Permanent Mesh Research Articles

Prophylactic Resorbable Synthetic Mesh to Prevent Wound Dehiscence and Incisional Hernia in High High-risk Laparotomy: A Pilot Study of Using TIGR Matrix Mesh.

Wound dehiscence and incisional hernia are potentially serious complications following abdominal surgery, especially if performed through a midline incision. Although prophylactic reinforcement with on-lay mesh has been shown to reduce this risk, a permanent mesh carries the risk of seroma formation, infection, and persistent pain. The aim of this study was to assess the safety of a reabsorbable on-lay mesh to reinforce the midline suture in patients with high risk for wound dehiscence or incisional hernia. Sixteen patients with three or more risk factors for wound dehiscence or incisional hernia were included. A TIGR(®) Matrix mesh, composed of a mixture of 40% copolymer fibers of polyglycolide, polylactide, and polytrimethylene carbonate and 60% copolymer fibers of polylactide and polytrimethylene carbonate, was placed on the aponeurosis with an overlap of five on either side and fixated with continuous monofilament polydioxanone suture. All postoperative complications were registered at clinical follow-up. Mean follow-up was 9 months. One patient developed a seroma that needed drainage and antibiotic treatment. One patient had a wound infection that needed antibiotic treatment. There was no complication requiring a reoperation. No wound dehiscence or incisional hernia was seen. On-lay placement of TIGR(®) Matrix is safe and may provide a feasible way of reinforcing the suture line in patients with high risk for postoperative wound dehiscence or incisional hernia. Larger samples are required, however, if one is to draw any conclusion regarding the safety and effectiveness of this technique.

Repeat operations a major problem when using permanent mesh to treat vaginal prolapse

Repeat operations a major problem when using permanent mesh to treat vaginal prolapse

Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.

Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.

How to Surgically Remove the Permanent Mesh Ring after the Onstep Procedure for Alleviation of Chronic Pain following Inguinal Hernia Repair.

A promising open inguinal hernia operation called Onstep was developed in 2005. The technique is without sutures to the surrounding tissue, causing minimal tension. A specific mesh is used with a memory recoil ring in the border, which may cause pain superficial to the lateral part of the mesh for slender patients. The aim of this study was to illustrate an easy procedure that alleviates/removes the pain. A male patient had persistent pain six months after the Onstep operation and therefore had a ring removal operation. The procedure is presented as a video and a protocol. At the eleven-month follow-up, the patient was free of pain, without a recurrence. It is advised to wait some months after the initial hernia repair before removing the ring, since the mesh needs time to become well integrated into the surrounding tissue. The operation is safe and easy to perform, which is demonstrated in a video.

Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review.

Open abdomen (OA) has been an effective treatment for abdominal catastrophes in traumatic and general surgery. However, management of patients with OA remains a formidable task for surgeons. The central goal of OA is closure of fascial defect as early as is clinically feasible without precipitating abdominal compartment syndrome. Historically, techniques such as packing, mesh, and vacuum-assisted closure have been developed to assist temporary abdominal closure, and techniques such as components separation, mesh-mediated traction, bridging fascial defect with permanent synthetic mesh, or biologic mesh have also been attempted to achieve early primary fascial closure, either alone or in combined use. The objective of this review is to present the challenges of these techniques for OA with a goal of early primary fascial closure, when the patient's physiological condition allows.

Synthetic surgical meshes used in abdominal wall surgery: Part I-materials and structural conformation.

Surgical implants are commonly used in abdominal wall surgery for hernia repair. Many different prostheses are currently offered to surgeons, comprising permanent synthetic polymer meshes and biologic scaffolds. There is a wide range of synthetic meshes currently available on the market with differing chemical compositions, fiber conformations, and mesh textures. These chemical and structural characteristics determine a specific biochemical and mechanical behavior and play a crucial role in guaranteeing a successful post-operative outcome. Although an increasing number of studies report on the structural and mechanical properties of synthetic surgical meshes, nowadays there are no consistent guidelines for the evaluation of mechanical biocompatibility or common criteria for the selection of prostheses. The aim of this work is to review synthetic meshes by considering the extensive bibliography documentation of their use in abdominal wall surgery, taking into account their material and structural properties, in Part I, and their mechanical behavior, in Part II. The main materials available for the manufacture of polymeric meshes are described, including references to their chemical composition, fiber conformation, and textile structural properties. These characteristics are decisive for the evaluation of mesh-tissue interaction process, including foreign body response, mesh encapsulation, infection, and adhesion formation. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 689-699, 2017.

