A review of available prosthetic material for abdominal wall repair

Safety and tissue remodeling assay of small intestinal submucosa meshes using a modified porcine surgical hernia model

In studies to date, meshes based on extracellular matrix (ECM) have been extensively used in clinical applications. Unfortunately, little is known about the function of the immunogenic residual, absorbable profile during the tissue repair process. Moreover, there needs to be a recognized preclinical animal model to investigate the safety and efficacy of extracellular matrix meshes. Herein, we designed and fabricated a kind of SIS mesh followed by a scanned electron micrograph characterization and tested α-Gal antigen clearance rate and DNA residual. In order to prove the biocompatibility of the SIS mesh, cell viability, chemotaxis assay and local tissue reaction were assessed by MTT and RTCA cytotoxicity test in vitro as well as implantation and degradation experiments in vivo. Furthermore, we developed a stable preclinical animal model in the porcine ventral hernia repair investigation, which using laparoscopic plus open hybridization method to evaluate tissue adhesion, explant mechanical performance, and histologic analysis after mesh implantation. More importantly, we established a semi-quantitative scoring system to examine the ECM degradation, tissue remodeling and regeneration in the modified porcine surgical hernia model for the first time. Our results highlight the application prospect of the improved porcine ventral hernia model for the safety and efficacy investigation of hernia repair meshes.

Microbiological epidemiology and antibiotic susceptibility of infected meshes after prosthetic abdominal wall repair

INTRODUCTION

Infectious complications of parietal mesh after prosthetic abdominal wall repair are rare. Their management is complex. Furthermore, the emergence of bacterial resistance, the presence of a foreign material, the need to continue an extended antibiotic therapy, and the choice of an appropriate treatment are crucial. The objective of this study is to access the microbiological epidemiology of infected parietal meshes in order to optimize the empirical antibiotic therapy.

METHODS

Between January 2016 and December 2021, a monocentric and retrospective study was performed in patients hospitalized for infected parietal meshes at Avicenne hospital, in Paris area. Clinical and microbiological data such as antibiotic susceptibility were collected.

RESULTS

Twenty-six patients with infected parietal meshes have been hospitalized during this period. Meshes were in preaponevrotic positions (n=10; 38%), retromuscular (n=6; 23%) and intraperitoneal (n=10; 38%). Among the 22 (84.6%) documented cases of infections, 17 (77.3%) were polymicrobial. A total of 54 bacteria were isolated, 48 of which had an antibiogram available. The most frequently isolated bacteria were: Enterobacterales (n=19), Enterococcus spp. (n=11) and Staphylococcus aureus (n=6), whereas anaerobes were poorly isolated (n=3). Concerning these isolated bacteria, amoxicillin-clavulanic acid, metronidazole-associated cefotaxime, piperacillin-tazobactam and meropenem were susceptible in 45.5%, 68.2%, 63.6%, 77.2%, of cases, respectively.

CONCLUSION

This work highlights that infections of abdominal parietal meshes may be polymicrobial and the association amoxicillin-clavulanic acid cannot be used as a probabilist antibiotic therapy because of the high resistance rate in isolated bacteria. The association piperacillin-tazobactam appears to be a more adapted empirical treatment to preserve carbapenems, a broad-spectrum antibiotic class.

Abdominoperineal Resection with Absorbable Mesh Repair of Perineal Defect for Fournier's Gangrene: A Case Report

Background

Fournier’s gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high.

Case Presentation

A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis.

Conclusion

Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Engineering multifunctional bactericidal nanofibers for abdominal hernia repair

The engineering of multifunctional surgical bactericidal nanofibers with inherent suitable mechanical and biological properties, through facile and cheap fabrication technology, is a great challenge. Moreover, hernia, which is when organ is pushed through an opening in the muscle or adjacent tissue due to damage of tissue structure or function, is a dire clinical challenge that currently needs surgery for recovery. Nevertheless, post-surgical hernia complications, like infection, fibrosis, tissue adhesions, scaffold rejection, inflammation, and recurrence still remain important clinical problems. Herein, through an integrated electrospinning, plasma treatment and direct surface modification strategy, multifunctional bactericidal nanofibers were engineered showing optimal properties for hernia repair. The nanofibers displayed good bactericidal activity, low inflammatory response, good biodegradation, as well as optimal collagen-, stress fiber- and blood vessel formation and associated tissue ingrowth in vivo. The disclosed engineering strategy serves as a prominent platform for the design of other multifunctional materials for various biomedical challenges.

