Experimental study of the characteristics of a novel mesh suture

Three-dimensional reconstruction under computed tomography and myopectineal orifice measurement under laparoscopy for quality control of inguinal hernia treatment

BACKGROUND

Inguinal hernias are common after surgery. Tension-free repair is widely accepted as the main method for managing inguinal hernias. Adequate exposure, coverage, and repair of the myopectineal orifice (MPO) are necessary. However, due to differences in race and sex, people's body shapes vary. According to European guidelines, the patch should measure 10 cm × 15 cm. If any part of the MPO is dissected, injury to the nerves, vascular network, or organs may occur during surgery, thereby leading to inguinal discomfort, pain, and seroma formation after surgery. Therefore, accurate localization and measurement of the boundary of the MPO are crucial for selecting the optimal patch for inguinal hernia repair.

AIM

To compare the size of the MPO measured on three-dimensional multislice spiral computed tomography (CT) with that measured via laparoscopy and explore the relevant factors influencing the size of the MPO.

METHODS

Clinical data from 74 patients who underwent laparoscopic tension-free inguinal hernia repair at the General Surgery Department of the First Affiliated Hospital of Anhui University of Science and Technology between September 2022 and July 2024 were collected and analyzed retrospectively. Transabdominal preperitoneal was performed. Sixty-four males and 10 females, with an average age of 58.30 ± 12.32 years, were included. The clinical data of the patients were collected. The boundary of the MPO was measured on three-dimensional CT images before surgery and then again during transabdominal preperitoneal. All the preoperative and intraoperative data were analyzed via paired t-tests. A t-test was used for comparisons of age, body mass index, and sex between the groups. In the comparative analysis, a P value less than 0.05 indicated a significant difference.

RESULTS

The boundaries of the MPO on 3-dimensional CT images measured 7.05 ± 0.47 cm and 6.27 ± 0.61 cm, and the area of the MPO was 19.54 ± 3.33 cm2. The boundaries of the MPO during surgery were 7.18 ± 0.51 cm and 6.17 ± 0.40 cm. The errors were not statistically significant. However, the intraoperative BD (the width of the MPO, P = 0.024, P < 0.05) and preoperative AC (the length of the MPO, P = 0.045, P < 0.05) significantly differed according to sex. The AC and BD measurements before and during surgery were not significantly different according to age, body mass index, hernia side or hernia type (P > 0.05).

CONCLUSION

The application of this technology can aid in determining the most appropriate dissection range and patch size.

Short-term outcomes of mesh-suture repair in the treatment of ventral hernias: a single-center study

BACKGROUND

Defect closure with mesh suture is a novel technique for hernia repair. Originally described as the construction of lightweight macroporous polypropylene mesh strips as a suture material, it is now available as an FDA-approved product. Mesh suture better distributes tensile forces and reduces fascial tearing compared to traditional suture but requires less implanted material and tissue dissection compared to planar mesh. Limited studies have demonstrated mesh suture's effectiveness in short-term recurrence rates. This study describes the short-term outcomes of our initial experience with mesh-suture-based herniorrhaphy.

METHODS

This study is an IRB-approved, single-center, retrospective review of surgeon case logs from May 2023 to February 2024. All patients who had undergone hernia repair utilizing mesh suture (Duramesh, Mesh Suture Inc, Chicago, IL) as the method of repair at our medical center were enrolled. A descriptive analysis regarding patient and hernia characteristics was performed and short-term outcomes were analyzed.

RESULTS

We identified 63 patients (Mean age 61, Mean BMI 31.0 kg/m2, 60% female) who had undergone mesh-suture repair since its availability at our institution. Hernias included 31.7% primary, 27.0% incisional, 34.9% parastomal, and 6.4% other. Of these, 8 (12.7%) were recurrent hernia repairs. The average defect size was 41.0 cm2, with a range from 0.25 to 459 cm2. Average length of stay was 3.2 days, with a range of 0 to 20. Eleven patients (17.5%) were readmitted in the 90-day postoperative period. With an average follow-up of 45 days, there were ten surgical site occurrences (including four surgical site infections) and three recurrences (4.8%).

CONCLUSIONS

Our initial experience with mesh-suture herniorrhaphy has demonstrated acceptable short-term rates of surgical site occurrences and recurrences. This provides additional support for its use, particularly in patients where a planar mesh-based repair might traditionally be avoided. Further studies of mesh-suture herniorrhaphy long-term recurrence rates and cost-effectiveness are needed.

[Mesh suture in the treatment of diaphragmatic hernias]

The paper studies the results of surgical treatment of the first 25 patients with diaphragmatic hernias who underwent laparoscopic surgeries for hiatal hernias using polypropylene mesh sutures using the proprietary method.

MATERIAL AND METHODS

Polypropylene mesh strips were used instead of traditional sutures to seal the crura of the diaphragm in 25 patients. The intervention technique and treatment outcomes are described. The study included 25 patients, 5 males and 20 females, operated on between 2019 and 2024 with a diagnosis of hiatal hernia (HH), aged 38 to 79 years.

