Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Hughes abdominal closure versus standard mass closure to reduce incisional hernias following surgery for colorectal cancer: the HART RCT

BACKGROUND

Incisional hernias can cause chronic pain and complications and affect quality of life. Surgical repair requires health-care resources and has a significant associated failure rate. A prospective, multicentre, single-blinded randomised controlled trial was conducted to investigate the clinical effectiveness and cost-effectiveness of the Hughes abdominal closure method compared with standard mass closure following surgery for colorectal cancer. The study randomised, in a 1 : 1 ratio, 802 adult patients (aged ≥ 18 years) undergoing surgical resection for colorectal cancer from 28 surgical departments in UK centres.

INTERVENTION

Hughes abdominal closure or standard mass closure.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of incisional hernias at 1 year, as assessed by clinical examination. Within-trial cost-effectiveness and cost-utility analyses over 1 year were conducted from an NHS and a social care perspective. A key secondary outcome was quality of life, and other outcomes included the incidence of incisional hernias as detected by computed tomography scanning.

RESULTS

The incidence of incisional hernia at 1-year clinical examination was 50 (14.8%) in the Hughes abdominal closure arm compared with 57 (17.1%) in the standard mass closure arm (odds ratio 0.84, 95% confidence interval 0.55 to 1.27; p = 0.4). In year 2, the incidence of incisional hernia was 78 (28.7%) in the Hughes abdominal closure arm compared with 84 (31.8%) in the standard mass closure arm (odds ratio 0.86, 95% confidence interval 0.59 to 1.25; p = 0.43). Computed tomography scanning identified a total of 301 incisional hernias across both arms, compared with 100 identified by clinical examination at the 1-year follow-up. Computed tomography scanning missed 16 incisional hernias that were picked up by clinical examination. Hughes abdominal closure was found to be less cost-effective than standard mass closure. The mean incremental cost for patients undergoing Hughes abdominal closure was £616.45 (95% confidence interval -£699.56 to £1932.47; p = 0.3580). Quality of life did not differ significantly between the study arms at any time point.

LIMITATIONS

As this was a pragmatic trial, the control arm allowed surgeon discretion in the approach to standard mass closure, introducing variability in the techniques and equipment used. Intraoperative randomisation may result in a loss of equipoise for some surgeons. Follow-up was limited to 2 years, which may not have been enough time to see a difference in the primary outcome.

CONCLUSIONS

Hughes abdominal closure did not significantly reduce the incidence of incisional hernias detected by clinical examination and was less cost-effective at 1 year than standard mass closure in colorectal cancer patients. Computed tomography scanning may be more effective at identifying incisional hernias than clinical examination, but the clinical benefit of this needs further research.

FUTURE WORK

An extended follow-up using routinely collected NHS data sets aims to report on incisional hernia rates at 2-5 years post surgery to investigate any potential mortality benefit of the closure methods. Furthermore, the proportion of incisional hernias identified by a computed tomography scan (at 1 and 2 years post surgery), but not during clinical examination (occult hernias), proceeding to surgical repair within 3-5 years after the initial operation will be explored.

TRIAL REGISTRATION

This trial is registered as ISRCTN25616490.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 34. See the NIHR Journals Library website for further project information.

Laparoscopy for the Treatment of Congenital Hernia: Use of Surgical Meshes and Mesenchymal Stem Cells in a Clinically Relevant Animal Model

More than a century has passed since the first surgical mesh for hernia repair was developed, and, to date, this is still the most widely used method despite the great number of complications it poses. The purpose of this study was to combine stem cell therapy and laparoscopy for the treatment of congenital hernia in a swine animal model. Porcine bone marrow-derived mesenchymal stem cells (MSCs) were seeded on polypropylene surgical meshes using a fibrin sealant solution as a vehicle. Meshes with (cell group) or without (control group) MSCs were implanted through laparoscopy in Large White pigs with congenital abdominal hernia after the approximation of hernia borders (implantation day). A successive laparoscopic biopsy of the mesh and its surrounding tissues was performed a week after implantation, and surgical meshes were excised a month after implantation. Ultrasonography was used to measure hernia sizes. Flow cytometry, histological, and gene expression analyses of the biopsy and necropsy samples were performed. The fibrin sealant solution was easy to prepare and preserved the viability of MSCs in the surgical meshes. Ultrasonography demonstrated a significant reduction in hernia size 1 week after implantation in the cell group relative to that on the day of implantation (p < 0.05). Flow cytometry of the mesh-infiltrated cells showed a non-significant increase of M2 macrophages when the cell group was compared with the control group 1 week after implantation. A significant decrease in the gene expression of VEGF and a significant increase in TNF expression were determined in the cell group 1 month after implantation compared with gene expressions in the control group (p < 0.05). Here, we propose an easy and feasible method to combine stem cell therapy and minimally invasive surgical techniques for hernia repair. In this study, stem cell therapy did not show a great immunomodulatory or regenerative effect in overcoming hernia-related complications. However, our clinically relevant animal model with congenital hernia closely resembles the clinical human condition. Further studies should be focused on this valuable animal model to evaluate stem cell therapies in hernia surgery.

