Biosynthetic Mesh Research Articles

Estudio histológico de las prótesis biosintéticas de poli-4-hidroxibutirato (PhasixTM) en un ser humano y revisión de la literatura

Introducción y objetivos: Intentando reducir los inconvenientes asociados a mallas biológicas y a no-reabsorbibles, se han desarrollado recientemente materiales biosintéticos. La experiencia con ellos es escasa y sus características histológicas solo han sido evaluadas en modelos animales.Nuestro objetivo es evaluar, por primera vez, la respuesta tisular al poli-4-hidroxibutirato mediante estudio anatomopatológico en un modelo humano y contrastarla con la animal disponible hasta la actualidad.Métodos: 20 mallas e poli-4-hidroxibutirato (PhasixTM, Bard) han sido implantadas por nuestro Servicio de Cirugía General. Presentamos una mujer de 52 años, quien requirió una colostomía de Harttmann y una laparostomía debido a una sigmoidectomía complicada. En la reconstrucción de la pared abdominal se empleó una malla biosintética (PhasixTM, Bard), por tratarse de una cirugía limpia-contaminada próxima a un estoma, el cual fue considerado posible foco infeccioso. 22 meses después, se realizó la restauración del tránsito intestinal, permitiendo tomar la muestra de pared abdominal que presentamos para estudio.Resultados: No se evidenciaron signos de recurrencia. Macroscópicamente, la malla podía observarse. El estudio anatomopatológico demostró una respuesta inflamatoria a cuerpo extraño. La tinción con hematoxilina-eosina reveló fibras de colágeno maduras y neoangiogénesis, determinando adecuada integración y remodelación tisular.Conclusiones: En nuestra paciente, la malla PhasixTM no se ha asociado a recidiva herniara y se ha integrado de forma similar a lo reportado previamente. El tiempo de reabsorción ha sido mayor, pudiendo favorecer un descenso de la tasa de recurrencia. Los resultados iniciales son prometedores, pero son necesarios más estudios para definir indicaciones clínicas y resultados.

Biosynthetic mesh increases peritoneal metastasis growth in animal model, the biological mesh does not!

Biosynthetic mesh increases peritoneal metastasis growth in animal model, the biological mesh does not!

Robotic Fundoplication for Gastroesophageal Reflux Disease and Hiatal Hernia: Initial Experience and Outcome

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common clinical presentation. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery. Between March 2014 and August 2016, 50 patients (18 males and 32 females) underwent robotic fundoplication (17 sliding and 33 paraesophageal hernias). The mean age of the patients was 58 years. Biosynthetic mesh was used in 28 patients with paraesophageal hernia. The mean operative time was 115 minutes (90-132) in the sliding hiatal hernia group, whereas it was 200 minutes (180-210) in the paraesophageal hiatal hernia group. The mean hospital stay was 36 hours (24-96). Eight patients experienced mild dysphagia which resolved after four weeks. No postoperative dysphagia was recorded at 30-month median follow-up. We experienced one recurrence in the sliding hernia group and two recurrences in the paraesophageal hernia group, with two patients treated robotically. Robotic fundoplication in treating sliding hiatal hernia is feasible and safe but is more challenging in the large paraesophageal group. Improved patient outcomes hinge on the operative technique used and increasing surgeon experience. The increased dexterity that robotic surgery affords enables the esophageal surgeon to more adeptly apply the traditional principles of laparoscopic fundoplication.

A post-market, prospective, multi-center, single-arm clinical investigation of Phasix\u2122 mesh for VHWG grade 3 midline incisional hernia repair: a research protocol