RESULTS

The mean surgery duration was 83.4 minutes (50 to 120 minutes), and intraoperative and postoperative complications were not observed. The mean hospital stay was 1.5 days (1 to 4 days). Four patients (16%) had a recurrence of hernia diagnosed using imaging studies, but there were no clinically significant recurrences in all 25 patients. Twenty (80%) patients permanently discontinued proton pump inhibitors (PPIs), and 2 (8%) significantly reduced their dose. Eighteen (72%) patients had complete resolution of their HH-related symptoms; in 4 (16%) patients, these symptoms significantly reduced. All patients were satisfied with the treatment outcomes.

CONCLUSIONS

The use of mesh sutures to seal the crura of the diaphragm supports the concept of pressure distribution and muscle resistance to incision, which is often seen with traditional suture material. In addition, the mesh material stimulates scar tissue growth through the pores of the prosthesis, strengthening the suture line.

Anatomical consideration and techniques in thread nose augmentation with mesh scaffold implant

INTRODUCTION

Non-surgical rhinoplasty has evolved with the introduction of volumizing threads, which offer a less invasive alternative to traditional methods by enhancing nasal contours while minimizing filler use. This technique is gaining popularity, particularly in Southeast Asia, due to its shorter recovery time, reduced risk profile, and ability to prevent the 'Avatar nose' effect. However, there is limited anatomical guidance available for its application, especially in the Asian population.

MATERIALS AND METHODS

This study analyzes the anatomical layers of the nose to guide the proper placement of volumizing threads. Three cases are presented, highlighting different approaches to nasal bridge enhancement, nasal tip augmentation, and combined use of threads and fillers. The placement of threads in the deep fat layer beneath the fibromuscular layer was emphasized to avoid vascular complications.

RESULTS

The cases demonstrated with mesh thread (Tess Inc., Korea) successful outcomes with well-defined nasal contours and patient satisfaction. The techniques used allowed for precise enhancements while minimizing risks associated with superficial thread placement and vascular injury.

CONCLUSION

Volumizing threads provide an effective and safe method for non-surgical rhinoplasty, particularly when informed by a thorough understanding of nasal anatomy. The results support the growing use of this technique in esthetic practice, especially in regions like Southeast Asia.

Early Experience with Mesh Suture for DIEP Flap Abdominal Site Closures

Background

The gold standard of microsurgical breast reconstruction is the deep inferior epigastric perforator (DIEP) free flap. As techniques have evolved, DIEP flaps have significantly reduced the morbidity previously caused by transverse rectus abdominis muscle (TRAM) and muscle-sparing TRAM flaps. However, abdominal wall complications continue to persist after DIEP flap surgery, with bulge rates reported as high as 33%.

Methods

The first 25 patients undergoing DIEP flap surgery with the use of Duramesh (MSI, Chicago, Ill.) by the senior author were identified. A retrospective chart review of patient and surgical details was performed. Charts were reviewed for outcomes, including surgical site infections, surgical site events, incisional hernia formation, and/or bulge. Standard descriptive summary statistics were used for patient characteristics, surgical details, and primary and secondary outcomes.

Results

Twenty-five patients were reviewed. Average follow-up duration was 216 ± 39 days. One patient (4%) developed a surgical site infection, and four patients (16%) developed a surgical site event. One patient developed a bulge, but no patients developed an incisional hernia.

Conclusions

Duramesh mesh suture provides a promising opportunity for DIEP surgeons to minimize both abdominal wall morbidity and mesh-related complications. Mesh suture can be used in a similar fashion as other sutures to perform primary closure of the anterior rectus sheath while also providing force-distribution benefits typically unique to planar mesh. This pilot study suggests that Duramesh is a safe, simple alternative to existing techniques in DIEP flap surgery and can be considered by microsurgeons to reduce fascial dehiscence, bulge, and/or hernia formation.

Polyurethane-based three-dimensional printing for biological mesh carriers

Repair and reconstruction of the myopectineal orifice area using meshes is the mainstay of surgical treatment of inguinal hernias. However, the limitations of existing meshes are becoming increasingly evident in clinical applications; thus, the idea of using three-dimensionally (3D)-printed biological meshes was put forward. According to the current level of the 3D printing technology and the inherent characteristics of biological materials, the direct use of the 3D printing technology for making biological materials into finished products suitable for clinical applications is not yet supported, but synthetic materials can be first printed into 3D form carriers, compounded with biological materials, and finally made into finished products. The purpose of this study was to develop a technical protocol for making 3D-printed biomesh carriers using polyurethane as a raw material. In our study: raw material, polyurethane; weight, 20-30 g/m2; weaving method, hexagonal mesh; elastic tension aspect ratio, 2:1; diameters of pores, 0.1-1 mm; surface area, 8 × 12 cm2; the optimal printing layer height, temperature and velocity were 0.1 mm, 210-220 °C and 60 mm/s. Its clinical significance lies in: (1) applied to preoperative planning and design a detailed surgical plan; (2) applied to special types of surgery including patients in puberty, recurrent and compound inguinal hernias; (3) significantly improve the efficiency of doctor-patient communication; (4) it can shorten the operation and recovery period by about 1/3 and can save about 1/4 of the cost for patients; (5) the learning curve is significantly shortened, which is conducive to the cultivation of reserve talents.

Correction of Rectus Abdominis Diastasis: A Prospective Comparative Study Between a New Suturable Polypropylene Mesh vs Polypropylene Standard Suture Plication

BACKGROUND

Duramesh (Mesh Suture Inc., Chicago, IL) is a new suturing concept, combining the principles of mesh with the precision, flexibility, and versatility of a suture, suitable also for abdominal rectus diastasis (ARD) correction.

