimate complications of current superior biological patches.

Abdominal hernia mesh repair in patients with inflammatory bowel disease: A systematic review

Background

Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons’ decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications.

Method

A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE’s recommendations. The research protocol was registered with PROSPERO (CRD42021247185).

Results

The present systematic search resulted in 11,243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate quality. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn’s disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition biological mesh, and gastrointestinal concomitant procedure.

Conclusion

Patients with IBD were subject, more so than controls to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques, and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.

Biodegradation of poly(L-lactic acid) and poly(ε-caprolactone) patches by human amniotic fluid in an in-vitro simulated fetal environment

Open spina bifida or myelomeningocele (MMC) is a devastating neurologic congenital defect characterized by primary failure of neural tube closure of the spinal column during the embryologic period. Cerebrospinal fluid leak caused by the MMC spinal defect in the developing fetus can result in a constellation of encephalic anomalies that include hindbrain herniation and hydrocephalus. The exposure of extruded spinal cord to amniotic fluid also poses a significant risk for inducing partial or complete paralysis of the body parts beneath the spinal aperture by progressive spinal cord damage in-utero. A randomized trial demonstrated that prenatal repair by fetal surgery, sometimes using patches, to cover the exposed spinal cord with a watertight barrier is effective in reducing the postnatal neurologic morbidity as evidenced by decreased incidence and severity of postnatal hydrocephalus and the reduced need for ventricular-peritoneal shunting. Currently, the use of inert or collagen-based patches are associated with high costs and inadequate structural properties. Specifically, the inert patches do not degrade after implantation, causing the need for a post-natal removal surgery associated with trauma for the newborn. Our present study is aimed towards in-vitro degradation studies of a newly designed patch, which potentially can serve as a superior alternative to existing patches for MMC repair. This novel patch was fabricated by blending poly(l-lactic acid) and poly(ε-caprolactone). The 16-week degradation study in amniotic fluid was focused on tracking changes in crystallinity and mechanical properties. An additional set of designed patches was exposed to phosphate-buffered saline (PBS), as a time-paired control. Crystallinity studies indicate the progress of hydrolytic degradation of the patch in both media, with a preference to bulk erosion in phosphate buffered saline and surface erosion in amniotic fluid. Mechanical testing results establish that patch integrity is not compromised up to 16 weeks of exposure either to body fluids analog (PBS) or to amniotic fluid.

Low Concentrated Fractionalized Nanofibers as Suitable Fillers for Optimization of Structural–Functional Parameters of Dead Space Gel Implants after Rectal Extirpation

Dead space after rectal resection in colorectal surgery is an area with a high risk of complications. In this study, our goal was to develop a novel 3D implant based on composite hydrogels enriched with fractionalized nanofibers. We employed, as a novel approach in abdominal surgery, the application of agarose gels functionalized with fractionalized nanofibers on pieces dozens of microns large with a well-preserved nano-substructure. This retained excellent cell accommodation and proliferation, while nanofiber structures in separated islets allowed cells a free migration throughout the gel. We found these low-concentrated fractionalized nanofibers to be a good tool for structural and biomechanical optimization of the 3D hydrogel implants. In addition, this nano-structuralized system can serve as a convenient drug delivery system for a controlled release of encapsulated bioactive substances from the nanofiber core. Thus, we present novel 3D nanofiber-based gels for controlled release, with a possibility to modify both their biomechanical properties and drug release intended for 3D lesions healing after a rectal extirpation, hysterectomy, or pelvic exenteration.

A case of disintegrated Strattice™ 4 years after immediate breast reconstruction

Acellular dermal matrices (ADMs) are used frequently in immediate breast reconstruction (IBR). In general, the porcine-derived ADM Strattice™ has been reported with good outcomes and low complication rates. Nonetheless, we report here a case of a 42-year-old, otherwise healthy woman with a history of uncomplicated bilateral prophylactic nipple-sparing mastectomies and subpectoral IBRs performed using Strattice™ and Mentor^® CPG™, who was referred to the Department of Plastic Surgery 4 years after this surgery due to changed appearance of her breast implants. Both CPG implants were found intact and there were no signs of infection but, surprisingly, the Strattice™ had completely disintegrated on both sides. Examinations did not show any malignancies, and at 1-year clinical follow-up, the patient had no signs of relapse. Thus, we suggest that the Strattice™ had disintegrated as a late aseptic foreign body reaction and emphasise the importance of surgeons being aware of this late and rare complication.

Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data.

BACKGROUND

Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation.

METHODS

A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I² = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups.

CONCLUSIONS

There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery

BACKGROUND

Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.

METHODS

PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.

RESULTS

23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low-moderate.

CONCLUSION

Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.

New Insights into the Application of 3D-Printing Technology in Hernia Repair

Abdominal hernia repair using prosthetic materials is among the surgical interventions most widely performed worldwide. These materials, or meshes, are implanted to close the hernial defect, reinforcing the abdominal muscles and reestablishing mechanical functionality of the wall. Meshes for hernia repair are made of synthetic or biological materials exhibiting multiple shapes and configurations. Despite the myriad of devices currently marketed, the search for the ideal mesh continues as, thus far, no device offers optimal tissue repair and restored mechanical performance while minimizing postoperative complications. Additive manufacturing, or 3D-printing, has great potential for biomedical applications. Over the years, different biomaterials with advanced features have been successfully manufactured via 3D-printing for the repair of hard and soft tissues. This technological improvement is of high clinical relevance and paves the way to produce next-generation devices tailored to suit each individual patient. This review focuses on the state of the art and applications of 3D-printing technology for the manufacture of synthetic meshes. We highlight the latest approaches aimed at developing improved bioactive materials (e.g., optimizing antibacterial performance, drug release, or device opacity for contrast imaging). Challenges, limitations, and future perspectives are discussed, offering a comprehensive scenario for the applicability of 3D-printing in hernia repair.