BackgroundIncisional heia is a frequent complication of midline laparotomy. The use of mesh in hernia repair has been reported to lead to fewer recurrences compared to primary repair. However, in Ventral Hernia Working Group (VHWG) Grade 3 hernia patients, whose hernia is potentially contaminated, synthetic mesh is prone to infection. There is a strong preference for resorbable biological mesh in contaminated fields, since it is more able to resist infection, and because it is fully resorbed, the chance of a foreign body reaction is reduced. However, when not crosslinked, biological resorbable mesh products tend to degrade too quickly to facilitate native cellular ingrowth. Phasix™ Mesh is a biosynthetic mesh with both the biocompatibility and resorbability of a biological mesh and the mechanical strength of a synthetic mesh. This multi-center single-arm study aims to collect data on safety and performance of Phasix™ Mesh in Grade 3 hernia patients.MethodsA total of 85 VHWG Grade 3 hernia patients will be treated with Phasix™ Mesh in 15 sites across Europe. The primary outcome is Surgical Site Occurrence (SSO) including hematoma, seroma, infection, dehiscence and fistula formation (requiring intervention) through 3 months. Secondary outcomes include recurrence, infection and quality of life related outcomes after 24 months. Follow-up visits will be at drain removal (if drains were not placed, then on discharge or staple removal instead) and in the 1st, 3rd, 6th, 12th, 18th and 24th month after surgery.ConclusionBased on evidence from this clinical study Depending on the results this clinical study will yield, Phasix™ Mesh may become a preferred treatment option in VHWG Grade 3 patients.Trial registrationThe trial was registered on March 25, 2016 on clinicaltrials.gov: NCT02720042.

Biosynthetic mesh for hernia repair decreases hospital budget

Biosynthetic mesh for hernia repair decreases hospital budget

Cost-Utility Analysis of Biologic and Biosynthetic Mesh in Ventral Hernia Repair: When Are They Worth It?

Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. Synthetic mesh was the preferred strategy, with a cost of $15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.

Budget Impact Analysis of a Biosynthetic Mesh for Incisional Hernia Repair

PurposeWith the development of newer prostheses for hernia repair, it is nowadays difficult to understand the total cost of managing patients treated with these advanced medical devices, especially in the complex abdomen, in which various complications may occur. The aim of this study was to determine the economic implications of these prostheses in order to inform decision making in the management of incisional hernia repair. MethodsA budget impact analysis model was developed to evaluate the economic consequences related to the management of patients undergoing complex (Centers for Disease Control and Prevention wound class II–III or Ventral Hernia Working Group grade 2/3) incisional hernia repair through biosynthetic, synthetic, or biological meshes, from the hospital perspective in Italy. The model was populated with complication rates mainly retrieved from the literature to compare the current scenario with 60%, 10%, and 30% rates of synthetic, biosynthetic, and biological mesh utilization, respectively, with future hypothetical scenarios that consider increasing rates of biosynthetic mesh utilization with respect to the other types of mesh in the next 5 years. Hospital costs of the different events were estimated based on health care resource consumption derived from an electronic survey addressed to key opinion leaders in the field. FindingsThe analysis compared the current scenario with future hypothetical scenarios that consider increasing utilization rates of biosynthetic meshes of 25%, 38%, and 44% in the next 1, 3, and 5 years, as estimated by clinicians. Considering 40,000 incisional hernia repairs per year, an increasing use of the biosynthetic meshes may result in a decrease in the total hospital budget of about €153 million in the next 5 years, with a savings per patient of about €770. ImplicationsThe findings of this study support the use of biosynthetic meshes for complex abdominal wall repairs in Italy, showing a potential decrease in the hospital budget in Italy after the diffusion of the new biosynthetic prostheses. Further studies and data from clinical practice would provide additional information to increase the understanding of the economic sustainability of these advanced devices.

Biologic and Biosynthetic Meshes in Ventral Hernia Repair: When Are They Worth It?

Schneeberger, Steven; Phillips, Sharon E. MSPH; Huang, LiChing PhD; Pierce, Richard A. MD, PhD, FACS; Etemad, Shervin A.; Poulose, Benjamin K. MD, MPH, FACS Author Information