OBJECTIVES

This prospective research aimed to compare mesh with the standard polypropylene suture plication for rectus diastasis repair with regard to safety (infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay); effectiveness (ARD recurrence by ultrasound sonography, palpability of the muscular suture, surgical time, and postoperative pain evaluation); and satisfaction of the patients based on the BODY-Q, a patient-reported outcome measure.

METHODS

Sixty-five of the initial 70 patients who underwent rectus diastasis repair with a 6-month follow-up were randomly divided into 2 groups, comprising 33 patients treated with Duramesh and 32 patients treated with standard 0 polypropylene suture plication. Data regarding infection, seroma, hematoma, surgical wound dehiscence, and fistula rates; hospital stay; ARD recurrence; palpability of the muscular suture; surgical time; postoperative pain evaluation (measured by visual analog scale, or VAS); and the BODY-Q were analyzed by Prism 9 (GraphPad Software Inc., San Diego, CA).

RESULTS

No significant differences were reported between the 2 groups with regard to infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay. The mesh decreased the time required to perform plication compared with standard polypropylene detached sutures. No statistically significant differences were found with respect to the VAS and BODY-Q data.

CONCLUSIONS

Duramesh 0 application for rectus diastasis repair is safe and effective without compromising aesthetic improvement when compared with standard 0 polypropylene plication.

LEVEL OF EVIDENCE: 2

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

Mesh Strip Repair for Midline Ventral Hernias: A Case Series

Background

Polypropylene mesh strip repair is a novel method of hernia closure. Currently, there is limited representation in the literature regarding both the reproducibility of this method and its outcomes. The present study sought to analyze a second institution's experience with fascial closure using the mesh strip technique with long-term follow-up.

Methods

A retrospective review of all patients undergoing abdominal wall reconstruction by the senior author was performed. Patients undergoing midline ventral hernia repair with mesh strip only fascial closure and greater than 1 year follow-up were including for analysis. Demographic data; operative details; and outcomes, specifically presence and timing of hernia recurrence, were recorded.

Results

Eighteen patients met inclusion criteria. Average follow-up was 860 ± 307 days. Nine patients (50%) had recurrence of their hernia after repair. Average time to recurrence was 602 ± 406 days, with the earliest recurrence occurring at 126 days postoperatively. Seven patients (39%) underwent concurrent anterior component separation (four unilateral, three bilateral), of which there were three recurrences, all occurring in patients with bilateral anterior component separation.

Conclusions

The mesh strip repair is a novel technique that shows uncertain reproducibility of outcomes, specifically with concurrent component separation techniques. With the recent Food and Drug Administration approval of a mesh suture, further multi-institutional analysis will allow for better characterization of the outcomes and indications for this technique.

Duramesh registry study: short-term outcomes using mesh suture for abdominal wall closure

Introduction

Sutures are flexible linear elements that join tissue and maintain their hold with a surgeon-created knot. Tension at the suture/tissue interface can cut the very tissues that sutures are designed to hold, leading to dehiscence and incisional hernia formation. A new suture design (Duramesh, Mesh Suture Inc., Chicago, IL) was approved for marketing by the United States Food and Drug Administration in September 2022. The multiple filaments of the mesh suture are designed to diffuse tension at the suture/tissue interface thereby limiting pull-through. The macroporosity and hollow core of the mesh suture encourage fibrovascular incorporation for a durable repair. We created the first registry and clinical report of patients undergoing mesh suture implantation to assess its real-world effectiveness.

Methods

A patient registry was created based on institutional implant logs from January to August 2023 at an integrated health-care system. Operative reports were reviewed by the study team to verify use of "Duramesh" by dictation. Retrospective chart review was conducted to evaluate patient and surgical characteristics, follow-up, and short-term outcomes of interest. Results were analyzed using descriptive statistics and Chi-squared analysis with Microsoft Excel and GraphPad Prism.

Results

Three hundred seventy-nine separate implantations by 56 surgeons across 12 (sub) specialties at a university hospital and two community hospitals were performed. Mesh suture was used for treatment of the abdominal wall in 314 cases. Follow-up averaged 80.8 ± 52.4 days. The most common abdominal wall indications were ventral hernia repair (N = 97), fascial closure (N = 93), abdominal donor site closure from autologous breast reconstruction (N = 51), and umbilical hernia repair (N = 41). Mesh suture was used in all Centers for Disease Control (CDC) wound classifications, including 92 CDC class 2 or 3 abdominal operations. There were 19 surgical site infections (6.1%) and 37 surgical site events (11.8%).

Conclusions

Short-term registry data demonstrates the wide diversity of surgical disciplines and scenarios in which mesh suture has been used to date. The early adoption of mesh suture into practice highlights that consequences of suture pull-through influence operative decision making. As this is the first interim report of the Duramesh mesh suture registry, follow-up is too short for characterization of long-term durability of abdominal wall closures.