Comparative study of peritoneal adhesions after intraperitoneal implantation in rats of meshes of polypropylene versus polypropylene/polyglecaprone versus polyester/porcine collagen

PURPOSE

To Compare the extent and intensity of adhesions formed between the intra-abdominal organs and the intraperitoneal implants of polypropylene mesh versus polypropylene/polyglecaprone versus polyester/porcine collagen used for correction of abdominal wall defect in rats.

METHODS

After the defect in the abdominal wall, thirty Wistar rats were placed in three groups (ten animals each) for intraperitoneal mesh implant: polypropylene group, polypropylene/polyglecaprone group, and polyester/porcine collagen group. The macroscopic evaluation of the extent and intensity of adhesions was performed 21 days after the implant.

RESULTS

The polypropylene group had a higher statistically significant impairment due to visceral adhesions (p value = 0.002) and a higher degree of intense adherence in relation to polypropylene/polyglecaprone and polyester/porcine collagen groups (p value<0.001). The polyester/porcine collagen group showed more intense adhesions than the polypropylene/polyglecaprone group (p value=0.035).

CONCLUSIONS

The intraperitoneal implantation of polypropylene meshes to correct defects of the abdominal wall caused the appearance of extensive and firm adhesions to intra-abdominal structures. The use of polypropylene/polyglecaprone or polyester/porcine collagen tissue-separating meshes reduces the number and degree of adhesions formed.

One-Step Surface Functionalized Hydrophilic Polypropylene Meshes for Hernia Repair Using Bio-Inspired Polydopamine

An ideal hernia mesh is one that absorbs drugs and withstands muscle forces after mesh implantation. Polypropylene (PP) mesh devices have been accepted as a standard material to repair abdominal hernia, but the hydrophobicity of PP fibers makes them unsuitable to carry drugs during the pre-implantation of PP meshes. In this study, for the first time, one-step functionalization of PP mesh surfaces was performed to incorporate bio-inspired polydopamine (PDA) onto PP surfaces. All PP mesh samples were dipped in the same concentration of dopamine solution. The surface functionalization of PP meshes was performed for 24 h at 37 °C and 80 rpm. It was proved by scanning electron microscopic (SEM) images and Fourier Transform Infrared Spectroscopy (FTIR) results that a thin layer of PDA was connected with PP surfaces. Moreover, water contact angle results proved that surface functionalized PP meshes were highly hydrophilic (73.1°) in comparison to untreated PP mesh surfaces (138.5°). Thus, hydrophilic PP meshes with bio-inspired poly-dopamine functionalization could be a good choice for hernia mesh implantation.

Surface modification of polypropylene surgical meshes for improving adhesion with poloxamine hydrogel adhesive

Tissue adhesive has notable clinical benefits in hernia repair fixation. A novel poloxamine tissue adhesive was previously shown to successfully bond collagen tissue with adequate adhesive strength. In application related to attachment of polypropylene (PP) mesh, the adhesive strength between the mesh and poloxamine hydrogel adhesive is limited by the hydrophobicity of PP monofilaments and lack of covalent bond formation. The purpose of this study was to compare two different surface modifications [bovine serum albumin (BSA) adsorption and poly-glycidyl methacrylate/human serum albumin (PGMA/HSA) grafting] of PP mesh for improving the adhesive strength between poloxamine hydrogel adhesive and PP mesh. The PGMA/HSA surface modification significantly improved the adhesive strength for meshes attached with poloxamine hydrogel tissue adhesive compared with unmodified meshes and meshes modified by BSA adsorption. An area of 1 cm² adhesive provided for a maximum adhesive strength of 65-70 kPa for meshes modified by PGMA/HSA, 4-13 kPa for meshes modified by BSA, and 22-45 kPa for unmodified meshes. Optical microscopy and infrared spectroscopy (FTIR) confirmed the improved adhesive strength was achieved through mechanical interlock of the hydrogel tissue adhesive into the PP mesh pores and chemical bonding of the albumin after successful PGMA/HSA grafting onto the PP monofilaments. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1047-1055, 2019.

