A retrospective, Italian multicenter study of complex abdominal wall defect repair with a Permacol biological mesh

Platelet-Rich Therapies in Hernia Repair: A Comprehensive Review of the Impact of Platelet Concentrates on Mesh Integration in Hernia Management

Mesh-augmented hernia repair is the gold standard in abdominal wall and hiatal/diaphragmatic hernia management and ranks among the most common procedures performed by general surgeons. However, it is associated with a series of drawbacks, including recurrence, mesh infection, and adhesion formation. To address these weaknesses, numerous biomaterials have been investigated for mesh coating. Platelet-rich plasma (PRP) is an autologous agent that promotes tissue healing through numerous cytokines and growth factors. In addition, many reports highlight its contribution to better integration of different types of coated meshes, compared to conventional uncoated meshes. The use of PRP-coated meshes for hernia repair has been reported in the literature, but a review of technical aspects and outcomes is missing. The aim of this comprehensive review is to report the experimental studies investigating the synergistic use of PRP and mesh implants in hernia animal models. A comprehensive literature search was conducted across PubMed/Medline, Web of Science, and Scopus without chronological constraints. In total, fourteen experimental and three clinical studies have been included. Among experimental trials, synthetic, biologic, and composite meshes were used in four, nine, and one study, respectively. In synthetic meshes, PRP-coating leads to increased antioxidant levels and collaged deposition, reduced oxidative stress, and improved inflammatory response, while studies on biological meshes revealed increased neovascularization and tissue integration, reduced inflammation, adhesion severity, and mechanical failure rates. Finally, PRP-coating of composite meshes results in reduced adhesions and improved mechanical strength. Despite the abundance of preclinical data, there is a scarcity of clinical studies, mainly due to the absence of an established protocol regarding PRP preparation and application. To this point in time, PRP has been used as a coating agent for the repair of abdominal and diaphragmatic hernias, as well as for mesh fixation. Clinical application of conclusions drawn from experimental studies may lead to improved results in hernia repair.

Design and development of pH-responsive levofloxacin-loaded metal-organic framework for the promising treatment of pediatric abdominal wound repair

With over 9 million fatalities per year expected by 2030, infectious diseases will remain a significant burden on the world economy and cause high mortality rates. An excellent method to increase the bioactivity of levofloxacin (LEV) in pediatric abdominal wound repair is the finding of a stimuli-based drug delivery system (DDS). We designed and developed an LEV incorporated with zeolite imidazole framework-8 (ZIF-8) as a promising nanocarrier for wound healing applications. The spectral analysis and morphological analysis confirm the formation of our newly fabricated composites. Mouse embryonic fibroblast NIH3T3 cells, the cytotoxicity, cytocompatibility, and cell proliferation characteristics of LEV@ZIF-8 were evaluated in vitro. LEV@ZIF-8 composite considerably improved the biocompatibility against NIH3T3 cells after 72-h of exposure, according to in vitro experiments. Under acidic circumstances, the pH-responsive drug release studies exhibit superior LEV release, and in physiological circumstances, there is no unintended drug release. The LEV@ZIF-8 composite-treated cells demonstrate the most remarkable cell growth and migration method in a very short time, according to the results of the wound scratch experiment. The composite exposure concentration depended on inhibition against various microorganisms in the antibacterial activity testing. According to the study, LEV@ZIF-8 are appropriate and effective DDS for stimuli-based pediatric abdominal wound repair.

Semiresorbable biologic hybrid meshes for ventral abdominal hernia repair in potentially contaminated settings: lower risk of recurrence

In case of potential contamination, implantation of synthetic meshes in hernia and abdominal wall surgery is problematic due to a higher risk of mesh infection. As an alternative, a variety of different biologic meshes have been used. However, relevant data comparing outcome after implantation of these meshes are lacking. Between January 2012 and October 2021, biologic meshes were used for reconstruction of the abdominal wall in 71 patients with preoperative or intraoperative abdominal contamination. In this retrospective study, semiresorbable biologic hybrid meshes (BHM) and completely resorbable meshes (CRM) were compared and analyzed using a Castor EDC database. In 28 patients, semiresorbable biologic hybrid meshes were used; in 43 patients, completely resorbable meshes were used. Both groups showed no difference in age, gender, BMI, operation duration, hernia size and Charlson comorbidity index. The risk degree of surgical-site occurrences was graded according to the Ventral Hernia Working Group (VHWG) classification, and the median value was 3 (range 2-4) in the BHM group and 3 (range 2-4) in the CRM group. Hernia recurrence within 24 months after hernia repair was significantly lower in the BHM group (3.6% vs. 28.9%; p = 0.03), while postoperative complication rate, with respect to seromas in need of therapy (61.4% vs. 55.5%, p = 0.43) and operative revision (28.6% vs. 16.3%, p = 0.22) was not different in either group. Biologic hybrid meshes can be used safely in case of possible contamination. BHM seems to reduce the risk of hernia recurrence compared to completely resorbable biologic meshes, but this has to be investigated further.