An obstetrician-gynecologist's review of hernias: risk factors, diagnosis, prevention, and repair

Management of obstetrical and gynecologic patients with hernias poses challenges to providers. Risks for hernia development include well-described factors that impair surgical wound healing and increase abdominal pressure. Among the diverse populations cared for by obstetricians and gynecologists, pregnant patients and those with gynecologic malignancies are at the highest risk for hernia formation. This article provides an overview of the existing literature, with a focus on patients cared for by obstetrician-gynecologists and commonly encountered preoperative and intraoperative scenarios. We highlight scenarios when a hernia repair is not commonly performed, including those of patients undergoing nonelective surgeries with known or suspected gynecologic cancers. Finally, we offer multidisciplinary recommendations on the timing of elective hernia repair with obstetrical and gynecologic procedures, with attention to the primary surgical procedure, the type of preexisting hernia, and patient characteristics.

Novel mesh suture may resist bone cutting seen with wire-based sternal closures

OBJECTIVE

Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution.

METHODS

Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force.

RESULTS

All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07).

CONCLUSIONS

Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.

Repair of traumatic flank hernia with mesh strip suture: a case report

Traumatic flank hernia is a relatively rare hernia. We report a case of a male patient with severe multiple trauma, including abdominal injury, who presented with flank hernia 3 years postinjury. The hernia was successfully repaired using mesh strips suture, and at the 12-month follow-up, no complications or recurrence was found. Our findings indicate that when it is difficult to secure a sufficient operative field for mesh anchoring in a traumatic flank hernia, a technique of sutured repair with mesh strips may be considered as a treatment option as it requires less dissection. Compared to the conventional planar mesh repair, this technique decreases the risk of injuries and ischemic necrosis of the surrounding tissues.

Report of novel application of T-line hernia mesh in ventral hernia repair

Introduction

Ventral hernia repair is one of the most common surgeries performed in the United States. Failure of hernia repairs can be attributed to sutures pulling through tissue or mesh (anchor point failure). T-Line Hernia Mesh is the first mesh designed to specifically prevent anchor point failure by distributing tension. This case study of two patients is the first clinical application of the novel T-Line Hernia Mesh.

Presentation of case

Two separate patients presented with symptomatic ventral hernia secondary to previous laparotomy. Patient 1 is a fifty-five year-old male who underwent open ventral hernia repair with T-Line Hernia Mesh onlay placement. Patient 2 is a fifty-eight year-old female with a symptomatic ventral hernia that underwent bilateral component separation and primary hernia repair with T-Line Hernia Mesh. Both patients postoperative course was uneventful with no reported surgical site occurrences or hernia recurrence.

Discussion

T-Line Hernia Mesh provides a new innovative approach to hernia surgery. This provides the first clinical outcomes. No complications were observed. In addition, this manuscript also demonstrates the surgical technique for the first time.

Conclusion

This cases and technical description provides the initial report for a new designed T-Line Hernia Mesh that could result in a paradigm shift in hernia surgery concepts.

•

T-Line Hernia Mesh® is an innovative unique design with mesh extensions that provide 15x the surface area and 275% stronger repair to overcome hernia recurrence.

•

This is the first clinical study that demonstrates open ventral hernia repair with the T-Line Hernia Mesh with onlay repair. No surgical site occurrences were observed.

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T-Line Hernia Mesh design and clinical outcomes advance may advance current paradigms in hernia repair surgery mesh fixation and tools

An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model

Purpose

Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model.

Methods

Twenty-four New Zealand female rabbits (3-4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery.

Results

Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different.

Conclusions

The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material.

Clinical Relevance

This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.

Suturable Mesh Demonstrates Improved Outcomes over Standard Suture in a Porcine Laparotomy Closure Model

Background:

Laparotomy closures fail due to suture pull-through. I hypothesize that a suturable mesh may limit pull-through via mechanisms of force distribution and fibrous encapsulation of the device filaments.

Methods:

Fifteen domestic swine 74 kg in size were randomly allocated to three groups for laparotomy closure with either size 0 suturable mesh, number 1 suturable mesh, or number 1 polypropylene. All three devices were placed in running fashion with 1-cm bites and 1-cm travels. Primary endpoints were hernia formation at 13 weeks and a semiquantitative analysis of the histological tissue response. Secondary endpoints included adhesions, surgical site occurrence (SSO), and documentation of “loose sutures.”

Results:

There were numerically fewer hernias in the number 1 suturable mesh group. Nine of the 10 suturable mesh devices were well encapsulated within the tissues and could not be pulled away, whereas four of the five polypropylene sutures were loose. Adhesions were least for number 1 suturable mesh. Histologically, the suturable mesh implanted devices showed good fibrovascular ingrowth and were judged to be “nonirritants.” The soft-tissue response was statistically greater (P = 0.006) for the number 1 suturable mesh than for the number 1 polypropylene.

Conclusions:

The mechanism by which meshes support closure sites is clearly demonstrated with this model. Suturable mesh has the potential to change surgical algorithms for abdominal wall closure.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Biomechanical Comparison of Tendon Coaptation Methods With a Meshed Suture Construct

PURPOSE

Tendon-to-tendon attachment constructs for tendon reconstructions or transfers need to be secure in order to allow early mobilization after surgery. The purpose of this study was to biomechanically compare 2 common constructs secured with a novel mesh suture versus a nonabsorbable braided suture.

METHODS

We used 100 cadaveric tendons to create 5 different tendon coaptation constructs (a to e) (10 coaptations per group): (a) Pulvertaft weave with a braided suture (PTe); (b) mesh suture (PTm); (c) single-pass, side-to-side (SP-STS) coaptation with 30-mm overlap using a mesh suture (SP-STS-30m); (d) SP-STS 50-mm overlap with a mesh suture (SP-STS-50m); and (e) SP-STS with 30-mm tendon overlap using a braided suture (SP-STS-30e). The tensile strength, bulk, gliding resistance, and failure type were compared.

