Best Mesh For Incisional Umbilical Repair?

Ann R Coll Surg Engl. 2022 May; 92(four): 272–278.

Which mesh for hernia repair?

Abstruse

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 master suture repair. Equally a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one tin be hard. This article outlines the full 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 (<http://www.pubmed.gov>). To capture all potentially relevant manufactures with the highest degree of sensitivity, the search terms were intentionally wide. Nosotros used the following terms: 'mesh, pore size, strength, recurrence, complications, lightweight, properties'. We also mitt-searched the bibliographies of relevant manufactures and product literature to identify boosted pertinent reports.

RESULTS AND CONCLUSIONS

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

Keywords: Hernia, Mesh, Filament, Tensile forcefulness, Porosity, Acellular dermi

History

Until 1958, abdominal wall hernias were closed with primary suture repair. In 1958, Usher published his technique using a polypropylene mesh. This led to the Lichtenstein repair some 30 years later on which popularised mesh for hernia repair. Currently, nigh one 1000000 meshes are used per yr world-wide.¹ The benefits of meshes were accepted for many years just the need for evidence-based medicine led to several trials designed to quantify their advantages. In 2002, the European union trialist collaboration analysed 58 randomised controlled trials and institute that the utilize of mesh was superior to other techniques. In item, they noted fewer recurrences and less postoperative pain with mesh repair.^two Although these results are non accepted by all surgeons,^three meshes take now virtually replaced suture repair in the developed world.

The original logic backside using a mesh was very simple: the mesh was a cloth which could be used to reinforce the abdominal wall with the germination of scar tissue. Information technology was expected that the all-time meshes would be those made of very strong material and able to induce the most fibrosis. Unfortunately, this fibrotic reaction led to hurting and movement restriction and it before long became clear that this needed to be minimised. In order to exercise this, the surface area, and therefore strength, of the mesh had to be reduced. Calculations of intra-abdominal pressures proved that this would be possible without compromising mesh function. In fact, the tensile strength of a mesh required to withstand the maximum abdominal pressure is only a tenth of that of most meshes (encounter Fig. 2). This realisation led to the concept of light-weight meshes.

Comparison of mesh strength with intestinal wall pressures.

Light-weight meshes were get-go introduced in 1998 (Vypro) and their superiority over the heavy-weight meshes is now widely accepted. These meshes have large pores (normally 3–five mm) and a small surface expanse. They stimulate a reduced inflammatory reaction and, therefore, take greater elasticity and flexibility.⁴ They as well shrink less and have been shown to decrease pain after Lichtenstein inguinal hernia repair. Unfortunately, despite these improvements, they continue to have complications such equally recurrence, infection and adhesion germination. Thus, the search for an ideal mesh continues.

The difficulty of finding a unmarried, 'ideal' mesh was best-selling by the development of composite meshes. These combine more than than one material and are the ground of nigh new mesh designs. The principal reward of the composite meshes is that they can be used in the intraperitoneal space with minimal adhesion germination. Despite the vast selection of brands bachelor, well-nigh all these meshes continue to utilise 1 or other of 3 bones materials – Polypropylene, Polyester and ePTFE. These are used in combination with each other or with a range of additional materials such every bit titanium, omega 3, monocryl, PVDF and hyaluronate. Contrary to the manufacturers' literature, information technology appears that none of these constructed materials is without disadvantages.^v

The bug encountered with synthetic materials led to the development of biomaterials and it is appropriate that the history of meshes should conclude with the well-nigh physiologically based implants. These consist of an acellular collagen matrix derived from human dermis (Aderm) or porcine modest intestine submucosa (Surgisis). The matrix allows soft tissue to infiltrate the mesh which eventually becomes integrated into the body by a process of remodelling. Unfortunately, this process also appears to lead to a rapid reduction in their mechanical strength, and concerns regarding this have restricted their use to infected environments (where ane would unremarkably utilize an absorbable synthetic material such equally Vicryl).

It is articulate that the evolution of meshes is non yet consummate and the ideal mesh has yet to be establish. As no such mesh exists, this article outlines the backdrop to be considered when choosing a suitable implant from the many bachelor.

Materials and Methods

We performed a search of the medical literature from 1950 to one May 2009, as indexed by Medline, using the PubMed search engine (<http://www.pubmed.gov>). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. Nosotros used: '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.

Mesh properties

TENSILE Strength

The tension placed on the intestinal wall tin exist calculated by the law of Laplace which states that (Fig. 1): 'in an elastic spherical vessel (abdomen), the tension, pressure, wall thickness and diameter are related by: Tension = (Diameter × Pressure)/(4 × Wall thickness)'.

The tension placed on the abdominal wall as calculated by the police of Laplace.

The maximum intra-abdominal pressures generated in salubrious adults occur whilst cough and jumping (Fig. ii). These are estimated to be about 170 mmHg.⁶ Meshes used to repair large hernias, therefore need to withstand at to the lowest degree 180 mmHg earlier bursting (tensile strength upwards to 32 N/cm). This is easily achieved as even the lightest meshes will withstand twice this pressure without bursting (for instance, burst force per unit area of Vypro = 360 mmHg^vii). This illustrates that the tensile strengths of 100 N/cm of the original meshes were vastly overestimated.

PORE SIZE

Porosity is the main determinant of tissue reaction. Pores must be more than 75 μm in society to permit infiltration by macrophages, fibroblasts, blood vessels and collagen. Meshes with larger pores permit increased soft tissue in-growth and are more flexible considering of the avoidance of granuloma bridging. Granulomas normally form effectually individual mesh fibres as part of the foreign body reaction. Bridging describes the process whereby individual granulomas get confluent with each other and encapsulate the entire mesh (Fig. 3). This leads to a potent scar plate and reduced flexibility. It occurs in meshes with small pores of less than 800 μm.