Massive Aortic Pseudoaneursym and Hemoptysis Following Delayed Migration of Methylmethacrylate for Chest Wall Reconstruction

INTRODUCTION: Chest wall defects greater than five centimeters generally require skeletal reconstruction to prevent flail physiology.1, 2 Autologous bone and fascia lata have been replaced with rigid prosthetics such as the methylmethacrylate mesh “sandwich.” This permanent, rigid framework can be contoured to any defect and avoids donor site morbidity. It is more malleable than metal hardware and obviates need of metal fixation that can erode into tissues or fracture ribs. Furthermore, it is radiolucent and easily seen on imaging. We report the first case of delayed methylmethacrylate migration causing significant cardiopulmonary injury and discuss post-operative management considerations. MATERIALS AND METHODS: A 58-year-old woman with a 15-centimeter left posterior chest wall mass underwent posteriolateral thoracotomy with elevation of a latissimus dorsi flap. The underlying mass was resected en bloc with ribs 5-9 and scapula tip. A sandwich of outer Vicryl mesh and inner methylmethacrylate was contoured to the chest wall and affixed with bilayer mesh to the thoracic wall. The muscle flap and overlying tissues were inset over the defect. RESULTS: Pathology revealed a benign spindle cell tumor. The patient had an uncomplicated recovery until fourteen months post-operatively, when she developed new chest pain following back massage. CT scan revealed minor plate migration, which was stable on four serial follow-up images. Two years later, she presented with sudden hemoptysis. Computed tomography revealed further plate migration, a massive descending aortic pseudoaneurysm, and aortic branch fistulization with pulmonary vasculature (Figures 1, 2). An endovascular aortic stent was placed emergently, and her hemoptysis resolved. She later underwent elective methylmethacrylate removal. She is doing well greater than 3 months postoperatively.Figure 1: Three dimensional sagittal view showing large bony defect including resected scapula (thin arrow). The methymethacrylate plate in yellow and surrounding hematoma (not shown) displace aorta anteriorly, while plate erosion caudally result in pseudoaneurysm (thick arrow) posterior to plate.Figure 2: Axial image showing pseudoaneursym (thick arrow) posterior to plate and contrast blush of aorto-pulmonic branch fistulization (thin arrow).CONCLUSION: Published complications with methylmethacrylate reconstruction relate to possible increased infection rate compared with autologous grafts or mesh alone.3 Only one series reported plate migration in two patients, which occurred immediately post-operatively.4 This first reported case of delayed migration highlights the consideration of permanent mesh fixation and long-term patient follow-up. If migration is noted, early operative repair may prevent erosion into vital intra-thoracic structures. Endovascular intervention when indicated averts the need for emergent chest wall reconstruction.

The development of SERI® Surgical Scaffold, an engineered biological scaffold.

The primary goal of reconstructive and revision surgery is to restore, repair, rebuild, and support damaged, weakened, or absent tissue. There are numerous approaches for soft tissue support and repair, including the use of autologous tissue, human- or animal-derived acellular dermal matrices, absorbable or permanent synthetic mesh, and, now, a new class of bioresorbable protein scaffold. Although many factors influence the choice of surgical approach and the specific product used for soft tissue support and repair, the goal is to improve long-term outcomes while minimizing complications and recurrences requiring further revisional surgery. In this review, the basic science, clinical characteristics, and clinical applications of SERI(®) Surgical Scaffold, a novel, engineered, highly purified silk product for soft tissue support and repair will be presented.

Can titanium mesh influence local recurrence management after implant-based breast reconstruction?

IntroductionTiLOOP® Bra is a permanent titanium-coated polypropylene mesh currently used in post-mastectomy breast reconstruction with implants. This mesh is generally presented as inducing low-grade inflammatory reactions, but only few reports focused on its possible side effects. In the case described here, the use of the mesh led to minor clinical problems that needed to be clinically and surgically managed at the same time as a local relapse.Case descriptionA patient with high-grade ductal carcinoma in situ underwent primary surgery (nipple-sparing mastectomy and one-stage reconstruction using the TiLOOP® Bra mesh) and was subsequently referred for radiological and clinical investigation when various nodules became apparent during a follow-up physical examination. Prior to the histopathological proof, the diagnosis of local recurrence was complicated by the occurrence of an extensive granulomatous reaction in the fixation areas along with mild inflammatory changes scattered on the surface of the mesh.Discussion and evaluationThis case illustrates a side effect of titanium-coated permanent mesh in immediate implant-based reconstruction, i.e. the formation of granulomas in the inframammary fold, probably in the area where the mesh had been folded or fixed. We propose a safer technical approach to avoid the problem and a clinical management strategy for patients at high risk of local recurrence who develop granuloma-like nodules.ConclusionsA surgical technique is suggested to prevent granuloma formation. If, however, subcutaneous nodules that may be local recurrences do appear, they should not be interpreted by default as a granulomatous reaction, but should be fully investigated and possibly excised.