RESULTS

There was no difference between the various tendon constructs and the suture type in terms of coaptation bulk. All SP-STS constructs with mesh suture had higher peak gliding resistance than any of the PT constructs regardless of suture type. Compared with the PT constructs, the SP-STS constructs with mesh or braided suture had a higher peak load, peak load normalized to repair length, and stiffness. Within each tendon coaptation construct group, Pulvertaft or SP-STS, the suture type did not affect any of the investigated parameters.

CONCLUSIONS

The SP-STS constructs are significantly stronger and stiffer than the PT constructs. The SP-STS with mesh suture exhibited greater gliding resistance than the PT constructs and may result in greater gliding resistance through physiological tissue planes. However, the use of a mesh suture did not affect strength, bulk, gliding resistance, or failure type when compared within a construct group.

CLINICAL RELEVANCE

The use of SP-STS constructs for tendon coaptations produces a stronger and stiffer construct than the PT weave; however, the use of a mesh suture may not provide any benefit over a braided suture.

A biomechanical comparison of a mesh suture to a polyblend suture in a porcine tendon model

Background

The suture-tendon interface turned out to be the weak point of a repaired rotator cuff. A double rip-stop (DRS) technique was developed to enhance the strength of the suture-tendon interface. The first aim of this study was to compare the suture-tendon interface strength between mesh suture and the No. 2 FiberWire (FW), which is commonly used in the clinic. The second aim was to compare the biomechanical properties of rotator cuff repair between mesh suture and No. 2 FiberWire using a typical suture-bridge (SB) and DRS techniques.

Methods

Eighteen porcine subscapularis tendon (SST) was randomly assigned to the Mesh-tendon group and FiberWire-tendon group. A single suture loop was passed through the SST with a Mesh suture or FiberWire. Thirty-two infraspinatus tendons (ISTs) were randomly assigned to four groups: SB-Mesh group: SB technique with Mesh suture, SB-FW group: SB technique with FiberWire, DRS-Mesh group: DRS technique with Mesh suture, and DRS-FW group: DRS technique with FiberWire. All repaired specimens were underwent failure testing. Failure modes, load to create a 3-mm gap, failure load, and stiffness were compared.

Results

There were no significant differences between the Mesh-tendon group and FiberWire-tendon group regarding the failure load, stiffness, and ultimate stress. When the same technique was used, the rotator cuff repaired with a mesh suture had the similar load to create a 3-mm gap, failure load, and stiffness compared with FiberWire. When the same suture was used, the DRS technique had a significantly higher load to create a 3-mm gap formation and failure load compared with the SB technique.

Conclusions

The repair failure strength and stiffness using the mesh suture were similar to the FiberWire suture regardless of the repair techniques. However, the repair strength in the DRS technique was significantly stronger than the SB technique when the same suture material was used.

Application of computer tomography-based 3D reconstruction technique in hernia repair surgery

BACKGROUND

Hernia is a common condition requiring abdominal surgery. The current standard treatment for hernia is tension-free repair using meshes. Globally, more than 200 new types of meshes are licensed each year. However, their clinical applications are associated with a series of complications, such as recurrence (10% - 24%) and infection (0.5% - 9.0%). In contrast, 3D-printed meshes have significantly reduced the postoperative complications in patients. They have also shortened operating time and minimized the loss of mesh materials. In this study, we used the myopectineal orifice (MPO) data obtained from preoperative computer tomography (CT)-based 3D reconstruction for the production of 3D-printed biologic meshes.

AIM

To investigate the application of multislice spiral CT-based 3D reconstruction technique in 3D-printed biologic mesh for hernia repair surgery.

METHODS

We retrospectively analyzed 60 patients who underwent laparoscopic tension-free repair for inguinal hernia in the Department of General Surgery of the First Hospital of Shanxi Medical University from September 2019 to December 2019. This study included 30 males and 30 females, with a mean age of 40 ± 5.6 years. Data on the MPO were obtained from preoperative CT-based 3D reconstruction as well as from real-world intraoperative measurements for all patients. Anatomic points were set for the purpose of measurement based on the definition of MPO: A: The pubic tubercle; B: Intersection of the horizontal line extending from the summit of the inferior edge of the internal oblique and transversus abdominis and the outer edge of the rectus abdominis, C: Intersection of the horizontal line extending from the summit of the inferior edge of the internal oblique and transversus abdominis and the inguinal ligament, D: Intersection of the iliopsoas muscle and the inguinal ligament, and E: Intersection of the iliopsoas muscle and the superior pubic ramus. The distance between the points was measured. All preoperative and intraoperative data were analyzed using the t test. Differences with P < 0.05 were considered significant in comparative analysis.

RESULTS

The distance between points AB, AC, BC, DE, and AE based on preoperative and intraoperative data was 7.576 ± 0.212 cm vs 7.573 ± 0.266 cm, 7.627 ± 0.212 cm vs 7.627 ± 0.212 cm, 7.677 ± 0.229 cm vs 7.567 ± 0.786 cm, 7.589 ± 0.204 cm vs 7.512 ± 0.21 cm, and 7.617 ± 0.231 cm vs 7.582 ± 0.189 cm, respectively. All differences were not statistically significant (P > 0.05).