Retrospective analysis of smaller than 3-cm umbilical hernia repair with the lightweight macroporous mesh

There is evidence that mesh repair for primary umbilical hernias results in fewer recurrences and similar wound complication rates compared to tissue repair. Various devices and surgical approaches are used in umbilical hernia repair. The ULTRAPRO PLUG (UPP) has been adopted for inguinal hernias and femoral hernias with excellent results. However, there are few reports on the use of UPP for umbilical hernia repair. Thus, the aim of this study was to evaluate efficacy and safety in the treatment of smaller than 3-cm umbilical hernias using the UPP.The medical records of 123 patients who underwent umbilical hernia repair using the UPP between October 2011 and September 2017 were reviewed. All patients were followed-up after 1 month and later in 2018. Demographics, surgical information, and immediate postoperative and long-term complications were assessed.Out of 123 patients, there were 37 male and 86 female patients with a mean age of 50.6 years. The median duration of hernia surgery was 20.5 min (range, 12-34), and 109 (88.6%) patients underwent day surgery. The median defect diameter was 1.4 cm (range, 0.5-3). No mortality or major complications occurred during the perioperative period. Long-term follow-up data were available for 107 (87.0%) patients. The median follow-up duration was 33 months (range, 5-76 months). Early postoperative complications included 1 case of seroma, 2 cases of fat liquefaction, and 1 case of superficial surgical site infection. During follow-up, there were 2 recurrences, 1 case of chronic mesh infection, and 2 patients with chronic postoperative pain.The ULTRAPRO PLUG offers a simple and quick means of repairing smaller than 3-cm umbilical hernias with lower recurrence rates and fewer postoperative complications.

Use of a Rat Model to Study Ventral Abdominal Hernia Repair

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal hernia typically requires implantation of a material to serve as a mechanical bridge across the defect in the abdominal wall. Biomaterials, such as porcine small intestinal submucosa (SIS), also serve as a lattice for cell growth into the implant and can naturally incorporate into the host tissue. Development of such repair materials benefits from use of animal models in which experimental abdominal wall defects are easily created and are amenable to repair in a reproducible fashion. The method offered here describes surgical creation and repair of ventral abdominal hernia in a rat model. When SIS is used to repair an experimental ventral abdominal hernia in this model, it is rapidly incorporated into host tissue within 28 days of implantation. Histologically, incorporation of their implanted material into host tissue is characterized by a robust fibrovascular response. Future refinements and applications of the rat abdominal hernia model may likely involve diabetic and/or obese animals as a means to more closely mimic common co-morbidities of man.

Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review

Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.

Flap surgical techniques for incisional hernia recurrences. A swine experimental model

Background and aim

In the age of synthetic prostheses most of hernia studies include a careful examination of the various types of prosthesis, their characteristics and their repair indications. Biological prostheses are also beginning to draw attention. But in terms of recurrence especially for poor or developing countries, the discussion is different, due to their high cost which makes them difficult to afford. In this article we present new flap reconstruction techniques for the reconstruction of the abdominal wall versus mesh repair, applied on swine models, outline the results of each technique, and specify the indications for their use.

Methods

An experimental protocol using four swine models (PIC-FII-337 hybrid breed pigs), five months old, was conducted. All animal care and operative procedures were studied following the protocol approved by the Ethics Committee of the University of Medicine and Pharmacy resolution no. 281/2014 of the Department of Surgery of the University of Agricultural Sciences and Veterinary Medicine); the study was carried out between November 2015 and February 2016. The primary objective was to compare the effect of surgical strategies in the treatment of the abdominal wall defect using variable flaps versus mesh repair in a large-animal models. Physical examination and ultrasound imaging of the abdominal wall repair were done on determined periods, during one month. The complications occurring after the abdominal wall repair were edema, collections, superficial dehiscence an recurrences.

Results

No recurrences were reported at one month results, all seromas reported were solved over time by natural drainage. Superficial necrosis appeared in two swine models and superficial dehiscence occurred in one model, the perforator ”plus” flap. Mesh infection was detected in the “onlay” swine model.