Abdominal hernias in camel (Camelus dromedaries): Clinical findings and treatment outcomes

The present study was designed to describe the clinical presentation of abdominal hernias and to evaluate the efficacy of polypropylene mesh in repair of such affection in camels. Twenty-six dromedary camels were included in this study on the basis of clinical and ultrasonographic evidence of abdominal hernia. Factors associated with prevalence and clinical findings of hernia were presented and hernioplasty using polypropylene mesh was evaluated as a surgical intervention. Out of 26 studied camels, abdominal hernia was prevalent in Wadeh camels than other breeds (17 vs. 9, P<0.01). Camels <6 years of age exhibited more hernias than other age groups (18 vs. 8, P<0.01). Moreover, females showed a significantly higher prevalence (19 vs. 7, P<0.01) of abdominal hernia compared to males (26.9%, n=7). The sensitivity (96.8%) and specificity (93.1%) of ultrasonography (US) for diagnosing hernia were higher in comparison to clinical examination (88.3%). At 3 weeks postoperatively, the clinical index score of 26 operated camels was significantly reduced in comparison with pretreated (22 vs. 4, P<0.005). However, only 2 cases had recurrence of the hernia and 2 camels had slight swelling in situ. By the 6th month post treatment, all treated camels were completely recovered. In conclusion, the polypropylene mesh is a viable and consistent alternative effective treatment for abdominal hernias in camels. In addition, the clinical index scores and US provide a precise paradigm for diagnosis and preoperative planning for abdominal hernias in dromedary camels.

Lightweight, Highly Permeable, Biocompatible, and Antiadhesive Composite Meshes for Intraperitoneal Repairs

Ventral hernia is a public health issue and millions of meshes are used to repair abdominal wall defects every year. Polypropylene-based composite meshes represent an important class of materials for intraperitoneal repair, but the meshes generally give rise to infection, seroma, migration, and adhesion, leading to severe consequence or even reoperation. Here, a facile and versatile one-way fabrication of lightweight, highly permeable, and biocompatible composite meshes with superior antiadhesion properties is proposed by modifying polypropylene meshes with well-defined polydopamine nanocoating. The resulting composite meshes are found to significantly enhance the biocompatibility and antiadhesion effect in rat model. The scalable production and excellent biomedical properties of composite meshes make them a promising candidate for future-generation ventral hernia repair materials.

Stomal Closure: Strategies to Prevent Incisional Hernia

Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.

Cost analysis of incisional hernia repair with synthetic mesh and biological mesh: an Italian study

Repair of an incisional hernia (IH) generates costs on several levels and domains of society. The aim of this study was to make a complete cost analysis of incisional hernia repair (IHR) with synthetic and biological mesh and to compare it with financial reimbursement. Patients were grouped into three levels to determine the complexity of their care, and hence, the costs involved. Group 1 included patients without comorbidities, who underwent a "standard" incisional hernia repair (SIHR), with synthetic mesh. Group 2 included patients with comorbidities, who underwent the same surgical procedure. Group 3 included all patients who underwent a "complex" IHR (CIHR) with biological mesh. Total costs were divided into direct (including preoperative and operative phases) and indirect costs (medications and working days loss). Reimbursement was calculated according to Diagnosis-Related Group (DRG). From 2012 to 2014, 76 patients underwent prosthetic IHR: group 1 (35 pts); group 2 (30 pts); and group 3 (11 pts). The direct costs of preoperative and operative phases for groups 1 and 2 were €5544.25 and €5020.65, respectively, and €16,397.17 in group 3. The total reimbursement in the three groups was €68,292.37 for group 1, €80,014.14 for group 2, and €72,173.79 for group 3, with a total loss of €124,658.43, €69,675.36, and €100,620.04, respectively. All DRGs underestimate the costs related to IHR and CIHR, thus resulting in an important economic loss for the hospital. The cost analysis shows that patient-related risk factors do not alter the overall costs. To provide a correct "cost-based" reimbursement, different DRGs should be created for different types of hernias and prostheses.