Muscle fragments on a scaffold in rats: a potential regenerative strategy in urogynecology.

The use of permanent synthetic meshes to improve the outcome of pelvic organ prolapse (POP) repair causes frequent and serious complications. The use of the synthetic, biodegradable scaffold methoxypolyethyleneglycol-polylactic-co-glycolic acid (MPEG-PLGA) seeded with autologous muscle fiber fragments (MFF), as an adjunct to native tissue POP repair, is a potential new alternative. A rat abdominal wall model of native repair was used with six animals in each of three groups: native repair, native repair + MPEG-PLGA, and native repair + MPEG-PLGA + MFF. MFF were labeled with PKH26-fluorescence dye. After 8weeks labeled cells were identified in tissue samples and histopathological and immunohistochemical analyses of connective tissue organization and desmin reactivity of muscle cells were performed. Fresh tissue samples were subjected to uniaxial biomechanical testing. Statistical analyses were performed using one-way analysis of variance (ANOVA). MPEG-PLGA was fully degraded after 8weeks. Desmin-immunopositive (6/6) and PKH26-positive cells (6/6) were found only after native repair + MPEG-PLGA + MFF, indicating survival, proliferation, and integration of cells originating from the MFF. This group also showed significantly increased stiffness in the high stiffness zone compared with native repair + MPEG-PLGA (p = 0.032) and borderline significantly higher stiffness compared to native repair (p = 0.054). In this pilot study, MPEG-PLGA scaffolds seeded with autologous MFF affected some histological and biomechanical properties of native tissue repair in an abdominal wall defect model in rats. The method thus appears to be a simple tissue engineering concept with potential relevance for native tissue repair of POP.

Early Application of Permanent Metallic Mesh Stent in Substitution for Temporary Polymeric Ureteral Stent Reduces Unnecessary Ureteral Procedures in Patients With Malignant Ureteral Obstruction

To identify risk factors for metal stent failure in patients who received polymeric double J (PDJ) ureteral stents for malignant ureteral obstructions (MUOs) and review our clinical experiences using a ureteral metallic stent. Patients who underwent metallic stent placement to replace a double J ureteral stent for nonurological MUO between January 2011 and February 2014 were included. The collected data included gender, age, laterality, cause of obstruction, PDJ ureteral stenting duration, immediate success of the metal stent, and additional procedures to relieve obstruction after metal stenting (eg, additional metal stenting or percutaneous nephrostomy (PCN) indwelling catheter placement). Cox regression tests were used for the statistical analyses. In this analysis 40 ureteral units were included. There was no initial technical failure. However, 9 (22.5%) units required additional procedures due to de novo ureteral obstruction, including additional indwelling metal stents (7.5%), additional PDJ stenting (10%), or indwelling percutaneous nephrostomy (5%). Univariate and multivariate analyses revealed that the duration of previous PDJ ureteral stenting was an independent prognostic factor for predicting ureteral metal stent failure (hazard ratio = 1.063, 95% confidence interval = 1.004-1.125; P = .037). Long-term indwelling of a PDJ ureteral stent increases the risk of additional management for de novo ureteral stricture after ureteral metal stent replacement for nonurological MUO. Our data suggest that careful patient selection and counseling for those at high risk are needed when metal stent replacement is considered for patients with long-term PDJ ureteral stents for MUO.

Emerging Trends in Abdominal Wall Reinforcement: Bringing Bio-Functionality to Meshes.

Abdominal wall hernia is a recurrent issue world-wide and requires the implantation of over 1 million meshes per year. Because permanent meshes such as polypropylene and polyester are not free of complications after implantation, many mesh modifications and new functionalities have been investigated over the last decade. Indeed, mesh optimization is the focus of intense development and the biomaterials utilized are now envisioned as being bioactive substrates that trigger various physiological processes in order to prevent complications and to promote tissue integration. In this context, it is of paramount interest to review the most relevant bio-functionalities being brought to new meshes and to open new avenues for the innovative development of the next generation of meshes with enhanced properties for functional abdominal wall hernia repair.

Early- Versus Late-Onset Prosthetic Mesh Infection: More than Time Alone.

