Large-pore Polypropylene Mesh Research Articles

V-004 ROBOTIC PARASTOMAL HERNIA REPAIR WITH RETROMUSCULAR MESH (PAULI TECHNIQUE)

Abstract Aim Parastomal hernia is a common complication of ostomy formation. We present a case of robotic parastomal hernia repair with retromuscular mesh (Pauli technique). Material and Methods Patient was 58 years-old man and had history of anterior resection of the rectum, terminal colostomy and onlay mesh parastomal hernia repair. After 2 months of parastomal hernia repair, the patient developed a recurrence (type III, European Hernia Society Classification). Results Robotic parastomal hernia repair was performed with transabdominal approach. Firstly, a small adhesiolysis of the colon to the stoma orifice was made. Then, the peritoneum and posterior sheath of the left rectus muscle was incised. The retrorectal space was dissected. The hernia sac was incised circumferentially. TAR dissection was launched lateral to the stoma. After the development of the landing zone for the mesh, the posterior retromuscular fascia was incised lateral to the stoma. The inner orifice of stoma was repositioned. A large-pore polypropylene mesh (20×28 cm) was placed in the retromuscular space and fixed it, lateral to the ostomy orifice. Finally, the retromuscular pocket was closed by suturing the posterior fascia to the linea alba. The patient was discharged on postoperative day 4 and had no complications. After 4 months of follow-up, no hernia recurrence had been recorded. Conclusions Robotic Pauli is a technique to repair parastomal hernias that provides wide coverage of the defect and avoids leaving mesh intraperitoneally. They could provide a secure repair and prevent postoperative complications (pain or intestinal ileus). It is technically challenging but feasible.

No difference in outcomes between large- and small-pore meshes in a prospective, randomized, multicenter trial investigating open retromuscular meshplasty for incisional hernia repair

Study designA randomized, controlled, prospective multicenter clinical trial with a parallel group design was initiated in eight surgical centers to compare a large-pore polypropylene mesh (Ultrapro®) to a small-pore polypropylene mesh (Premilene®) within a standardized retromuscular meshplasty for incisional hernia repair.MethodsBetween 2004 and 2006, patients with a fascial defect with a minimum diameter of 4 cm after vertical midline laparotomy were recruited for the trial. Patients underwent retromuscular meshplasty with either a large-pore or a small-pore mesh to identify the superiority of the large-pore mesh. Follow-up visits were scheduled at 5 and 21 days and 4, 12, and 24 months after surgery. A clinical examination, a modified short form 36 (SF-36®), a daily activity questionnaire, and an ultrasound investigation of the abdominal wall were completed at every follow-up visit. The primary outcome criterion was foreign body sensation at the 12-month visit, and the secondary endpoint criteria were the occurrence of hematoma, seroma, and chronic pain within 24 months postoperatively.ResultsIn 8 centers, 181 patients were included in the study. Neither foreign body sensation within the first year after surgery (27.5% Ultrapro®, 32.2% Premilene®) nor the time until the first occurrence of foreign body sensation within the first year was significantly different between the groups. Regarding the secondary endpoints, no significant differences could be observed. At the 2-year follow-up, recurrences occurred in 5 Ultrapro® patients (5.5%) and 4 Premilene® patients (4.4%).ConclusionDespite considerable differences in theoretical and experimental works, we have not been able to identify differences in surgical or patient-reported outcomes between the use of large- and small-pore meshes for retromuscular incisional hernia repair.Trial registrationClinical Trials NCT04961346 (16.06.2021) retrospectively registered.