CONCLUSION

The use of multislice spiral CT-based 3D reconstruction technique before hernia repair surgery allows accurate measurement of data and relationships of different anatomic sites in the MPO region. This technique can provide precise data for the production of 3D-printed biologic meshes.

Biomechanical Parameters of Mesh Reinforcement and Analysis of a Novel Device for Incisional Hernia Prevention

BACKGROUND

Prophylactic mesh augmentation (PMA) is an effective technique utilized to reduce the risk of incisional hernia. This study analyzes the biomechanical characteristics of a mesh-reinforced closure and evaluates a novel prophylactic mesh implantation device (SafeClose Roller System; SRS).

MATERIALS AND METHODS

A total of eight senior-level general surgery trainees (≥4 years of training) from the University of Pennsylvania Health System participated in the study. Biomechanical strength, mesh stiffness, mesh uniformity, and time efficiency for fixation were compared among hand-sewn mesh fixation, SRS mesh fixation and a no-mesh fixation control. Porcine abdominal wall specimens served as simulated laparotomy models.

RESULTS

Biomechanical load strength was significantly higher for mesh reinforced repairs (P = 0.009). The SRS resulted in a stronger biomechanical force than hand-sewn mesh (21.2 N stronger, P = 0.317), with more uniform mesh placement (P < 0.01), faster time of fixation (P < 0.001) and with less discrete hand-movements (P < 0.001).

CONCLUSIONS

Mesh reinforcement for incisional reinforcement has a significant impact on the strength of the closure. The utilization of a mesh-application system has the potential to amplify the advantages of mesh reinforcement by providing efficiency and consistency to fixation methods, with similar biomechanical strength to hand-sewn mesh. Additional in vivo analysis and randomized controlled trials are needed to further assess clinical efficacy.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

Evaluation of a new suture material (Duramesh™) by measuring suture tension in small and large bites techniques for laparotomy closure in a porcine model

PURPOSE

After closure of laparotomies, sutures may pull through tissue due to too high intra-abdominal pressure or suture tension, resulting in burst abdomen and incisional hernia. The objective of this study was to measure the suture tension in small and large bites with a new suture material.

METHODS

Closure of the linea alba was performed with small bites (i.e., 5 mm between two consecutive stitches and 5 mm distance from the incision) and large bites (i.e., 10 mm × 10 mm) with Duramesh™ size 0 (2 mm) and PDS II 2-0 in 24 experiments on six porcine abdominal walls. The abdominal wall was fixated on an artificial computer-controlled insufflatable abdomen, known as the 'AbdoMan'. A custom-made suture tension sensor was placed in the middle of the incision.

RESULTS

The suture tension was significantly lower with the small bites technique and Duramesh™ when compared with large bites (small bites 0.12 N (IQR 0.07-0.19) vs. large bites 0.57 N (IQR 0.23-0.92), p  < 0.025). This significant difference was also found in favour of the small bites with PDS II 2-0 (p  < 0.038). No macroscopic tissue failure was seen during or after the experiments.

CONCLUSION

Closure of the abdominal wall with the small bites technique and Duramesh^™ was more efficient in dividing suture tension across the incision when compared to large bites. However, suture tension compared to a conventional suture material was not significantly different, contradicting an advantage of the new suture material in the prevention of burst abdomen and incisional hernia during the acute, postoperative phase.

Evaluation of hollow mesh augmentation on the biomechanical properties of the flexor tendon repaired with modified Kessler technique

Purpose

The aim of the study was to test flexor tendon repair with a novel hollow mesh suture augmentation served as a centre core cable [Triple-C (Tri-C)] in an in vitro study using a turkey model.

Methods

Forty long digits from white turkey feet were divided into the following four groups based on repair techniques: Group 0, intact tendon without repair; Group 1, modified Kessler (MK) repair only (MKo); Group 2, MK repair plus Tri-C (MK ​+ ​Tri-C); and Group 3, MK repair plus an additional outside knot plus Tri-C (MK-2knots ​+ ​Tri-C). Mechanical evaluations were performed for all groups.

Results

The frictions of the two groups with Tri-C were not significantly different than those of the MKo group. The ultimate tensile strength of the MK ​+ ​Tri-C group was not significantly different from that of the MKo group or the MK-2knots ​+ ​Tri-C group. In contrast, the MK-2knots ​+ ​Tri-C group had a significantly greater ultimate tensile strength compared with that of the MKo group. Forces at 2-mm gap formation in the groups with Tri-C were significantly stronger than that of MK alone.

Conclusion

Our data have demonstrated that MK repair augmented with the centre hollow mesh suture increased failure strength without inducing increased friction.

The translational potential of this article

Our study elucidates that a Tri-C augmentation designed in this study can achieve mechanical enhancements without increasing the repaired tendon friction. Hence, this novel technique has potential biological validity and clinical application.

Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model

PURPOSE

Conventional suture repairs, when stressed, fail by suture rupture, knot slippage, or suture pull-through, when the suture cuts through the intervening tissue. The purpose of this study was to compare the biomechanical properties of flexor tendon repairs using a novel mesh suture with traditional suture repairs.