PS01.072: IT IS NOT ALWAYS RISKY USING MESH IN THE TREATMENT OF HIATAL HERNIA

Abstract Background Many studies have shown that the importance of using mesh for paraesophageal hernia repair (PEHR) is to prevent recurrence. Unfortunately, it is associated with high risk of complications such as esophageal or gastric erosion. The aim of this study is to report the results of 38 patients who underwent laparoscopic PEHR with the use of a BioSynthetic mesh (GoreÒ Bio AÒ tissue Reinforcement.USA). Methods Observational, retrospective, single-center cohort study. We analysed retrospectively 38 consecutive patients with diagnosis of symptomatic Hiatal Hernia (HH) treated laparoscopically with an absorbable BioSynthetic mesh, between 2011–2017. The classic radiologic classification was used to classify the HH before surgery. This classification consists in four types/stages (I-IV). I: Sliding HH, II: Paraesophageal HH, III: Mixed form and IV: Intrathoracic stomach—upside-down hernia. All patients with Type III—IV hiatal hernia who underwent laparoscopic PEHR using an absorbable BioSynthetic mesh were included. We evaluated the results after PEHR with a symptoms questionnaire using a score 0–4 (Likert scale) and with an esophagogram and an esophagogastroduodenoscopy (EGD) analyzing the surgical success. Success was considered with symptomatic score improvement and/or absence of any symptomatic HH at the esophagogram and/or EGD. Results 38 patients: 7 males and 31 women. Median age: 66 (range 40–71). 12/38 (31,6%) patients had a type III HH and 26/38 (68,4%) a type IV. All these patients had been treated with a laparoscopic PEHR, using an absorbable BioSynthetic mesh as a reinforcement of the crura and Nissen fundoplication. The median follow-up was 12 months. 16/38 (42%) had a follow-up > 24 months. Success was evident in 95% of the patients. We observed 2 recurrences, one with a symptomatic type I HH and the other with an early type III HH recurrence. Conclusion The use of an absorbable synthetic mesh as a reinforcement of the crura in the treatment of the PEH has encouraging good results in the mild term follow up, with an extremely low incidence of complications. Disclosure All authors have declared no conflicts of interest.

Updates in Mesh and Biomaterials.

Prior publications of the Surgical Clinics of North America have highlighted the technical challenges of abdominal wall reconstruction. This article provides an update on synthetic, biologic, and biosynthetic mesh research since the 2013 Surgical Clinics of North America hernia publication and highlights the future of mesh research. This update features research that has been conducted since the prior publication to guide surgeons to choose the best and most appropriate mesh for their patients.

Optimal management of mesh infection: Evidence and treatment options

Mesh reinforcement is generally considered the standard of care in ventral hernia repair. Infection is a common complication following ventral hernia repair. Infection extending to the mesh is a complex problem. Knowledge of current treatment strategies is necessary for surgeons performing abdominal wall reconstruction. A comprehensive literature review was performed of current literature to assess risk factors and treatment options for mesh infection. Modifiable risk factors for mesh infections include active smoking, poorly controlled diabetes mellitus, abdominal skin or wound issues, and obesity. Operative factors that increase the risk of mesh infection include prior hernia repair, enterotomy and contamination of the surgical field. Of the synthetic meshes, lightweight polypropylene has the highest likelihood of salvage. Patients that are current smokers, those with other synthetic mesh types, and those infected with MRSA are rarely salvaged. Following excision of infected mesh, multi-staged abdominal wall reconstruction can be considered. Biologic or biosynthetic mesh is recommended when repairing incisional hernias following excision of infected mesh and likely represent the patient's best chance at a definitive hernia repair. Wound VAC-assisted delayed primary closure should be considered in higher-risk patients. Mesh infection is a complex complication that is commonly encountered by surgeons performing hernia repair. Prevention through patient optimization should be performed whenever appropriate. However, when patients develop a mesh infection, most will require complete mesh excision and recurrent hernia repair.

A New Proposal of Pelvic Floor Reconstruction Using Biosynthetic Mesh after Abdominoperineal Radical Surgery in Gynecological Cancer: A Case Series

Background: The purpose was to analyze the casuistry of pelvic floor reconstruction (PFR) with biological mesh (BM) after exenterative radical surgery. Methods: Six patients treated with radical surgery and reconstruction of the perineal defect, conducted with a BM, since April 2011 to June 2016, are described. Results: A total of 5 pelvic exenterations and an anterior pelvic supralevator exenteration were performed, 2 cases included a radical vulvectomy. In 5 patients the BM was placed intraoperatively, combined with myocutaneous bilateral gracilis flap or omentoplasty. Another case required deferred mesh placement due to evisceration through the perineal hole. Mean surgical time was 510 minutes and a median hospitalization of 26 days. Complications were mainly due to infections and abdominal wall dehiscence. There were no pelvic organ prolapses and no mesh had to be removed. The mean follow-up was 8.5 months; halfof the patients are free of disease. Conclusion: Though limited evidence, BM can be a safe and feasible option in cases of radical surgical gynecological procedures with a wide loss of soft tissue. More data is required.

