Abdominal wall hernia repair: from prosthetic meshes to smart materials

Hernia reconstruction is one of the most frequently practiced surgical procedures worldwide. Plastic surgery plays a pivotal role in reestablishing desired abdominal wall structure and function without the drawbacks traditionally associated with general surgery as excessive tension, postoperative pain, poor repair outcomes, and frequent recurrence. Surgical meshes have been the preferential choice for abdominal wall hernia repair to achieve the physical integrity and equivalent components of musculofascial layers. Despite the relevant progress in recent years, there are still unsolved challenges in surgical mesh design and complication settlement. This review provides a systemic summary of the hernia surgical mesh development deeply related to abdominal wall hernia pathology and classification. Commercial meshes, the first-generation prosthetic materials, and the most commonly used repair materials in the clinic are described in detail, addressing constrain side effects and rational strategies to establish characteristics of ideal hernia repair meshes. The engineered prosthetics are defined as a transit to the biomimetic smart hernia repair scaffolds with specific advantages and disadvantages, including hydrogel scaffolds, electrospinning membranes, and three-dimensional patches. Lastly, this review critically outlines the future research direction for successful hernia repair solutions by combing state-of-the-art techniques and materials.

Fabrication of Mechanically Enhanced, Suturable, Fibrous Hydrogel Membranes

Poly(vinyl-alcohol) hydrogels have already been successfully utilised as drug carrier systems and tissue engineering scaffolds. However, lacking mechanical strength and suturability hinders any prospects for clinical and surgical applications. The objective of this work was to fabricate mechanically robust PVA membranes, which could also withstand surgical manipulation and suturing. Electrospun membranes and control hydrogels were produced with 61 kDa PVA. Using a high-speed rotating cylindrical collector, we achieved fibre alignment (fibre diameter: 300 ± 50 nm). Subsequently, we created multilayered samples with different orientations to achieve multidirectional reinforcement. Finally, utilising glutaraldehyde as a cross-linker, we created insoluble fibrous-hydrogel membranes. Mechanical studies were performed, confirming a fourfold increase in the specific loading capacities (from 0.21 to 0.84 Nm²/g) in the case of the monolayer samples. The multilayered membranes exhibited increased resistance from both horizontal and vertical directions, which varies according to the specific arrangement. Finally, the cross-linked fibrous hydrogel samples not only exhibited specific loading capacities significantly higher than their counterpart bulk hydrogels but successfully withstood suturing. Although cross-linking optimisation and animal experiments are required, these membranes have great prospects as alternatives to current surgical meshes, while the methodology could also be applied in other systems as well.

Absorbable Electrospun Poly-4-hydroxybutyrate Scaffolds as a Potential Solution for Pelvic Organ Prolapse Surgery

Women with pelvic organ prolapse (POP) have bothersome complaints that significantly affect their quality of life. While native tissue repair is associated with high recurrence rates, polypropylene knitted implants have caused specific implant-related adverse events that have detrimental, often irreversible, effects. We hypothesize that surgical outcome can be improved with a tissue-engineered solution using an absorbable implant that mimics the natural extracellular matrix (ECM) structure, releases estrogen, and activates collagen metabolism by fibroblasts as the main regulators of wound healing. To this aim, we produced electrospun poly-4-hydroxybutyrate (P4HB) scaffolds and biofunctionalized them with estradiol (E2). The cell-implant interactions relevant for POP repair were assessed by seeding primary POP vaginal fibroblasts isolated from patients on electrospun P4HB scaffolds with 1%, 2%, or 5% E2 and without E2. To test our hypothesis on whether ECM mimicking structures should improve regeneration, electrospun P4HB was compared to knitted P4HB implants. We evaluated vaginal fibroblast proliferation, ECM deposition, and metabolism by quantification of collagen, elastin, and matrix metalloproteinases and by gene expression analysis for 28 days. We established effective E2 drug loading with a steady release over time. Significantly higher cell proliferation, collagen-, and elastin deposition were observed on electrospun P4HB scaffolds as compared to knitted P4HB. For this study, physical properties of the scaffolds were more determinant on the cell response than the release of E2. These results indicate that making these electrospun P4HB scaffolds E2-releasing appears to be technically feasible. In addition, electrospun P4HB scaffolds promote the cellular response of vaginal fibroblasts and further studies are merited to assess if their use results in improved surgical outcomes in case of POP repair.