METHODS

Sixty human cadaveric flexor digitorum profundus tendons were harvested and assigned to 1 of 3 suture repair groups: 3-0 and 4-0 braided poly-blend suture or 1-mm diameter mesh suture. All tendons were repaired using a 4-strand core cruciate suture configuration. Each tendon repair underwent linear loading or cyclic loading until failure. Outcome measures included yield strength, ultimate strength, the number of cycles and load required to achieve 1-mm and 2-mm gap formation, and failure.

RESULTS

Mesh suture repairs had significantly higher yield and ultimate force values when compared with 3-0 and 4-0 braided poly-blend suture repairs under linear testing. The average force required to produce repair gaps was significantly higher in mesh suture repairs than in conventional suture. Mesh suture repairs endured a significantly greater number of cycles and force applied before failure compared with both 3-0 and 4-0 conventional suture.

CONCLUSIONS

This ex vivo biomechanical study of flexor tendon repairs using a novel mesh suture reveals significant increases in average yield strength, ultimate strength, and average force required for gap formation and repair failure with mesh suture repairs compared with conventional sutures.

CLINICAL RELEVANCE

Mesh suture-based flexor tendon repairs could lead to improved healing at earlier time points. The findings could allow for earlier mobilization, decreased adhesion formation, and lower rupture rates after flexor tendon repairs.

Theoretic and Evidence-Based Laparotomy Closure with Sutures and Meshes

The ultimate tensile strength of newly apposed tissue is the sum of the strength of the physical construct holding the tissues and the strength of biologic healing. For successful incisional hernia repair, the total strength of the repair must remain greater than the forces applied. While much work has been done to understand the science of wound healing-the ability of an open defect to contract and close-far less has been done to understand the healing of 2 newly approximated previously nonwounded surfaces held together with sutures or other implants. In this article, the elements of ultimate tensile strength on laparotomy closure as well as their progression over time will be related to clinical studies of abdominal wall closure.

Abdominal wall closure

Wound closure time is not coffee time

Preclinical Evaluation of Mesh Implants: The Pathologist’s Perspective

Surgical and laparoscopic implantation of mesh devices is on the rise for a variety of applications. The complexity and range of evolving mesh designs calls for consistent and detailed pathologic evaluation in determining host responses and assessing overall safety. This review addresses the components of evaluation of mesh implants in animal models, with emphasis on histologic parameters, semiquantitative scoring matrices, and morphometric analyses that have been specifically adapted to this class of implants. Necropsy assessment should include implant persistence, architecture, and associated host responses such as exudation and adhesions. Microscopic evaluation should focus on primary relevant responses such as bioresorption, integration/tissue ingrowth, neovascularization, and inflammation. Selection of the best means of processing and evaluation can be complicated, as meshes may include one or more biologic components (e.g., collagen), synthetic polymer fibers, coatings, and other molecules. The architecture of some meshes can influence tissue responses and complicate sampling, sectioning, and evaluation. Recognition of specific study objectives and knowledge of anticipated responses helps to determine the appropriate histologic or immunochemical stains, while understanding of mesh composition and anticipated persistence in tissue determines the suitability of paraffin or resin embedding, and both guide the evaluation of mesh devices in the preclinical setting.

Creating a Small Anchor to Eliminate Large Knots in Mesh and Tape Suture

Wide mesh or tape sutures are used to close high-tension wounds such as in hernia or tendon repair. However, wide sutures produce large knots that are susceptible to increased palpability, infection, and foreign body response. To prevent such adverse events, we developed a small suture anchor to replace wide suture knots. The suture anchor was iteratively developed using three-dimensional (3D) design software and produced via 3D printing. Anchor prototypes underwent monotonic, cyclic fatigue, and stress-life testing in a benchtop soft tissue suture model. Results were compared to a standard of care knot and alternative suture fixation devices. The final anchor design was selected based on minimal size and mechanical performance. The size of the final anchor (200 mm3) was 33% smaller than a tape suture knot and 68% smaller than a mesh suture knot. Monotonic testing of mesh and tape sutures revealed a significantly greater anchor failure load compared to knot and alternative fixations (p < 0.05). Additionally, all anchors successfully completed cyclic fatigue testing without failure while other fixations, including knot, failed to complete cyclic fatigue testing multiple times. Stress-life testing demonstrated durable anchor fixation under varying tensile stresses. Failure mode analysis revealed anchor fracture and tissue failure as modes of anchor failure, each of which occurred at supraphysiologic forces. We created a small suture anchor that significantly outperforms knot and alternative suture fixations in benchtop testing and addresses concerns of increased palpability, infection, and foreign body response from large suture knots.

Rotator cuff repair with a novel mesh suture: An ex vivo assessment of mechanical properties

Surgical repair is a common treatment for rotator cuff tear; however, the retear rate is high. A high degree of suture repair strength is important to ensure rotator cuff integrity for healing. The purpose of this study was to compare the mechanical performance of rotator cuffs repaired with a mesh suture versus traditional polydioxanone suture II and FiberWire sutures in a canine in vitro model. Seventy-two canine shoulders were harvested. An infraspinatus tendon tear was created in each shoulder. Two suture techniques-simple interrupted sutures and two-row suture bridge-were used to reconnect the infraspinatus tendon to the greater tuberosity, using three different suture types: Mesh suture, polydioxanone suture II, or FiberWire. Shoulders were loaded to failure under displacement control at a rate of 20 mm/min. Failure load was compared between suture types and techniques. Ultimate failure load was significantly higher in the specimens repaired with mesh suture than with polydioxanone suture II or FiberWire, regardless of suture technique. There was no significant difference in stiffness among the six groups, with the exception that FiberWire repairs were stiffer than polydioxanone suture II repairs with the simple interrupted technique. All specimens failed by suture pull-out from the tendon. Based on our biomechanical findings, rotator cuff repair with the mesh suture might provide superior initial strength against failure compared with the traditional polydioxanone suture II or FiberWire sutures. Use of the mesh suture may provide increased initial fixation strength and decrease gap formation, which could result in improved healing and lower re-tear rates following rotator cuff repair. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:987-992, 2018.