Early Wound Morbidity after Open Ventral Hernia Repair with Biosynthetic or Polypropylene Mesh

Recently introduced slow-resorbing biosynthetic and non-resorbing macroporous polypropylene meshes are being used in hernias with clean-contaminated and contaminated wounds. However, information about the use of biosynthetic meshes and their outcomes compared with polypropylene meshes in clean-contaminated and contaminated cases is lacking. Here we evaluate the use of biosynthetic mesh and polypropylene mesh in elective open ventral hernia repair (OVHR) and investigate differences in early wound morbidity after OVHR within clean-contaminated and contaminated cases. All elective, OVHR with biosynthetic mesh or uncoated polypropylene mesh from January 2013 through October 2016 were identified within the Americas Hernia Society Quality Collaborative. Association of mesh type with 30-day wound events in clean-contaminated or contaminated wounds was investigated using a 1:3 propensity-matched analysis. Biosynthetic meshes were used in 8.5% (175 of 2,051) of elective OVHR, with the majority (57.1%) used in low-risk or comorbid clean cases. Propensity-matched analysis in clean-contaminated and contaminated cases showed no significant difference between biosynthetic mesh and polypropylene mesh groups for 30-day surgical site occurrences (20.7% vs 16.7%; p= 0.49) or unplanned readmission (13.8% vs 9.8%; p= 0.4). However, surgical site infections (22.4% vs 10.9%; p= 0.03), surgical site occurrences requiring procedural intervention (24.1% vs 13.2%; p= 0.049), and reoperation rates (13.8% vs 4.0%; p=0.009) were significantly higher in the biosynthetic group. Biosynthetic mesh appears to have higher rates of 30-day wound morbidity compared with polypropylene mesh in elective OVHR with clean-contaminated or contaminated wounds. Additional post-market analysis is needed to provide evidence defining best mesh choices, location, and surgical technique for repairing contaminated ventral hernias.

Crura augmentation with Bio-A® mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients.

The potential utility of both non-absorbable and absorbable meshes to reinforce the esophageal hiatus and prevent recurrent hernia has been investigated in observational studies and a few randomized clinical trials. Use of absorbable mesh has been associated with lesser side-effects, but the long-term safety and effectiveness are still debated. This rather scanty clinical evidence is due to heterogeneity and bias regarding the type of mesh and operation used, the modalities of follow-up, and the reporting of objective results. The aim of the study was to assess safety, quality of life, and recurrence-free probability after laparoscopic repair of hiatal hernia reinforced with a synthetic absorbable mesh. Observational, retrospective, single-center cohort study. All patients with hiatal hernia who underwent laparoscopic crura repair using a biosynthetic mesh (Gore Bio A® tissue reinforcement, Flagstaff, AZ) were included. Pre- and post-operative symptoms were assessed with the GERD-HRQL questionnaire. Objective follow-up consisted of upper gastrointestinal endoscopy and barium swallow study. From September 2011 to March 2016, a total of 100 patients underwent hiatal hernia repair using a Bio-A® mesh. All surgical procedures were completed laparoscopically. Postoperative morbidity rate was 10%. All patients had a minimum follow-up of 6months, and the median follow-up was 30 (IQR=22) months. No mesh-related complications occurred. The incidence of recurrent hernia ≥2cm was 9%, and eight of the nine patients had a preoperative type III hernia. The median GERD-HRQL score was significantly reduced after operation (p<0.001). The recurrence-free probability at 1 and 5years was, respectively, 0.99 (CI 0.97-1.00) and 0.84 (CI 0.74-0.97), and no reoperation was required. No association was found between age, BMI, hernia size, previously failed surgical repairs and hernia recurrence. The use of a synthetic absorbable mesh to reinforce the esophageal hiatus is safe and appears to be effective and durable over a medium-term follow-up.

Long-Term Effectiveness of Strattice in the Laparoscopic Closure of Paraesophageal Hernias.