In-vitro Characterization of a Hernia Mesh Featuring a Nanostructured Coating

Abdominal hernia repair is a frequently performed surgical procedure worldwide. Currently, the use of polypropylene (PP) surgical meshes for the repair of abdominal hernias constitutes the primary surgical approach, being widely accepted as superior to primary suture repair. Surgical meshes act as a reinforcement for the weakened or damaged tissues and support tissue restoration. However, implanted meshes could suffer from poor integration with the surrounding tissues. In this context, the present study describes the preliminary evaluation of a PCL-Gel-based nanofibrous coating as an element to develop a multicomponent hernia mesh device (meshPCL-Gel) that could overcome this limitation thanks to the presence of a nanostructured biomimetic substrate for enhanced cell attachment and new tissue formation. Through the electrospinning technique, a commercial PP hernia mesh was coated with a nanofibrous membrane from a polycaprolactone (PCL) and gelatin (Gel) blend (PCL-Gel). Resulting PCL-Gel nanofibers were homogeneous and defect-free, with an average diameter of 0.15 ± 0.04 μm. The presence of Gel decreased PCL hydrophobicity, so that membranes average water contact angle dropped from 138.9 ± 1.1° (PCL) to 99.9 ± 21.6°, while it slightly influenced mechanical properties, which remained comparable to those of PCL (E = 15.7 ± 2.7 MPa, σ R = 7.7 ± 0.6 ε R = 118.8 ± 13.2%). Hydrolytic and enzymatic degradation was conducted on PCL-Gel up to 28 days, with maximum weight losses around 20 and 40%, respectively. The meshPCL-Gel device was obtained with few simple steps, with no influences on the original mechanical properties of the bare mesh, and good stability under physiological conditions. The biocompatibility of meshPCL-Gel was assessed by culturing BJ human fibroblasts on the device, up to 7 days. After 24 h, cells adhered to the nanofibrous substrate, and after 72 h their metabolic activity was about 70% with respect to control cells. The absence of detectable lactate dehydrogenase in the culture medium indicated that no necrosis induction occurred. Hence, the developed nanostructured coating provided the meshPCL-Gel device with chemical and topographical cues similar to the native extracellular matrix ones, that could be exploited for enhancing the biological response and, consequently, mesh integration, in abdominal wall hernia repair.

Regenerated silk fibroin (RSF) electrostatic spun fibre composite with polypropylene mesh for reconstruction of abdominal wall defects in a rat model

Abdominal wall defects are associated with abdominal wall surgery, infection and tumour resection. Polypropylene (PP) mesh, which has excellent mechanical strength, is currently the primary clinical repair material. In repairing the abdominal wall, the mesh can erode the bowel and cause other problems. Constructing a barrier that induces a weak inflammatory response and promotes rapid recovery of the peritoneum is important. We used electrospinning technology to construct a silk fibroin coating on the abdominal surface of a PP patch. A rat model was used to compare the inflammatory responses, regeneration of peritoneal tissue, and antiadhesion effects of electrospun regenerated silk fibroin (RSF) coatings, polycaprolactone (PCL) coatings, and noncoated PP meshes. The inflammatory responses, antiadhesion fractions, and areas of RSF and PCL were better than those of PP at 6 weeks. RSF was associated with complete peritoneal regeneration, in contrast to PCL. At 12 weeks, the structure of the PCL peritoneum was unstable, and the adhesion fraction and area were significantly higher than those of RSF. The intact peritoneum could not be effectively regenerated. The RSF group exhibited lower IL-6 levels than the PCL and PP groups but higher VEGF, IL-10 and TGF-β levels, making RSF more conducive to the regeneration of peritoneal and abdominal wall tissues.

Electrospun nanofiber mesh with fibroblast growth factor and stem cells for pelvic floor repair

Surgical outcome following pelvic organ prolapse (POP) repair needs improvement. We suggest a new approach based on a tissue-engineering strategy. In vivo, the regenerative potential of an electrospun biodegradable polycaprolactone (PCL) mesh was studied. Six different biodegradable PCL meshes were evaluated in a full-thickness abdominal wall defect model in 84 rats. The rats were assigned into three groups: (1) hollow fiber PCL meshes delivering two dosages of basic fibroblast growth factor (bFGF), (2) solid fiber PCL meshes with and without bFGF, and (3) solid fiber PCL meshes delivering connective tissue growth factor (CTGF) and rat mesenchymal stem cells (rMSC). After 8 and 24 weeks, we performed a histological evaluation, quantitative analysis of protein content, and the gene expression of collagen-I and collagen-III, and an assessment of the biomechanical properties of the explanted meshes. Multiple complications were observed except from the solid PCL-CTGF mesh delivering rMSC. Hollow PCL meshes were completely degraded after 24 weeks resulting in herniation of the mesh area, whereas the solid fiber meshes were intact and provided biomechanical reinforcement to the weakened abdominal wall. The solid PCL-CTGF mesh delivering rMSC demonstrated improved biomechanical properties after 8 and 24 weeks compared to muscle fascia. These meshes enhanced biomechanical and biochemical properties, demonstrating a great potential of combining tissue engineering with stem cells as a new therapeutic strategy for POP repair. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 108B:48-55, 2020.

Mechanical Considerations for Electrospun Nanofibers in Tendon and Ligament Repair

Electrospun nanofibers possess unique qualities such as nanodiameter, high surface area to volume ratio, biomimetic architecture, and tunable chemical and electrical properties. Numerous studies have demonstrated the potential of nanofibrous architecture to direct cell morphology, migration, and more complex biological processes such as differentiation and extracellular matrix (ECM) deposition through topographical guidance cues. These advantages have created great interest in electrospun fibers for biomedical applications, including tendon and ligament repair. Electrospun nanofibers, despite their nanoscale size, generally exhibit poor mechanical properties compared to larger conventionally manufactured polymer fiber materials. This invites the question of what role electrospun polymer nanofibers can play in tendon and ligament repair applications that have both biological and mechanical requirements. At first glance, the strength and stiffness of electrospun nanofiber grafts appear to be too low to fill the rigorous loading conditions of these tissues. However, there are a number of strategies to enhance and tune the mechanical properties of electrospun nanofiber grafts. As researchers design the next-generation electrospun tendon and ligament grafts, it is critical to consider numerous physiologically relevant mechanical criteria and to evaluate graft mechanical performance in conditions and loading environments that reflect in vivo conditions and surgical fixation methods.