Conclusions

In terms of recurrences, contaminated abdominal wall defects or other contraindications to the use of prosthetic materials, biological mesh repair or flap surgery are the only surgical options. Based on our findings and considering the high cost reported by the biological meshes use, flap surgery becomes the suitable treatment for such cases, allowing a good reconstruction of the abdominal wall.

Xenograft biologic mesh in parietal and general surgery: Technical assessment and review of clinical effectiveness and safety data

STUDY AIM

To describe the main technical characteristics of biologic prostheses used for parietal reinforcement and to present the state of the art on their risk/benefit ratio.

METHODS

We conducted a technical analysis of manufacturer specifications of the biologic prostheses that are currently available in France accompanied by a literature review by selecting meta-analyses and systematic reviews, randomized controlled trials and publications of health technology rating agencies.

RESULTS

Biological implants for parietal reinforcement are mainly intended for use in a contaminated environment where the use of synthetic prostheses is contra-indicated. We identified fourteen systematic reviews and meta-analyses and one randomized controlled trial. Six ongoing clinical trials were identified as well as two clinical trials that had been interrupted. In the current state of knowledge, there are no high-level evidence data on the therapeutic contribution of biologic prostheses that allow prioritization of the various biologic prostheses according to their characteristics or their different manufacturing processes.

CONCLUSION

Pending the results of current randomized controlled trials to validate the indications and an eventual specific reimbursement, indications for the use of biologic parietal reinforcement prostheses seems to be limited to rare clinical situations and only after collegial discussion.

Surgical mesh for ventral incisional hernia repairs: Understanding mesh design

Surgical mesh has become an indispensable tool in hernia repair to improve outcomes and reduce costs; however, efforts are constantly being undertaken in mesh development to overcome postoperative complications. Common complications include infection, pain, adhesions, mesh extrusion and hernia recurrence. Reducing the complications of mesh implantation is of utmost importance given that hernias occur in hundreds of thousands of patients per year in the United States. In the present review, the authors present the different types of hernia meshes, discuss the key properties of mesh design, and demonstrate how each design element affects performance and complications. The present article will provide a basis for surgeons to understand which mesh to choose for patient care and why, and will explain the important technological aspects that will continue to evolve over the ensuing years.

Surgical mesh for ventral incisional hernia repairs: Understanding mesh design

Surgical mesh has become an indispensable tool in hernia repair to improve outcomes and reduce costs; however, efforts are constantly being undertaken in mesh development to overcome postoperative complications. Common complications include infection, pain, adhesions, mesh extrusion and hernia recurrence. Reducing the complications of mesh implantation is of utmost importance given that hernias occur in hundreds of thousands of patients per year in the United States. In the present review, the authors present the different types of hernia meshes, discuss the key properties of mesh design, and demonstrate how each design element affects performance and complications. The present article will provide a basis for surgeons to understand which mesh to choose for patient care and why, and will explain the important technological aspects that will continue to evolve over the ensuing years.

Regenerative biomaterials: a review

The authors present a review of biomaterials, substances traditionally derived from human or animal tissue or, more recently, biodegradable synthetics modeled after naturally occurring resources. These constructs differ from purely synthetic materials in that they are degraded or incorporated into a host's tissue. These biomaterials include a diverse array of medical products, such as acellular dermal matrix, bone substitutes, and injectables. In this review, the authors examine various clinical applications, including burn reconstruction and wound healing, breast surgery, complex abdominal wall reconstruction, craniofacial repair, and cosmetic surgery. Biomaterials such as acellular dermal matrix have proven beneficial in difficult-to-treat applications; however, more prospective data are needed to determine their true efficacy and cost-effectiveness.

Tissue integration and inflammatory reaction in full-thickness abdominal wall repair using an innovative composite mesh

PURPOSE

When composite meshes are used in abdominal wall repair, seroma formation may persist and delay the desired integration leading to recurrence. This study compares tissue integration and inflammatory response in abdominal wall repair with composites with different absorbable synthetic barriers.