OC-033 SLOWLY RESORBABLE VERSUS PERMANENT SYNTHETIC MESH IN OPEN RETROMUSCULAR VENTRAL HERNIA REPAIR - 3 YEAR RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Abstract Introduction Implantation of synthetic meshes provides long-term hernia repair, but may result in mesh-related complications. The longterm resorbable mesh used in this study maintains more than 50% of its strength for 6 months and is completely resorbed after 3 years. Methods This multi-centre, randomized controlled trial compared the use of the TIGR® Matrix Surgical Mesh (Novus Scientific, Sweden) with a large-pore polypropylene mesh (Soft®mesh, BD, UK) in primary ventral and incisional hernia repair. Retromuscular mesh repair was performed. Primary endpoint was hernia recurrence rate after a 3 year follow-up period. Secondary endpoints were hernia recurrence rate at 1 year and 2 years, as well as perioperative morbidity and longterm complications including pain. Results Seventy-nine patients were included, but 69 patients received study treatment. Fifty-seven patients (82.6%) completed follow-up of 3 years. One patient (2.9%) developed a seroma after hernia repair with TIGR mesh. Three patients had a reintervention for hematoma (8.6%) in the control group versus two reinterventions (5.9%) after repair with TIGR mesh (p=0.673. One patient underwent late re-operation and mesh removal after hernia repair with TIGR mesh due to chronic wound infection. During three years follow-up, seven (10.1%) patients experienced a hernia recurrence, two (5.7%) in the control group and five (14.7%) after TIGR mesh (p=0.15). Conclusion Although not statistically significant, this multicentric RCT showed a higher recurrence rate for longterm degradable mesh patients after 3 years of follow-up. These results call for larger studies with long-term follow-up comparing slowly resorbable mesh materials with permanent mesh products.

Prospective Comparative Study of Laparoscopic Totally Extra-Peritoneal Repair for Inguinal Hernia with Light Weight Polypropylene Mesh V/S 3D Anatomically Shaped Large Pore Polypropylene Mesh

Prospective Comparative Study of Laparoscopic Totally Extra-Peritoneal Repair for Inguinal Hernia with Light Weight Polypropylene Mesh V/S 3D Anatomically Shaped Large Pore Polypropylene Mesh

Minimally invasive mesh salvaging technique on treatment of hernia mesh infection: A case series

IntroductionThe aim of the presentation is to demonstrate a new conservative approach for the salvage treatment of the infected hernia mesh. MethodsThree patients with polypropylene mesh infection following an open umbilical and incisional hernia repair performed by placing the mesh in the onlay position are presented. The infection manifested itself with a systemic inflammatory response and an infected fluid collection surrounding the mesh. All patients were treated conservatively by a minimally invasive technique according to the stepwise protocol. ResultsAn effective, rapid response to the conservative treatment was observed. A total of five to six procedures were necessary in a period of up to twenty days. Mesh salvage was achieved, and the long-term outcome demonstrates neither the recurrence of infection nor hernia.An enclosed space at the infection site is the main precondition for providing a sufficient concentration of the antiseptic for a long enough time to act effectively at the infection site. The fast killing effect on the mesh infection and a good long-term outcome in all presented patients prove that this technique is superior to the the current techniques in appropriately selected patients from the point of treatment duration. ConclusionAn effective mesh salvaging conservative treatment is possible when the infection manifests itself as an infected fluid collection surrounding the monofilament, large-pore polypropylene mesh and should be the first-line option. Open surgical approach should be reserved as a second-line option if the first fails.

Preclinical bioassay of a novel antibacterial mesh for the repair of abdominal hernia defects

BackgroundIn hernia surgery, soaking of meshes in antibiotics before implantation is a prophylactic strategy for minimizing the risk of infection while providing minimal, local, drug doses. This study describes the development and application of an antibacterial mesh coating comprising a carboxymethylcellulose gel loaded with rifampicin in a preclinical model of Staphylococcus aureus and S. epidermidis infection in rabbits. MethodsAntibacterial activity and cytocompatibility (with fibroblasts) of unloaded carboxymethylcellulose gel and 0.13 mg/mL rifampicin-carboxymethylcellulose gel were assessed in vitro. Then, partial abdominal wall defects (5 × 2 cm) were created in New Zealand white rabbits (n = 34), the wound inoculated with 0.25 mL of 106 CFU Staphylococcus aureus/ S. epidermidis (n = 17 each), and the defect then repaired with a lightweight, monofilament, large pore polypropylene mesh either uncoated (n = 3) or coated with carboxymethylcellulose gel (n = 7) or rifampicin-carboxymethylcellulose gel (n = 7). By postoperative day 14, coating performance was evaluated by determining bacterial adhesion (via sonication), host tissue incorporation (via histology), macrophage response via immunostaining), and bloodstream drug diffusion (via high-performance liquid chromatography). ResultsIn vitro, rifampicin-carboxymethylcellulose gel demonstrated great activity against Staphylococcus aureus/S. epidermidis, while being innocuous for fibroblasts. In vivo, rifampicin-carboxymethylcellulose gel-coated implants displayed full bacterial clearance and optimal tissue integration, irrespective of the strain of Staphylococcus. In contrast, uncoated and carboxymethylcellulose gel-coated implants exhibited macro/microscopic signs of infection and impaired tissue integration. Macrophage responses were less in rifampicin-carboxymethylcellulose gel implants than in uncoated mesh (Staphylococcus aureus/S. epidermidis; P < .01) and carboxymethylcellulose gel (S. epidermidis; P < .05) implants. Bloodstream levels of rifampicin were undetectable. ConclusionSoaking meshes in rifampicin-carboxymethylcellulose gel inhibited effectively the bacterial adhesion to the mesh without compromising the tissue repair. This antibiotic gel constitutes an easy-to-use and effective prophylactic strategy that potentially reduce the prevalence of postoperative mesh infection.

