Biosynthetic Resorbable Prosthesis is Useful in Single-Stage Management of Chronic Mesh Infection After Abdominal Wall Hernia Repair

Quality of life assessment of patients after removal of late-onset infected mesh following open tension-free inguinal hernioplasty: 3-year follow-up

PURPOSE

Open tension-free inguinal hernioplasty is one of the common surgical methods used today to treat inguinal hernias due to its simplicity and low recurrence rate. With the widespread use of tension-free inguinal hernia repair, the number of patients with mesh infections is gradually increasing. However, there is a lack of studies assessing the quality of life of patients after the removal of late-onset infected meshes in open inguinal hernias. The aim of this study was to analyse and assess the quality of life, pain severity and anxiety of patients after late-onset infection mesh removal following open inguinal hernioplasty.

METHODS

Data from 105 patients admitted to our hospital from January 2014 to January 2019 who developed delayed mesh infection after open tension-free inguinal hernia repair were retrospectively analysed. 507 patients without mesh infection after open inguinal hernioplasty were included as cross-sectional controls. The baseline data of the two groups were matched for propensity score matching (PSM) with a caliper value of 0.05 and a matching ratio of 1:1. Patients are followed up by telephone or outpatient consultations for 3 years to assess quality of life, pain and anxiety after removal of the infected mesh.

RESULTS

The 105 patients who developed late-onset mesh infection after inguinal hernia repair had a mean age of 64.07 ± 12.90 years and a mean body mass index (BMI) of 24.64 ± 2.67 (kg/m2). The mean follow-up time was 58 months and 10.5% (10/105) of the patients were lost to follow-up. At the 3-year follow-up there was one case of hernia recurrence and five cases of mesh reinfection. The patients' quality of life scores, pain scores and anxiety scores improved after surgery compared to the preoperative scores (all p < 0.01).

CONCLUSION

Patients with late-onset mesh infection after inguinal hernioplasty showed an improvement in quality of life, pain and anxiety compared to preoperative after removal of the infected mesh. Mesh-plug have a higher risk of mesh infection due to their poor histocompatibility and tendency to crumple and shift.

Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula

The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.

Fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for soft tissue repair and reconstruction: A scoping review

Background

Poly-4-hydroxybutyrate (P4HB) is a fully resorbable, biologically-produced polymer with a strength and flexibility comparable to permanent synthetic polymers. The objective was to identify/summarize all peer-reviewed publications involving P4HB mesh.

Methods

A scoping review was conducted within PubMed and included articles published through October 2022.

Results

A total of n = 79 studies were identified (n = 12 in vitro/bench; n = 14 preclinical; n = 6 commentaries; n = 50 clinical). Of the clinical studies, n = 40 reported results applicable to hernia and n = 10 to plastic/reconstructive surgery and involved patients of all Centers for Disease Control (CDC) wound classes and Ventral Hernia Working Group (VHWG) grades.

Conclusion

P4HB mesh provides long-term hernia repair strength and exhibits promising clinical outcomes beyond its resorption period. Future studies should include randomized controlled trials comparing P4HB to other biomaterials, as well as optimal patient selection, operative technique, long-term outcomes, minimization of potential mesh-related complications, and potential contraindications/complications for P4HB in hernia/abdominal wall reconstruction.

Biosynthetic meshes in contaminated fields: where are we now? A systematic review and meta-analysis in humans

PURPOSE

Selection of an appropriate mesh reinforcement for hernia repair in contaminated fields is a significant problem for surgeons. To date the proper mesh for contaminated fields has not been found. Biosynthetic meshes have emerged as new treatment option in contaminated fields. This study aims to evaluate the postoperative outcomes of biosynthetic meshes in contaminated fields.

METHODS

Systematic electronic search (PubMed, Medline, Embase, Scopus), according to PRISMA criteria, was performed. A literature search of scientific papers was performed by two reviewers until April 2021. Articles were chosen based on reference to biosynthetic meshes, their use in infected fields, and in human subjects. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of studies. According to CDC-Centers for Disease Control classes patients were divided into two subgroups, group 1 (CDC class 2) and group 2 (CDC classes 3-4).

RESULTS

The research included 21 articles and 1619 patients were analyzed. Long-term follow-up showed a significant higher recurrence rate than short-term follow-up. P < 0.001. Meta-analysis of these studies showed that the SSI were significantly higher in CDC classes 3-4 than CDC class 2 (P < 0.01). No differences were found in SSO (P = 0.06) and recurrence (P = 0.37) rate among the two groups. Phasix™ was the most common mesh in 15 studies. The mean follow-up was 23.0 months. The surgical site infection (SSI) rate was 17.3%. The surgical site occurrence (SSO) rate was 32.4%. Recurrence rate was 11.5%.