Modifying hernia mesh design to improve device mechanical performance and promote tension-free repair

PURPOSE

Approximately 348,000 ventral hernia repairs are performed annually in the United States and the incisional hernia recurrence rate is approximately 20% as a result of suture and mesh device failure. Device failure is related to changes at the suture/tissue interface that leads to acute or chronic suture pull-through and surgical failure. To better manage mechanical tension, we propose a modified mesh design with extensions and demonstrate its mechanical superiority.

METHODS

Comparative uniaxial static tensile testing was conducted on polypropylene suture and a modified mesh. Subsequently, a standard of care (SOC) mesh and modified mesh were evaluated using a tensometer in an acute hernia bench-top model.

RESULTS

Modified mesh breaking strength, extension knot breaking strength, extension disruption, and extension anchoring were superior to suture (p < .05). Modified mesh ultimate tensile strength of anchoring was superior to SOC mesh (p < .05). Various stitch patterns and modifications in device design significantly improved device tension-free performance far beyond clinically relevant benchmarks (p < .05).

CONCLUSIONS

Testing demonstrates that the modified mesh outperforms SOC mesh and suture in all tested failure modes. SOC hernia mesh tears through tissue at stress levels below maximum physiologic stress, whereas, the modified hernia mesh is up to 200% stronger than SOC mesh at resisting suture tearing through tissue and maintains anchoring at stresses far beyond clinically relevant benchmarks. Modifying hernia mesh design significantly improves device mechanical performance and enhances tension-free repair.

Mesh sutured repairs of contaminated incisional hernias

BACKGROUND

We sought to evaluate the results of a new mesh sutured repair technique for closure of contaminated incisional hernias.

METHODS

48 patients with contaminated hernias 5 cm wide or greater by CT scan were closed with mesh sutures. Surgical site occurrence, infections, and hernia recurrence were compared to similar patient series reported in the literature.

RESULTS

Of the 48 patients, 20 had clean-contaminated wounds, 16 had contaminated wounds, and 12 were infected. 69% of the patients underwent an anterior perforator sparing components release for hernias that averaged 10.5 cm transversely (range 5 cm-25 cm). SSO occurred in 27% of patients while SSI was 19%. There were no fistulas or delayed suture sinuses. With a mean follow-up of almost 12 months, 3 midline hernias recurred (6%). In these same patients, three parastomal hernias repaired with mesh sutures failed out of 4 attempted for a total failure rate of 13%.

CONCLUSION

Mesh sutured closure represents a simplified and effective surgical strategy for contaminated midline incisional hernia repair.

Current Risk Stratification Systems Are Not Generalizable across Surgical Technique in Midline Ventral Hernia Repair

Background:

Current ventral hernia repair risk estimation tools focus on patient comorbidities with the goal of improving clinical outcomes through improved patient selection. However, their predictive value remains unproven.

Methods:

Outcomes of patients who underwent midline ventral hernia repair with retrorectus placement of mid-weight soft polypropylene mesh between 2010 and 2015 were retrospectively reviewed and compared with predicted wound-related complication risk from 3 tools in the literature: Carolinas Equation for Determining Associated Risk, the Ventral Hernia Working Group (VHWG) grade, and a modified VHWG grade.

Results:

A total of 101 patients underwent hernia repair. Mean age was 56 years and mean body mass index was 29 m/kg² (range, 18–51 m/kg²). We found no significant relationship between the risk estimated by Carolinas Equation for Determining Associated Risk (B = 1.45, P = 0.61) and actual wound-related complications. VHWG grades >1 were not statistically different with regard to rate of wound complication compared with VHWG grade 1 (grade 2: B = 0.05, P = 0.95; grade 3: B = −0.21, P = 0.86; grade 4: B = 2.57, P = 0.10). Modified VHWG grades >1 were not statistically different with regard to rate of wound complication compared with modified VHWG grade 1 (grade 2: B = 0.20, P = 0.80; grade 3: B = 1.03, P = 0.41).

Conclusions:

Current risk stratification tools overemphasize patient factors, ignoring the importance of technique in minimizing complications and recurrence. We attribute our low complication rate to retrorectus placement of a narrow, macroporous polypropylene mesh with up to 45 suture fixation points for force distribution in contrast to current strategies that employ wide meshes with minimal fixation.

Mesh Sutured Repairs of Abdominal Wall Defects

Supplemental Digital Content is available in the text.

A new closure technique is introduced, which uses strips of macroporous polypropylene mesh as a suture for closure of abdominal wall defects due to failures of standard sutures and difficulties with planar meshes.

The state of midline closure of the abdominal wall

A neglected subject