Prosthetic mesh used for ventral incisional hernia makes hernia repair surgery simple, effective, and safe. The mesh infection is a formidable complication and bimodal distribution. The differences between early- and late-onset are unknown. This is a cohort study of patients undergoing ventral incisional hernia (VIH) repair from January 2003 to September 2013. Data of specific risk variables were collected from electronic medical record systems in Jinling Hospital. And, the quality of lives was evaluated by WHO Quality of Life-BREF. A total of 102 VIH repair patients were analyzed and followed including the noninfection group and early- and late-onset group. There were significant differences between the early- and late-onset group in clinical manifestation, descriptive analysis of the study population, and postoperative quality of lives. These differences might imply the different pathophysiologic process of early- and late-onset mesh infection. Permanent prosthetic mesh should be used with caution, and the study of intraperitoneal onlay mesh is still needed in long-term follow-up.

Use of Acellular Dermal Matrix Combined with a Component Separation Technique for Repair of Contaminated Large Ventral Hernias: A Possible Ideal Solution for this Clinical Challenge

Repair of large contaminated ventral hernias is always challenging because of massive loss of muscular and fascial tissues, high risk of surgical infection and recurrence, and contraindication to use of a permanent prosthesis. This study reviewed retrospectively data of 35 patients with contaminated large ventral hernias who received repair using acellular dermal matrix combined with a component separation technique from 2009 to 2011. Twenty-one males and 14 females were identified with a mean age of 45.5 ± 12.5 years and a mean body mass index of 22.5 ± 5.8 kg/m(2). Simultaneously, nine patients underwent bowel fistula resection, 13 patients underwent ostomy takedown, five patients underwent recurrent colon cancer dissection, and eight patients underwent infectious permanent mesh removal and wound débridement. Mean defect size was 125.0 ± 23.5 cm(2). The aponeurosis of the external oblique muscle was transected and separated from internal oblique muscle to reach abdominal closure. Acellular dermal matrix was placed in an onlay fashion and mean mesh size was 300.0 ± 65.0 cm(2). Thirty-five patients had a mean follow-up period of 36.5 ± 12.5 months. Wound bleeding and partial dehiscence occurred at 36 hours postoperatively. Five patients reported abdominal wall pain during the first postoperative month. Five patients developed surgical site infection. Four patients were detected to develop seroma with volume more than 20 mL by B-ultrasound examination. No recurrence and chronic foreign body sensation were followed up. Use of acellular dermal matrix combined with a component separation technique is safe and efficient management for repair of contaminated large ventral hernia, in which permanent prosthesis placement is contraindicated.

Case-matched series of a non-cross-linked biologic versus non-absorbable mesh in laparoscopic ventral rectopexy

Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh. Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh. Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group. LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.

Properties of meshes used in hernia repair: a comprehensive review of synthetic and biologic meshes.

Data on the mechanical properties of the adult human abdominal wall have been difficult to obtain rendering manufacture of the ideal mesh for ventral hernia repair a challenge. An ideal mesh would need to exhibit greater biomechanical strength and elasticity than that of the abdominal wall. The aim of this study is to quantitatively compare the biomechanical properties of the most commonly used synthetic and biologic meshes in ventral hernia repair and presents a comprehensive literature review. A narrative review of the literature was performed using the PubMed database spanning articles from 1982 to 2012 including a review of company Web sites to identify all available information relating to the biomechanical properties of various synthetic and biologic meshes used in ventral hernia repair. There exist differences in the mechanical properties and the chemical nature of different meshes. In general, most synthetic materials have greater stiffness and elasticity than what is required for abdominal wall reconstruction; however, each exhibits unique properties that may be beneficial for clinical use. On the contrary, biologic meshes are more elastic but less stiff and with a lower tensile strength than their synthetic counterparts. The current standard of practice for the treatment of ventral hernias is the use of permanent synthetic mesh material. Recently, biologic meshes have become more frequently used. Most meshes exhibit biomechanical properties over the known abdominal wall thresholds. Augmenting strength requires increasing amounts of material contributing to more stiffness and foreign body reaction, which is not necessarily an advantage.