The efficacy of absorbable versus non-absorbable fixation in laparoscopic totally extraperitoneal (tep) repair of large inguinal hernias

Our study aims to compare clinical outcomes of laparoscopic Totally Extra-peritoneal (TEP) repair with mesh fixation in large inguinal hernias using titanium versus absorbable tacks. This is a case control study of patients who underwent laparoscopic TEP repair with mesh fixation of large inguinal hernias in our institution from 2010 to 2015. In all patients a standard 10×15cm large-pore polypropylene mesh was used and a standardized fixation technique was followed. Patient demographics, presentation, defect size as per the European Hernia Society Groin Hernia Classification, post-operative complications and recurrence rates were collected and analysed. 20 patients had mesh fixation with titanium tackers (Group TT) were compared with 37 patients who had mesh fixation with absorbable tacks (Group AT). Mean age was 57.00 (±13.78) in Group TT and 49.00 (±17.15) in Group AT. All patients were males. The median defect size was L3M2 in Group TT and L2M2 in Group AT. All patients were followed up for a mean period of 24 months (range: 1-48 months). Post-operatively, one patient in Group AT developed chronic pain. One Group TT patient and four Group AT patients developed seromas, which were treated conservatively. There were no recurrences in Group TT, while one Group AT patient developed a medial recurrence. Both titanium and absorbable tacks showed similar post-operative complications and pain scores. As such, they both appear safe and feasible for mesh fixation during laparoscopic repair of large inguinal hernias.

Long-term retromuscular and intraperitoneal mesh size changes within a randomized controlled trial on incisional hernia repair, including a review of the literature

Purpose Ingrowth of fibroblasts in a polypropylene mesh may cause contraction and a later recurrence. We assessed mesh contraction in intraabdominal and retromuscular implantation after incisional hernia repair.MethodsA cohort of patients within an RCT on laparoscopic (LHR) versus open hernia repair (OHR) had their mesh borders marked with metal clips. X-ray was performed on postoperative day 1 and after 1 year. Total length, width, and dislocation were measured. A tacker fixated large-pore polypropylene mesh was used in LHR, and a retromuscular small-pore heavy-weight mesh was sutured to the midline in OHR. Patient’s pain was assessed before surgery and after 1 year.ResultsFor analysis 37/47 patients remained: 20 LHR and 17 OHR. Hernia defect area was median 41 cm2 in LHR and 25 cm2 in OHR (p < 0.140). Implanted mesh size was 300 cm2 for LHR and 240 cm2 for OHR (p < 0.341). After 1 year the mesh area decreased by 4.4% and 0.5% in LHR and OHR, respectively (p < 0.063). Longitudinal distance decreased by 2.8% in LHR and by 2.6% in OHR (p < 0.269). Transverse distance decreased by 1.6% in LHR but increased by 3.1% in OHR (p < 0.005). Dislocation was seen in four LHR and one OHR. Two recurrent and one port-site hernia were diagnosed after LHR. Measurements between observers were identical in 58% and consensus was made in the remainder. Pain was not correlated to mesh area change.ConclusionsMesh contraction after 1 year is not a clinical issue for an intraperitoneal large-pore mesh or a retromuscular small-pore mesh. It is not correlated to postoperative pain.