Polypropylene-based composite mesh versus standard polypropylene mesh in the reconstruction of complicated large abdominal wall hernias: a prospective randomized study

PURPOSE

To compare polypropylene mesh positioned onlay supported by omentum and/or peritoneum versus inlay implantation of polypropylene-based composite mesh in patients with complicated wide-defect ventral hernias.

METHODS

This was a prospective randomized study carried out on 60 patients presenting with complicated large ventral hernia in the period from January 2012 to January 2016 in the department of Gastrointestinal Surgery unit and Surgical Emergency of the Main Alexandria University Hospital, Egypt. Large hernia had an abdominal wall defect that could not be closed. Patients were divided into two groups of 30 patients according to the type of mesh used to deal with the large abdominal wall defect.

RESULTS

The study included 38 women (63.3 %) and 22 men (37.7 %); their mean age was 46.5 years (range, 25-70). Complicated incisional hernia was the commonest presentation (56.7 %).The operative and mesh fixation times were longer in the polypropylene group. Seven wound infections and two recurrences were encountered in the propylene group. Mean follow-up was 28.7 months (2-48 months).

CONCLUSIONS

Composite mesh provided, in one session, satisfactory results in patients with complicated large ventral hernia. The procedure is safe and effective in lowering operative time with a trend of low wound complication and recurrence rates.

The economic burden of incisional ventral hernia repair: a multicentric cost analysis

PURPOSE

A systematic review of literature led us to take note that little was known about the costs of incisional ventral hernia repair (IVHR).

METHODS

Therefore we wanted to assess the actual costs of IVHR. The total costs are the sum of direct (hospital costs) and indirect (sick leave) costs. The direct costs were retrieved from a multi-centric cost analysis done among a large panel of 51 French public hospitals, involving 3239 IVHR. One hundred and thirty-two unitary expenditure items were thoroughly evaluated by the accountants of a specialized public agency (ATIH) dedicated to investigate the costs of the French Health Care system. The indirect costs (costs of the post-operative inability to work and loss of profit due to the disruption in the ongoing work) were estimated from the data the Hernia Club registry, involving 790 patients, and over a large panel of different Collective Agreements.

RESULTS

The mean total cost for an IVHR in France in 2011 was estimated to be 6451€, ranging from 4731€ for unemployed patients to 10,107€ for employed patients whose indirect costs (5376€) were slightly higher than the direct costs.

CONCLUSION

Reducing the incidence of incisional hernia after abdominal surgery with 5 % for instance by implementation of the European Hernia Society Guidelines on closure of abdominal wall incisions, or maybe even by use of prophylactic mesh augmentation in high risk patients could result in a national cost savings of 4 million Euros.

Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis

BACKGROUND

Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to performing a components separation is controversial. The authors' goal was to perform the first cost-utility analysis on the use of synthetic mesh in addition to performing components separation when performing a complex ventral hernia repair in a noncontaminated field.

METHODS

A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs (Ventral Hernia Workgroup I and II) requiring components separation with or without synthetic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, Diagnosis-Related Group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of components separation with and without synthetic mesh in reconstructing ventral hernias.

RESULTS

At average retail costs, the decision model revealed a cost increase of $541.69 and a 0.0357 increase in quality-adjusted life-years when using synthetic mesh, yielding a cost-effective incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year. Univariate sensitivity analysis revealed that synthetic mesh is cost-effective when it costs less than $2049.97.

CONCLUSIONS

The addition of synthetic mesh when performing components separation in repairing complex ventral hernias is cost-effective when using average retail prices. Physicians and hospitals should use synthetic mesh in patients with noncontaminated wounds.

Economics of abdominal wall reconstruction

The economic aspects of abdominal wall reconstruction are frequently overlooked, although understandings of the financial implications are essential in providing cost-efficient health care. Ventral hernia repairs are frequently performed surgical procedures with significant economic ramifications for employers, insurers, providers, and patients because of the volume of procedures, complication rates, the significant rate of recurrence, and escalating costs. Because biological mesh materials add significant expense to the costs of treating complex abdominal wall hernias, the role of such costly materials needs to be better defined to ensure the most cost-efficient and effective treatments for ventral abdominal wall hernias.