CONCLUSION

This is the first systematic review and meta-analysis on the clinical outcomes of abdominal wall repair using biosynthetic mesh in contaminated-infected settings. The results show good results in patients at high risk of postoperative wound complications. The aim of this study is to add to the growing literature on biosynthetic mesh a picture of current literature evidence to help future researchers performing further studies on this topic.

Establishing Peer Consensus About the Use of Long-Term Biosynthetic Absorbable Mesh for Hernia (Grades 2-3) as the Standard of Care

BACKGROUND

Standard synthetic and biologic meshes, often used in hernia repair, have commonly been used and each have their strengths but associated drawbacks. Long-term biosynthetic absorbable (LTBA) mesh has been developed to combine the strengths of synthetic and biologic meshes without the associated weaknesses. As a newer type of mesh, the supporting evidence base is still growing, and their optimum use has yet to be defined. This consensus was initiated to provide insight into those situations where a LTBA might be considered the Standard of Care in ventral hernia repair grades 2-3 (original classification, 2010) of the Ventral Hernia Working Group.

METHODS

A steering group of expert surgeons identified 35 statements, based around the evidence supporting LTBA, surgical technique, patients type most suitable for LTBA, risk-benefit of LTBA, patient and surgeon considerations, LTBA value. Surgeons involved in hernia repair received an online survey to assess consensus with these statements. Consensus was defined as high if ≥ 70% and very high if ≥ 90% of respondents agreed. Statements that had not achieved consensus agreement were revised and these were then issued for a subsequent round. Finally, 34 statements were included.

RESULTS

Two hundred fifty-five surgeons were involved. Fourteen statements (41%) achieved very high consensus, 24 achieved consensuses (≥ 70-< 90%), whilst one (3%) just failed to achieve consensus with an agreement score of 69%.

CONCLUSIONS

Expert consensus opinion about the use of LTBA for hernia (Grades 2-3) as the Standard of Care was achieved. Based on the consensus scores, the steering group derived eleven keys.

Outcomes of mid-term and long-term degradable biosynthetic meshes in single-stage open complex abdominal wall reconstruction

OBJECTIVE

To assess clinical outcomes in patients that underwent open single-stage complex abdominal wall reconstruction (CAWR) with biosynthetic mesh.

METHODS

Retrospective observational study of two prospectively registered series of consecutive patients undergoing CAWR with either long-term degradable (LTD) Phasix^™ or mid-term degradable (MTD) BIO-A^® biosynthetic mesh in a single institution between June 2016 and December 2019.

RESULTS

From 169 patients with CAWR, 70 consecutive patients were identified who underwent CAWR with either LTD or MTD biosynthetic mesh. More than 85% of patients had an incisional hernia that could be classified as moderately complex to major complex due to a previous wound infection (67%), one or more complicating comorbidities (87.1%), one or more complicating hernia characteristics (75.7%) or contaminated or dirty defects (37.1%). Concomitant component separation was performed in 43 of 70 patients (61.4%). Overall surgical site infection (SSI) rate in these CAWR patients was 45.7%. Seventeen of 70 patients (24.3%) had computed tomography (CT) - and culture-confirmed SSI in direct contact of mesh, suspicious of mesh infection. Mesh removal for persistent local infection occurred in 10% (7 of 70) after a median of 229 days since surgery. Salvage rate of mesh after direct contact with infection was 58.8%. All removed meshes were in the LTD group. Seven patients (10%) had a recurrence; four patients in the LTD group (10%) had a recurrence at a median follow-up of 35 months and three patients in the MTD group (10%) at a median follow-up of 11 months. Three of the seven recurrences occurred in patients with SSI in persistent and direct contact with mesh.

CONCLUSIONS

Comorbid patients undergoing open complex abdominal wall reconstruction are at high risk of postoperative wound complications regardless of which type of biosynthetic mesh is used. When in persistent and direct contact with infection, long-term biodegradable biosynthetic meshes may need to be removed, whereas mid-term biodegradable biosynthetic meshes can be salvaged.

Prosthetic meshes for hernia repair: State of art, classification, biomaterials, antimicrobial approaches, and fabrication methods

Worldwide, hernia repair represents one of the most frequent surgical procedures encompassing a global market valued at several billion dollars. This type of surgery usually requires the implantation of a mesh that needs the appropriate chemical, physical and biological properties for the type of repair. This review thus presents a description of the types of hernias, current hernia repair methods, and the state of the art of prosthetic meshes for hernia repair providing the most important meshes used in clinical practice by surgeons working in this area classified according to their biological or chemical nature, morphology and whether bioabsorbable or not. We emphasise the importance of surgical site infection in herniatology, how to deal with this microbial problem, and we go further into the future research lines on the production of advanced antimicrobial meshes to improve hernia repair and prevent microbial infections, including multidrug-resistant strains. A great deal of progress has been made in this biomedical field in the last decade. However, we are still far from an ideal antimicrobial mesh that can also provide excellent integration to the abdominal wall, mechanical performance, low visceral adhesion and minimal inflammatory or foreign body reactions, among many other problems.