Prevention of Incisional Hernias by Prophylactic Mesh-augmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment: A Randomized Controlled Trial.

The incidence of incisional hernias after abdominal aortic aneurysm repair is high. Prophylactic mesh-augmented reinforcement during laparotomy closure has been proposed in patients at high risk of incisional hernia. A multicenter randomized trial was conducted on patients undergoing elective abdominal aortic aneurysm repair through a midline laparotomy (Clinical.Trials.gov: NCT00757133). In the study group, retromuscular mesh-augmented reinforcement was performed with a large-pore polypropylene mesh (Ultrapro, width 7.5 cm). The primary endpoint was the incidence of incisional hernias at 2-year follow-up. Between February 2009 and January 2013, 120 patients were recruited at 8 Belgian centers. Patients' characteristics at baseline were similar between groups. Operative and postoperative characteristics showed no difference in morbidity or mortality. The cumulative incidence of incisional hernias at 2-year follow-up after conventional closure was 28% (95% confidence interval [CI], 17%-41%) versus 0% (95% CI, 0%-6%) after mesh-augmented reinforcement (P < 0.0001; Fisher exact test). The estimated "freedom of incisional hernia" curves (Kaplan-Meier estimate) were significantly different across study arms (χ = 19.5, P < 0.0001; Mantel-Cox test). No adverse effect related to mesh-augmented reinforcement was observed, apart from an increased mean time to close the abdominal wall for mesh-augmented reinforcement compared with the control group: 46 minutes (SD, 18.6) versus 30 minutes (SD, 18.5), respectively (P < 0.001; Mann-Whitney U test). Prophylactic retromuscular mesh-augmented reinforcement of a midline laparotomy in patients with abdominal aortic aneurysm is safe and effectively prevents the development of incisional hernia during 2 years, with an additional mean operative time of 16 minutes.

Active Staphylococcus aureus infection: Is it a contra-indication to the repair of complex hernias with synthetic mesh? A prospective observational study on the outcomes of synthetic mesh replacement, in patients with chronic mesh infection caused by Staphylococcus aureus

IntroductionThe management of chronic mesh infection is challenging and controversial. The use of synthetic material to repair the abdominal wall in the infected setting is not recommended, especially in the presence of active infection caused by Staphylococcus aureus. MethodsThis is a prospective observational study designed to evaluate the outcomes in patients with active mesh infection caused by Staphylococcus aureus. Patients underwent simultaneous removal and replacement of polypropylene mesh. The treatment protocol included the complete removal of infected mesh, followed by the anatomical reconstruction, and reinforcement of the abdominal wall using a new onlay polypropylene mesh. Early and late wound complications, medical complications, and hernia recurrences were analyzed. ResultsFrom 2006 until 2014, 22 patients with a mean age of 57.2 years and mean BMI of 29,3 kg/m2 were studied. Sinuses were present in 21 patients. A recurrent ventral hernia was observed in 14 patients; two patients required a complex abdominal wall reconstruction due to enteric fistulas. Bowel resections or other potentially contaminated procedures were associated in 10 patients. Fourteen patients (63.6%) had an uneventful postoperative course; 5 (22.7%) patients had wound infections requiring debridement and three required partial (2) or total (1) mesh removal. Two patients died due to medical complications. Adverse results on long-term follow-up included one hernia recurrence after complete mesh removal and one persistent sinus after partial mesh removal requiring a reoperation to remove mesh remnants. All of the patients were considered free of infection after a mean follow-up of 44 months. ConclusionsSynthetic mesh replacement in patients with active Staphylococcus aureus infection has an acceptable incidence of postoperative wound infection and prevents hernia recurrence. Large-pore polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

Reply to comment to Long-term outcomes (>5 years follow-up) with porcine acellular dermal matrix (Permacol) in incisional hernias at risk for infection: Negro P, D'Amore L, Ceci F, Gossetti F (DOI 10.1007/s10029-015-1406-1).