Prosthetic reinforcement reduces the recurrence rate of large paraesophageal hernias (PEH), but the use of synthetic or biosynthetic mesh in the repair remains controversial. PEH repair has reported recurrence rates of 12% to 42%, and primary repair of PEH by suture closure under tension is at high risk of disruption. Synthetic mesh use in large PEH repair has shown to reduce recurrence but can lead to problems including mesh erosion, ulceration, stricture, and dysphagia. The objective of this study was to examine the long-term safety and efficacy of Strattice biologic mesh, a porcine acellular dermal matrix, in crural reinforcement of laparoscopic large PEH repair. Thirty-five patients with symptomatic PEH (>5 cm) were consented to receive Strattice for PEH repair. Patients were seen in clinic preoperatively, at surgery, and 2 weeks, 6 months, and 12 months postoperatively. Patients were given a standard subjective reflux test at each visit and a 12-month barium swallow X-ray to test for recurrence. Hernia recurrence was documented in 14.3% of cases by the end of the 1-year follow-up. Symptoms improved in 75% to 100% of patients by 6 months, and 33% to 100% of patients were still reporting symptom improvement at 12 months. Strattice mesh in PEH repair results in similar outcomes to other absorbable meshes, and the recurrence rate is within the 12% to 42% range of recurrences reported in studies outside of our institution. The use of Strattice mesh in large PEH repair had results similar to other biomaterial meshes and successfully decreased patients' symptom scores through surgical intervention.

Multicenter, Prospective, Longitudinal Study of the Recurrence, Surgical Site Infection, and Quality of Life After Contaminated Ventral Hernia Repair Using Biosynthetic Absorbable Mesh: The COBRA Study.

Objective:The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months.Background:CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic meshes has reported chronic biomaterial infections and high hernia recurrence rates.Methods:Patients with a contaminated or clean-contaminated operative field and a hernia defect at least 9 cm2 had a biosynthetic mesh (open, sublay, retrorectus, or intraperitoneal) repair with fascial closure (n = 104). Endpoints included overall Kaplan-Meier estimates for hernia recurrence and postoperative wound infection rates at 24 months, and the EQ-5D and Short Form 12 Health Survey (SF-12). Analyses were conducted on the intent-to-treat population, and health outcome measures evaluated using paired t tests.Results:Patients had a mean age of 58 years, body mass index of 28 kg/m2, 77% had contaminated wounds, and 84% completed 24-months follow-up. Concomitant procedures included fistula takedown (n = 24) or removal of infected previously placed mesh (n = 29). Hernia recurrence rate was 17% (n = 16). At the time of CVH repair, intraperitoneal placement of the biosynthetic mesh significantly increased the risk of recurrences (P ≤ 0.04). Surgical site infections (19/104) led to higher risk of recurrence (P < 0.01). Mean 24-month EQ-5D (index and visual analogue) and SF-12 physical component and mental scores improved from baseline (P < 0.05).Conclusions:In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.

Early Patient Morbidity after Open Ventral Hernia Repair with Permanent Synthetic vs Biosynthetic Mesh

Early Patient Morbidity after Open Ventral Hernia Repair with Permanent Synthetic vs Biosynthetic Mesh

Reducing Postoperative Abdominal Bulge Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Onlay Monofilament Poly-4-Hydroxybutyrate Biosynthetic Mesh.

Background The purpose of this study was to evaluate the use of a biosynthetic mesh onlay on reducing postoperative abdominal bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods All patients undergoing DIEP reconstructions from January, 2010 to January, 2014 at a tertiary center were reviewed. Patients were divided into two groups for comparison based on whether a biosynthetic mesh onlay (Phasix [monofilament poly-4-hydroxybutyrate], Bard Inc., Warwick, RI) was used for reinforcement of the anterior rectus fascia. Rates of postoperative abdominal bulge were compared between the groups utilizing standard statistical methods. Results During the study period, 319 patients underwent 553 DIEP reconstructions, 160 (50.2%) used mesh and 159 (49.8%) did not (nonmesh). The mean follow-up was 16.4 ± 11.1 months. There was no difference in age (49 ± 9.3 years), current tobacco use, diabetes, or mean body mass index (BMI, 29.4 ± 4.4) between the mesh and nonmesh groups (p > 0.05); however, there was a higher proportion of obese patients (BMI > 30) in the mesh group (45.0 vs. 33.3%; p = 0.03). Abdominal bulge rate following DIEP with mesh was lower than the nonmesh group (0 vs. 5.0%; p = 0.004). In the entire sample, 234 (73.4%) underwent bilateral DIEP and 85 (26.6%) underwent unilateral DIEP. In unilateral DIEP patients, the bulge rate was similar between the mesh and nonmesh groups (0 vs. 4.4%; p > 0.05); however, in bilateral DIEP patients, the bulge rate was lower in the mesh group compared with a nonmesh group (0 vs. 5.5%; p = 0.008). Conclusion Reinforcement of the anterior rectus with an onlay monofilament poly-4-hydroxybutyrate biosynthetic mesh may reduce the risk of postoperative bulge rate in patients undergoing DIEP reconstruction.