METHODS

Full-thickness defects created in the abdominal wall of rabbits were repaired using polypropylene prosthesis or the following composites: Physiomesh™ (Phy); Ventralight™ (Vent) and "new composite mesh" (Ncm) not yet used clinically in humans. The collected seroma was evaluated for IFN-γ/IL-4 by ELISA. Tissue integration, anti- (IL-13/TGFβ-1/IL-10/IL-4) and pro-inflammatory (TNF-α/IL-6/IFN-γ/VEGF) cytokine mRNA expression and TGFβ/VEGF immunolabeling were evaluated at 14 and 90 days post-implant.

RESULTS

Seroma was observed in 10 of 12 Phy/Vent and 4 of 12 Ncm. Wound fluid IFN-γ showed a time-dependent significant increase in Vent and tendency to decrease in Ncm, while all composites exhibited IL-4 upward trend. Prostheses were fully infiltrated by an organized connective tissue at end time although the area had shown prior seroma. A stable mesothelium was developed, except in adhesion areas. Vent/Phy displayed a significant increase in TNF-α/IFN-γ-mRNA over time. Significant decrease in VEGF mRNA was observed in Phy/Ncm, while a significant increase of TGFβ-1 mRNA was evident in all composites over time. Ncm exhibited the highest TGFβ protein expression area at short term and the greatest percentage of VEGF positive vessels at end time.

CONCLUSION

Ncm could be an appropriate candidate to improve clinical outcome showing the lower development of seroma and optimal tissue integration with minimal pro-inflammatory cytokine response over time and consistent pro-wound healing cytokine expression.

Synthetic Mesh Repair for Incisional Hernia Treatment in High-risk Patients for Surgical Site Occurrences

Patients with incisional hernias (IH) and risk factors for surgical site occurrences (SSOs) such as defined comorbidities and/or potential contaminations are considered to be treated with bioprosthetics. A retrospective analysis of consecutive patients who had undergone elective IH repair with synthetic mesh materials between 2009 and 2013 was conducted. Only patients who were classified into Grades II and III according to the classification of the Ventral Hernia Working Group (VHWG) were considered for the study. Primary outcome parameter was the incidence of SSO. The relationships among demographics, hernia characteristics, surgical technique, and SSOs were also evaluated. Overall, 108 patients were included (Grade II: 68, Grade III: 40). SSO was identified in 14 patients. Having two or more comorbidities ( P = 0.04), an open sublay technique ( P = 0.005), duration of operation ( P = 0.02), larger hernia defects ( P = 0.001), and using larger mesh sizes ( P = 0.01) were associated with significantly higher rates of SSO. Affiliation to VHWG Grading II or III showed no impact on SSO occurrence. Synthetic mesh repair both in an “open sublay” and laparoscopic intraperitoneal technique is safe regarding patients with risk factors for SSO. The recommendations of the VHWG must be declined and a modification of the grading system is warranted overlooking a more liberal use of synthetic meshes.

Long-term results of femoral hernia repair with ULTRAPRO Plug

BACKGROUND

The infrainguinal plug technique for femoral hernia (FH) has gained popularity for its feasibility, simplicity, and encouraging rate of success, but materials and structures of traditional mesh plugs may cause postoperative discomfort, plug migration, and even recurrence. The new hernia repair device ULTRAPRO Plug (UPP) may avoid those problems.

MATERIALS AND METHODS

In 121 of patients, a total of 125 elective FH repairs with UPP were performed between March 2009 and March 2013. Demographics, surgical information, and outcome were assessed.

RESULTS

Out of 121 patients, 105 were female. The mean age was 57.6 y. FHs occurred more often on the right (72) than the left (45), and in 4 patients the hernias were bilateral. Mean duration of a hernia surgery was 14.7 min, and 91% patients were discharged within 24 h. Mean time to complete return to daily activities was 7.4 d. No mortality or major complications occurred during the perioperative period. Median follow-up was 26 mo, and the total follow-up rate was 91%. No recurrence or chronic mesh infection was noted. Postoperative chronic pain in two patients, sensory loss in one patient, and foreign body sensation in three patients were found in the follow-up.

CONCLUSIONS

Repair of FHs with UPP through an infrainguinal approach is a simple and effective procedure without major postoperative events.