Cost analysis of the use of small stitches when closing midline abdominal incisions

PURPOSE

Suturing with small stitches instead of with large reduces the risk for surgical site infection and incisional hernia in continuously closed midline abdominal incisions. The purpose was to analyse if using small stitches generated cost savings.

METHODS

Between 2001 and 2006 closure of midline incisions using small stitches was, in a randomised trial, compared with the use of large stitches. In 2011 all patients included in the randomised trial, who until then, had had an incisional hernia repair, were recorded. The cost for an open incisional hernia repair with mesh reinforcement during 2010 was calculated. The analysis included both direct and indirect costs.

RESULTS

Of 321 patients closed with small stitches incisional hernia occurred in 11 and 3 needed repair. Of 370 patients closed with large stitches herniation occurred in 45 and 14 needed repair. The direct cost per hernia repair was 59,909 Swedish krona (SEK) and the indirect cost was 26,348 SEK. Suturing time with small stitches was 4.6 min longer, increasing the cost for the index operation by 1,076 SEK. From the societal perspective (direct and indirect costs), using small stitches generated a cost reduction of 1,339 SEK for each patient. From the perspective of the public payer (direct costs) the cost reduction was 601 SEK. Using small stitches generated cost savings from a societal perspective if the suturing time was not prolonged over 10.3 min.

CONCLUSIONS

Using small stitches when closing midline abdominal incisions with a continuous single-layer technique generates cost savings.

Financial implications of ventral hernia repair: a hospital cost analysis

INTRODUCTION

Complicated ventral hernias are often referred to tertiary care centers. Hospital costs associated with these repairs include direct costs (mesh materials, supplies, and nonsurgeon labor costs) and indirect costs (facility fees, equipment depreciation, and unallocated labor). Operative supplies represent a significant component of direct costs, especially in an era of proprietary synthetic meshes and biologic grafts. We aim to evaluate the cost-effectiveness of complex abdominal wall hernia repair at a tertiary care referral facility.

METHODS

Cost data on all consecutive open ventral hernia repairs (CPT codes 49560, 49561, 49565, and 49566) performed between 1 July 2008 and 31 May 2011 were analyzed. Cases were analyzed based upon hospital status (inpatient vs. outpatient) and whether the hernia repair was a primary or secondary procedure. We examined median net revenue, direct costs, contribution margin, indirect costs, and net profit/loss. Among primary hernia repairs, cost data were further analyzed based upon mesh utilization (no mesh, synthetic, or biologic).

RESULTS

Four-hundred and fifteen patients underwent ventral hernia repair (353 inpatients and 62 outpatients); 173 inpatients underwent ventral hernia repair as the primary procedure; 180 inpatients underwent hernia repair as a secondary procedure. Median net revenue ($17,310 vs. 10,360, p < 0.001) and net losses (3,430 vs. 1,700, p < 0.025) were significantly greater for those who underwent hernia repair as a secondary procedure. Among inpatients undergoing ventral hernia repair as the primary procedure, 46 were repaired without mesh; 79 were repaired with synthetic mesh and 48 with biologic mesh. Median direct costs for cases performed without mesh were $5,432; median direct costs for those using synthetic and biologic mesh were $7,590 and 16,970, respectively (p < .01). Median net losses for repairs without mesh were $500. Median net profit of $60 was observed for synthetic mesh-based repairs. The median contribution margin for cases utilizing biologic mesh was -$4,560, and the median net financial loss was $8,370. Outpatient ventral hernia repairs, with and without synthetic mesh, resulted in median net losses of $1,560 and 230, respectively.

CONCLUSIONS

Ventral hernia repair is associated with overall financial losses. Inpatient synthetic mesh repairs are essentially budget neutral. Outpatient and inpatient repairs without mesh result in net financial losses. Inpatient biologic mesh repairs result in a negative contribution margin and striking net financial losses. Cost-effective strategies for managing ventral hernias in a tertiary care environment need to be developed in light of the financial implications of this patient population.