Negro and colleagues have responded to our prior report of the unsatisfactory results of the use of porcine acellular dermal matrix (PADM) in the ‘‘repair’’ of complicated ventral hernias. These authors suggest that placement of the PADM in the retromuscular, intramural plane resulted in better outcomes with a surprisingly low recurrence rate and a lesser infection rate; whereas, a bridging technique of repair was unsatisfactory as we reported. These authors raise an important point about the retromuscular plane; we suspect that the reasons for these differences are that this plane probably offers a much more vascularized environment and is possibly more resistant to development of a seroma which can serve as a source of infection. Their findings are similar to a recent report by Carbonell et al. [1] who reviewed about 100 patients with types 2 and 3 wounds who underwent a concomitant ventral hernia repair with retromuscular placement of a permanent light or medium weight, large pore polypropylene mesh; the results of Carbonell et al. were quite similar to those of Negro and colleagues. We would encourage Negro and associates to continue this work but ask them the following ‘‘would they thus suggest that all abdominal wall reconstructions amenable to a Rives–Stoppa retromuscular repair or a posterior components separation repair be performed with such a bioprosthesis rather than with a permanent prosthesis like polypropylene?’’

Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery.

To reduce the incidence of incisional hernia (IH) in colorectal surgery by implanting a mesh on the overlay position. The incidence of IH in colorectal surgery may be as high as 40%. IH causes severe health and cosmetic problems, and its repair increases health care costs. Randomized, controlled, prospective trial. Patients undergoing any colorectal procedure (both elective and emergency) through a midline laparotomy were divided into 2 groups. The abdomen was closed with an identical technique in both groups, except for the implantation of an overlay large-pore polypropylene mesh in the study group. Patients were followed up clinically and radiologically for 24 months. A total of 107 patients were included: 53 in the study group and 54 in the control group. Both groups were homogeneous, except for a higher incidence of diabetes in the mesh group. There were 20 emergency procedures in the study group and 17 in the control group. There were no statistical differences in surgical site infections, seromas, or mortality between the groups (33.3%, 13.8%, and 3.7% in the control group and 18.9%, 13.2%, and 3.8% in the study group). No mesh rejection was reported. The incidence of IH was 17 of 54 (31.5%) in the control group and 6 of 53 (11.3%) in the study group (P = 0.011). The incidence of IH is high in patients undergoing elective or emergency surgery for colorectal diseases. The addition of a prophylactic large-pore polypropylene mesh on the overlay position decreases the incidence of IH without adding morbidity.

The design of an industry-sponsored randomized controlled trial to compare synthetic mesh versus biologic mesh for inguinal hernia repair

Biologic prostheses are designed to support tissue regeneration rather than just result in a strong scar plate, as is the case with synthetic mesh. It is not known if these newer materials will result in earlier return to normal activities and/or less post-herniorrhaphy groin pain. METHOD/STUDY DESIGN: A prospective, randomized, controlled, third-party-blinded multicenter trial was designed to compare the use of a non-cross linked porcine dermis biologic graft [Strattice(TM) Reconstructive Tissue Matrix (RTM), LifeCell, Branchburg, NJ] versus light weight, large pore polypropylene mesh (UltraPro(TM), Ethicon, Somerville, NJ). The study design called for recruitment of 170 men. These men are being followed for a minimum of 2years. The primary aim of this study is to compare the safety and effectiveness of the two materials in a Lichtenstein inguinal hernia repair as measured by resumption of activities of daily living. Secondary outcomes include chronic pain, postoperative complications and the incidence of re-herniation at 12 and 24months. This paper discusses the study design, patient recruitment and the current status of the clinical trial. The study involves nine medical centers, all with extensive experience in hernia repair. After 24months of enrollment, 172 men were randomized and recruitment was then closed. All patients underwent elective repair of primary unilateral inguinal hernias as an outpatient operation. Follow up data are being collected. Data analyses are scheduled at 3, 12, and 24months postoperatively. We report the design of a multi-center, third-party blinded, randomized clinical trial comparing a new surgical device with existing technology in the repair of inguinal hernias. We believe this investigator-designed and conducted trial could serve as a model for similar trials examining surgical devices performed in collaboration with industry.