Repair of Perineal Hernia Following Abdominoperineal Excision with Biological Mesh: A Systematic Review.

Perineal hernia (PerH) following abdominoperineal excision (APE) procedure is a recognized complication. PerH was considered an infrequent complication of APE procedure; however, PerH rates of up to 45% have been reported in recent publications following a laparoscopic APE procedure. Various methods of repair of PerH with the use of synthetic meshes or myocutaneous flap have been described, although there is no general agreement on an optimal strategy. The use of biological meshes for different operations is growing in popularity, and these have been promoted as being superior and safer when compared to synthetic meshes. Although the use of biologics is becoming popular claims of better outcomes are largely unsupported by evidence. The aim of this systematic review is to evaluate the currently available evidence supporting the use of biologic or biosynthetic meshes for the repair of PerH that develop following an APE. A systematic review of all English language literature relevant to repair of PerH following APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE, EMBASE, and the Cochrane Library of Systematic Reviews for relevant literature. Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words "PerH," "APE," "morbidity," "biologics," "biosynthetic," and "hernia." Studies in which the use of biological meshes was not reported were excluded from the review. Various outcome measures, including operative technique, complication rates, recurrence rates, type of mesh, management of recurrences, and risk factors, were extracted. Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) was used to assess the quality of evidence. The systematic review of the literature identified three case reports, four case series, and one pooled analysis that were included in the final review. Overall, these studies were of poor quality providing level 4 evidence. Various different approaches and techniques of repair of PerH were described; however, it was difficult to extract information with regard to the primary and secondary outcome measures. There is no general agreement to the optimal operative strategy to repair PerH following an APE. There is insufficient evidence to recommend any specific operative approach or repair technique for PerH following an APE.

Open and Laparo-Endoscopic Repair of Incarcerated Abdominal Wall Hernias by the Use of Biological and Biosynthetic Meshes.

Although recently published guidelines recommend against the use of synthetic non-absorbable materials in cases of potentially contaminated or contaminated surgical fields due to the increased risk of infection (1, 2), the use of bio-prosthetic meshes for abdominal wall or ventral hernia repair is still controversially discussed in such cases. Bio-prosthetic meshes have been recommended due to less susceptibility for infection and the decreased risk of subsequent mesh explantation. The purpose of this review is to elucidate if there are any indications for the use of biological and biosynthetic meshes in incarcerated abdominal wall hernias based on the recently published literature. A literature search of the Medline database using the PubMed search engine, using the keywords returned 486 articles up to June 2015. The full text of 486 articles was assessed and 13 relevant papers were identified including 5 retrospective case cohort studies, 2 case-controlled studies, and 6 case series. The results of Franklin et al. (3-5) included the highest number of biological mesh repairs (Surgisis(®)) by laparoscopic IPOM in infected fields, which demonstrated a very low incidence of infection and recurrence (0.7 and 5.2%). Han et al. (6) reported in his retrospective study, the highest number of treated patients due to incarcerated hernias by open approach using acellular dermal matrix (ADM(®)) with very low rate of infection as well as recurrences (1.6 and 15.9%). Both studies achieved acceptable outcome in a follow-up of at least 3.5 years compared to the use of synthetic mesh in this high-risk population (7). Currently, there is a very limited evidence for the use of biological and biosynthetic meshes in strangulated hernias in either open or laparo-endoscopic repair. Finally, there is an urgent need to start with randomized controlled comparative trials as well as to support registries with data to achieve more knowledge for tailored indication for the use of biological meshes.