A novel solution to reduce the complications of distal shunt catheter displacement associated with obesity

Despite the varied sources of hydrocephalus, all shunt-treated conditions involve redirection of CSF to the body, commonly the peritoneum. Migration of the distal catheter tip out of the peritoneal space can occur, leading to the need for reoperation. Although uncommon, the authors have recently had 3 such cases in obese patients involving distal tubing retropulsion in otherwise uncomplicated surgeries. In addressing this issue, the authors performed anchoring of the distal catheter tubing through a small abdominal mesh, which is commonly used for hernia repair to increase catheter tube friction without compromising CSF flow. The results suggest this method may mitigate the chance of peritoneal catheter displacement in patients with higher than normal intraabdominal pressure.

One-year follow-up after incisional hernia treatment: results of a prospective randomized study

BACKGROUND

The incidence of incisional hernia after midline laparotomies ranges from 10 to 20%. The recurrence rate after this hernia surgery varies from 25 to 52% using autogenous tissue. The use of prosthetic meshes can decrease the postoperative hernia recurrence by up to 10%. The aim of this prospective randomized clinical study was to analyze and compare the results of three different incisional hernia surgical techniques.

MATERIALS AND METHODS

One hundred and sixty-one patients who underwent incisional hernia surgery were randomized into three groups. The Keel technique was used in the first group, the "Onlay" technique (prosthetic mesh is fixed on the external abdominal muscle slip) in the second group, and the "Sublay" technique (prosthetic mesh is placed on the posterior abdominal muscle sheath) in the third group. Age, sex, hospitalization time, body mass index (BMI), intraabdominal pressure, postoperative complications, postoperative pain, normal physical activity recovery time, and recurrence rate were compared between the groups. The postoperative follow-up period was 12 months.

RESULTS

Fifty-four patients in the Keel group, 57 patients in the "Onlay" group, and 50 patients in the "Sublay" group were operated. Age, hospitalization time, and BMI were similar in all of the groups. The operative time was significantly longer in the prosthetic mesh groups compared with the Keel group. The intraabdominal pressure changes before and after surgery was significantly higher in the Keel group compared with the prosthetic mesh groups (5.66 ± 2.5 mmHg vs. 1.88 ± 1 mmHg vs. 1.76 ± 1 mmHg; P < 0.05). The postoperative wound complications rate was significantly higher in the "Onlay" technique group compared with the Keel and "Sublay" technique groups (49.1% vs. 22.2% vs. 24%; P < 0.05). Postoperative pain (VAS score) was significantly lower in the "Onlay" and "Sublay" groups (5.53 ± 1.59 vs. 3.96 ± 1.56 vs. 3.78 ± 1.97; P < 0.05). All of the patients in "Sublay" group recovered to normal physical activity during the 6 months follow-up period compared with 94.4% of patients in the Keel group and 98.3% of patients in the "Onlay" group. The recurrence rate was 22.2% in the Keel group, 10.5% in the "Onlay" group, and 2% in the "Sublay" group during the follow-up period. The general complications rate after hernia surgery was 5.6%. Postoperative pneumonia was the most frequent complication, which appeared in 4.3% of patients. There was no postoperative death in our prospective study.

CONCLUSIONS

Mesh repair is the first-choice technique for incisional hernia treatment. The results of the "Sublay" technique are better than the "Onlay" technique.

Which mesh for hernia repair?

INTRODUCTION

The concept of using a mesh to repair hernias was introduced over 50 years ago. Mesh repair is now standard in most countries and widely accepted as superior to primary suture repair. As a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one can be difficult. This article outlines the general properties of meshes and factors to be considered when selecting one.

MATERIALS AND METHODS

We performed a search of the medical literature from 1950 to 1 May 2009, as indexed by Medline, using the PubMed search engine (www.pubmed.gov). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. We used the following terms: 'mesh, pore size, strength, recurrence, complications, lightweight, properties'. We also hand-searched the bibliographies of relevant articles and product literature to identify additional pertinent reports.

RESULTS AND CONCLUSIONS

The most important properties of meshes were found to be the type of filament, tensile strength and porosity. These determine the weight of the mesh and its biocompatibility. The tensile strength required is much less than originally presumed and light-weight meshes are thought to be superior due to their increased flexibility and reduction in discomfort. Large pores are also associated with a reduced risk of infection and shrinkage. For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others. Finally, biomaterials such as acellular dermis have a place for use in infected fields but have yet to prove their worth in routine hernia repair.