Frozen bean curd-inspired Xenogeneic acellular dermal matrix with triple pretreatment approach of freeze-thaw, laser drilling and ADSCs pre-culture for promoting early vascularization and integration

Xenogeneic acellular dermal matrix (ADM) is widely used in clinical practice given its good biocompatibility and biomechanical properties. Yet, its dense structure remains a hindrance. Incorporation of laser drilling and pre-culture with Adipose-derived stem cells (ADSCs) have been attempted to promote early vascularization and integration, but the results were not ideal. Inspired by the manufacturing procedure of frozen bean curd, we proposed a freeze-thaw treatment to enhance the porosity of ADM. We found that the ADM treated with -80°C3R+-30°C3R had the largest disorder of stratified plane arrangement (deviation angle 28.6%) and the largest porosity (96%), making it an optimal approach. Human umbilical vein endothelial cells on freeze-thaw treated ADM demonstrated increased expression in Tie-2 and CD105 genes, proliferation, and tube formation in vitro compared with those on ADM. Combining freeze-thaw with laser drilling and pre-culture with ADSCs, such tri-treatment improved the gene expression of pro-angiogenic factors including IGF-1, EGF, and VEGF, promoted tube formation, increased cell infiltration, and accelerated vascularization soon after implantation. Overall, freeze-thaw is an effective method for optimizing the internal structure of ADM, and tri-treatments may yield clinical significance by promoting early cell infiltration, vascularization, and integration with surrounding tissues.

Abdominal Wall Defect Reconstruction with Use of Biological Mesh and Negative Pressure Wound Therapy: a Case Report

Objectives: Complex abdominal wall reconstruction cases constitute a challenging issue, with high morbidity and mortality rates. Materials and methods: A young trauma patient presented abdominal dehiscence after multiple laparotomies. The fascial defect was managed with the use of a biological mesh, while initially primary wound closure was attempted. Due to cutaneous dehiscence, the use of negative pressure wound therapy was decided. Results: Granulation tissue formation was noticed on the eighth day while complete wound closure was achieved after 57 days. Conclusions:In conclusion, the combined use of biological mesh and negative pressure wound therapy is feasible in the management of complicated abdominal defects.

A novel surgical solution to impossible fascial closure due to contaminated abdominal cavities: A case report

Introduction

Chronic, large, and old incisional hernias often lead to surgical complications and major hindrances during emergent laparotomies. The most challenging stages of the laparotomy in such cases occur during opening and fascial closure.

Case presentation

This article explains the novel surgical technique employed for the complex abdominal closure upon concluding an emergent laparotomy on a 68-year-old female patient. This innovative technique is appropriate for patients with contaminated abdominal cavities and scant fascia who require abdominal operations in cases where biological mesh is not available or is not a viable option.

Conclusion

This surgical technique can help surgeons restrict abdominal contents and organs (particularly the bowel loops) and prevent migration out of the abdominal cavity during the early post-operative stages, hence, reducing post-surgical complications. The discussed surgical technique ensures that the abdominal fascia defect is limited using skin flaps. This defect later develops into a small hernia sac within a few weeks. Patients then need to have a secondary delayed elective operation on this significantly smaller sized hernia for repair using synthetic mesh.

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In repairing large hernias, if there is no contamination, the best method is to repair with mesh.

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In the presence of contamination and small hernia, initial repair seems reasonable.

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If there is a large hernia, the use of biological mesh is a good option if possible.

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In our country, due to the existence of sanctions in such circumstances, using the proposed method can be a good alternative.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients

AIM

The aim of this work was to assess whether placement of a biological mesh (Permacol^® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis.

METHOD

We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3 cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups.

RESULTS

Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3 cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4 ± 1.4 cm vs. 6 ± 2.9 cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7 cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132).

CONCLUSION

Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

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.

The use of Permacol® biological mesh for complex abdominal wall repair

BACKGROUND

Complex abdominal wall repair (CAWR) remains challenging, especially in contaminated fields where the use of a synthetic mesh is associated with prohibitively complication rates. Consequently, biological mesh has been proposed as an alternative. The aim of our study was to evaluate the safety and efficacy of using Permacol® in patients who had CAWR.

METHODS

We retrospectively reviewed the files of patients who had CAWR using the Permacol® mesh. Analysis included patients' preoperative characteristics, procedural parameters, and early and late post-operative complications including mainly recurrence. A multivariate regression model was performed to determine factors that influence 24-months recurrence rate.

RESULTS

Between January 2009 and December 2018, 75 patients. The most common indication was hernia in a contaminated field (48.0%) and abdominal wall defect greater than 10 cm in diameter (36%). Overall, 44% of our patients were Centers for Disease Control (CDC) class II or III and 81.3% fall into category II or III according to the Ventral Hernia Working Group (VHWG) classification. Recurrence rate of our series was 9.3%. Complete fascial closure was achieved in 60 patients (80%). Upon univariate analysis complete fascial closure, posterior component separation, seroma drainage, BMI >30 kg/m2 and age >65 years, VHWD grade >2, DINDO CLAVIEN class > 2 affected the recurrence rate at 2 years follow up. When subcutaneous drains are placed prophylactically, recurrence rates drop from 38.7% (5/14) to 3.3% (2/61 patients) when drains are placed at the time of operation (p=0.02). Only fascial closure affected the 24-months recurrence rate on multivariate analysis (p<0.001).

CONCLUSIONS

Permacol® surgical implant use for CAWR is safe with a relatively low rate of hernia recurrence at 2 years. Prophylactic subcutaneous drain placement may reduce the risk of hernia recurrence. The presence of contaminated fields does not appear to influence hernia recurrence when Permacol® is used, in fact, the only factor that affects recurrence rate at 24-months on multivariate analysis is completeness of the fascial closure.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.