Synchronous Ventral Hernia Repair in Bariatric Patients

Dear Editor, We note with interest the article of Eid et al. [1] and correspondence in the journal recently on the topic issue of timing of ventral hernia in bariatric patients. We note that this correspondence recommends a range of options in managing these patients but provides little evidence to back up these recommendations. While the issue of ventral hernia is obviously complex, we are concerned that recommending non-standard treatments may lead to outcomes that expose patients to increased risks and repeated surgical procedures. The use of suture and absorbable mesh repairs have been shown to have high recurrence rates, and leaving hernias untreated will expose patients to the certain requirement for later surgery and the risks of small bowel obstruction associated with their rapid weight loss. With this consideration, we consider all patients undergoing bariatric procedures with ventral hernias as candidates for synchronous repair, unless they had massive abdominal wall defects or cutaneous redundancy, in which case they are usually offered sleeve gastrectomy followed by delayed abdominal wall reconstruction. This number is small. We have attempted to answer the question of whether patients having bariatric surgery can have simultaneous ventral hernia repair if it is felt that the defect is amenable to laparoscopic repair by studying our outcomes [2]. In our series of 45 patients undergoing synchronous bariatric surgery and ventral hernia repair, the results were similar to those of laparoscopic repair alone. Two patients developed infected seromas that responded to simple drainage, and there have been no mesh removals or clinical hernia recurrence to date. This fits with the results of a Cochrane review comparing open and laparoscopic techniques concluding that laparoscopic hernia repair infection rates were 3.14 % (range 0–6.06 %) [3]. While valid concerns exist about the potential complication rate of using permanent mesh in patients having bariatric surgery, the rate of complications appear reassuringly low. Surgeons can be comfortable making decisions based on data, and in this situation, these data suggest that patients presenting for bariatric surgery with concomitant hernia can be offered standard treatment with the expectation of standard outcomes. The outcomes of non-standardised techniques such as suture repair or using biologics are poorly known, and since these repairs are either more likely to fail or are more complex than usual laparoscopic repair methods, they are hard to recommend in the face of established safe and effective techniques. In the future, a multicentre study may be able to provide sufficient numbers for a case-control or randomised trial, but until this occurs, clinicians must incorporate current evidence through available case-series, experience and extrapolation from published trials of established techniques.

Permanent mesh results in long-term symptom improvement and patient satisfaction without increasing adverse outcomes in hiatal hernia repair

BackgroundThe purpose of this study is to evaluate symptom relief, patient satisfaction, and safety of permanent mesh following Nissen fundoplication and hiatal hernia repair. MethodsPatients who underwent Nissen fundoplication and hiatal hernia repair with permanent mesh (Crurasoft; Davol, Inc, Bard, Warwick, RI) between 2005 and 2011 were identified. A retrospective chart review was conducted. Long-term follow-up data were obtained via telephone interviews using a modified 5-point Likert scale. ResultsForty-one patients were identified. Twenty-six patients (63%) had complete follow-up data. Mean follow-up period was 65 months (14 to 96 months). Symptomatic improvement occurred in 23 patients (88%). Twenty-three patients (88%) reported overall satisfaction with the procedure as either excellent or good, and 23 of 26 patients (89%) would undergo surgery again. Three patients (12%) reported hernia recurrence. There were no mesh erosions. ConclusionThe use of permanent (Crurasoft; Davol, Inc) mesh resulted in symptom improvement as well as patient satisfaction, and no mesh erosions were seen.

Adverse Events Associated With Pelvic Organ Prolapse Surgeries That Use Implants

To estimate the rate of vaginal implant exposure associated with biologic grafts and permanent mesh used for pelvic organ prolapse (POP) surgery, to describe treatments used for these complications, and to estimate response rates to these treatments. The secondary aims were to describe the operative and perioperative complications. This was a retrospective analysis of female members of Kaiser Permanente Southern and Northern California and Hawaii who underwent POP surgeries with biologic grafts and permanent mesh between September 2008 and May 2010. Inpatient and outpatient electronic medical records were reviewed for postoperative adverse events. During the 21-month period, 1,282 women, mean age of 62 years (±10 standard deviation), median parity of 3 (interquartile range 2-4), and median body mass index of 28 (interquartile range 24-30) underwent prolapse repairs with 1,484 implants with a mean follow-up time of 358 days (±276 standard deviation). Vaginal exposures occurred more often with permanent mesh (53/847 [6%]) than biologic grafts (10/637 [1.6%]) (P<.001). Resolution of vaginal exposure after the first treatment occurred in 24 of 63 (38%), whereas 39 of 63 (62%) required multiple treatments. Surgical excision was performed in 20 of 63 (32%) exposures. Permanent mesh exposures were more likely to require surgical excision (20/53 [38%]) than biologic graft exposures (zero of 10) (P=.02). Vaginal exposure occurred more frequently with permanent mesh than biologic graft, may require multiple treatments, and occasionally require surgical excision. : II.

A multicenter prospective observational cohort study of permanent synthetic mesh versus biologic mesh reinforcement for open ventral hernia repair in clean-contaminated and contaminated surgical sites

A multicenter prospective observational cohort study of permanent synthetic mesh versus biologic mesh reinforcement for open ventral hernia repair in clean-contaminated and contaminated surgical sites