Implantation of biologic mesh in ventral hernia repair-does it make sense?

Abstract

Biological acellular porcine dermis mesh, such as Permacol™, has been used since 2009 to treat abdominal incisional hernias in a septic context. This study investigated the risk factors for incisional hernia recurrence after biological mesh augmentation. Over a period of 6years from February 2009 to February 2015, 68 patients underwent surgery. The mesh was placed intraperitoneally with closure of the anterior fascia in 27 cases (39.7%). The biological mesh was placed in the retromuscular pre-fascial plane in 1 case (1.5%) and pre-aponeurotic plane in 1 case (1.5%). Closure of the anterior fascia was not achieved in 39 cases, including 20 cases in which the mesh was placed intraperitoneally (intraperitoneal bridging group, 29.4%) and 19 cases in which the mesh was placed between the edges of the fascia (inlay bridging group, 27.9%). There were 37 cases of postoperative surgical site infections (54.4%), and Clavien-Dindo morbidity staging indicated stage I-II and III-IV complications in 19.1% and 44.1% of the cases, respectively. The recurrence rate was 61.8%, and the mortality rate was 0%. The rate of recurrence was significantly lower in the «fascia approximated» group (37%), p = 0.001). Univariate analyses of risk factors for procedural failure indicated an increased risk of recurrence in cases of postoperative surgical site infections, complications of Clavien-Dindo grade III or higher, an absent fascial closure in front of the mesh (OR = 8.69), an operating time longer than 180min, and a VHWG score higher than 2. After logistic regression, the risk factors for recurrence were postoperative infections (OR = 6.2), placement of bridged biological mesh (OR = 22.3), and postoperative morbidity grade III or higher (OR = 16.7). Patients with postoperative surgical site infections are at an increased risk for recurrence, and bridged mesh placements lack efficacy. Overall, this study challenges the purported advantage of biologics in treating incisional hernia repairs.