New technical approach for the repair of an abdominal wall defect after a transverse rectus abdominis myocutaneous flap: a case report

IntroductionBreast reconstruction with autologous tissue transfer is now a standard operation, but abnormalities of the abdominal wall contour represent a complication which has led surgeons to invent techniques to minimize the morbidity of the donor site.Case presentationWe report the case of a woman who had bilateral transverse rectus abdominis myocutaneous flap (TRAM-flap) breast reconstruction. The surgery led to the patient developing an enormous abdominal bulge that caused her disability in terms of abdominal wall and bowel function, pain and contour. In the absence of rectus muscle, the large defect was repaired using a combination of the abdominal wall component separation technique of Ramirez et al and additional mesh augmentation with a lightweight, large-pore polypropylene mesh (Ultrapro®).ConclusionThe procedure of Ramirez et al is helpful in achieving a tension-free closure of large defects in the anterior abdominal wall. The additional mesh augmentation allows reinforcement of the thinned lateral abdominal wall.

A lightweight, partially absorbable mesh (Ultrapro) for endoscopic hernia repair: experimental biocompatibility results obtained with a porcine model

A meticulous surgical technique, a mesh of adequate dimensions, and use of a mesh with good biocompatibility properties are decisively important for minimizing the development of recurrences after endoscopic hernia repair surgery. Mesh "shrinkage" is a function of the mesh's biocompatibility, that is, the properties of the mesh. Large-pore, lightweight polypropylene meshes possess the best biocompatibility, and the newly developed meshes meet these requirements. Using a totally extraperitoneal technique in an experimental animal model, 10 domestic pigs were implanted with a lightweight, large-pore polypropylene mesh containing an absorbable component consisting of poliglecaprone (Ultrapro). After a period of 91 days, diagnostic laparoscopy followed by explantation of the specimens for macroscopic, histologic, and immunohistochemical evaluation was performed. The mean mesh shrinkage was a mere 1.9%. The partial volume of the inflammatory cells was a low 15.8%. The markers of cell turnover, namely Ki67 and the apoptosis index, were, at 5.8 and 2.1, respectively, also very low. The extracellular matrix showed a low value of transforming growth factor-beta (TGF-beta) (50.8). The mean value of collagen 1 was 136.9. As a result of its good biocompatibility and elastic properties, the lightweight, large-pore Ultrapo mesh showed only a very slight tendency to "shrink." This renders it extremely well suited for clinical use in hernia repair surgery, and its minimal shrinkage characteristic should help in achieving low complication and recurrence rates.

Biomechanical analyses of overlap and mesh dislocation in an incisional hernia model in vitro

Incisional hernia repair is one of the most common surgical complications. Despite the introduction of mesh techniques of repair, recurrences are still prevalent. The aim of the current study was to evaluate the dependence of mesh dislocation on defect size, facial overlap, mesh-position, and orientation of the mesh in cases of anisotropic stretchability. An in vitro incisional hernia model was used, which consisted of a pressure chamber, an elastic silicone pad representing the peritoneal sac, and a silicone mat with bovine muscle tissue representing the abdominal wall. Intrinsic pressure (up to 200 mm Hg) was generated within the pressure chamber by continuous inflation with CO(2). A slit-like or flap-like defect was created in the silicone mat to simulate small or large hernia defects, respectively. The implanted mesh was arranged in both onlay and sublay configurations. A large pore polypropylene mesh with significant anisotropic stretchability was investigated, whereas overlaps of 2, 3, and 4 cm were applied. Despite the application of pressures up to 200 mm Hg, no mesh ruptures occurred. In the slit-like defect model, the minimal overlap required to prevent dislocation at 200 mm Hg was 3 cm using the sublay technique provided that the mesh was positioned with its most stretchable axis parallel to the largest slit dehiscence. Perpendicular rotation of the mesh resulted in dislocation at 160 mm Hg, despite using an overlap of 3 cm. Mesh reinforcement showed less stability in both the onlay position and the flap-like defect. An overlap of 3 cm is sufficient to prevent early mesh dislocation. Meshes with anisotropic stretchability should be orientated with the most stretchable axis in the direction of least overlap.