Granulomas forming effectually individual mesh fibres and bridging where individual granulomas become confluent with each other and encapsulate the entire mesh.

WEIGHT

The weight of the mesh depends on both the weight of the polymer and the amount of material used (pore size).^nine

Heavy-weight meshes utilize thick polymers, have modest pore sizes and high tensile forcefulness. These meshes typically weigh 100 chiliad/grand² (i.5 g for 10 × 15 cm mesh). The strength is derived from a large mass of material, which activates a profound tissue reaction and dense scarring.

Light-weight meshes are equanimous of thinner filaments and have larger pores (> 1 mm). Their weight is typically 33 g/m² (0.five k for 10 × 15 cm mesh). They initiate a less pronounced foreign body reaction and are more than elastic. Despite a reduced tensile forcefulness, they tin still withstand pressures above the maximum abdominal pressure of 170 mmHg (minimum tensile strength 16 Northward/cm).

A new generation of even lighter meshes include the titanium/propylene composite meshes. These accept been shown to exist associated with a more rapid recovery in a recent, randomised controlled trial (RCT).⁸ The lightest of these (Extralight TiMesh) may have insufficient tensile strength in some situations (maximum tensile strength 12 Northward/cm).

REACTIVITY/BIOCOMPATIBILITY

Modern biomaterials are physically and chemically inert. They are generally stable, non-immunogenic and not-toxic. Despite this, they are not biologically inert.^seven A strange body reaction is triggered by their presence. This involves inflammation, fibrosis, calcification, thrombosis and germination of granulomas. Information technology is very different from the physiological wound healing of suture repair.⁹

The foreign torso reaction is fairly uniform regardless of the blazon of foreign material, merely the extent of the reaction is afflicted by the amount of material present. Thus pore size is once once more the determining factor for meshes. As described above, meshes with minor pores develop stiff scar plates which are avoided in meshes with larger pores where there is a gap between the granulomas.

Meshes also appear to alter collagen limerick. During normal scar healing, the initial, young, type 3 collagen is chop-chop replaced by stronger, type I collagen. This process is delayed in the presence of a foreign body such as a mesh. The outcome is a much lower ratio of type I/III collagen, leading to reduced mechanical stability.^{7 , ix , 10} This effect occurs regardless of the type of mesh used, although the corporeality of collagen laid downwards is college in microporous meshes.

ELASTICITY

The natural elasticity of intestinal wall at 32 Due north/cm is near 38%. Calorie-free-weight meshes have an elasticity of about 20–35% elasticity at 16 Northward/cm.^seven Heavy-weight meshes have merely one-half this elasticity (4–16% at 16 Northward/cm) and can restrict intestinal distension.

CONSTITUTION

Mesh fibres tin can exist monofilament, multifilament (braided), or patches (for example, ePTFE). Multifilament fibres have a higher risk of infection.

SHRINKAGE

Shrinkage occurs due to contraction of the scar tissue formed around the mesh. Scar tissue shrinks to about threescore% of the former expanse of the wound.⁷ The smaller pores of heavy-weight meshes atomic number 82 to more than shrinkage due to the formation of a scar plate (Fig. 4).

Shrinkage properties of different meshes. Prolene shrinks 75–94%, PTFE shrinks twoscore–50%, Vypro II shrinks 29%, Ultrapro shrinks < 5%, and Sofradim shrinks < five%.

Complications of meshes

Most complications are merely a reflection of the backdrop already described. Thus, when choosing a mesh, the surgeon must decide which properties are the most important for the specific situation. For example, materials such every bit ePTFE have a adept contour for adhesion take chances but a loftier risk of infection. Incontrast, Polypropylene meshes are durable and have a depression infection adventure merely they accept piddling flexibility and a loftier adhesion adventure. The primary factors to consider in relation to complications are outlined below.

INFECTION Adventure

Mesh infection is feared considering it is difficult to eradicate without removing the mesh and can become clinically apparent many years after implantation.^eleven Mesh infection remains about 0.i–iii%,^{12 , 13} although this is obviously higher in the infected fields, for example, in parastomal hernia repair.

Although widely practiced, at that place is no evidence that routine prophylaxis with antibiotics confers whatsoever protection confronting infection. In contrast there is some evidence that the infection risk tin can exist lowered by impregnating meshes with antiseptics.^fourteen

The risk of infection is mainly determined by the type of filament used and pore size. Microporous meshes (for instance, ePTFE) are at higher risk of infection because macrophages and neutrophils are unable to enter small pores (< ten μm). This allows leaner (< 1 μm) to survive unchallenged within the pores. A similar problem applies to multifilament meshes. The meshes at lowest gamble of infection are, therefore, those fabricated with monofilament and containing pores greater than 75 μm. Eradication of infection in such meshes tin be achieved without their removal.¹⁵

ADHESION RISK

The popularisation of laparoscopic intraperitoneal mesh placement has led to increasing concern regarding mesh-related adhesions. Adhesions effect from the fibrin exudates that follow whatsoever kind of trauma. These exudates form temporary adhesions until the fibrinolytic organization absorbs the fibrin. Absorption is delayed in the presence ischaemia, inflammation or foreign bodies (for example, meshes). In these situations, they mature into tissue adhesions.

All meshes produce adhesions when placed adjacent to bowel, but their extent is determined by pore size, filament construction and surface area. Heavy-weight meshes induce an intense fibrotic reaction which ensures strong adherence to the abdominal wall but also causes dense adhesions. In contrast, microporous ePTFE does not allow tissue in-growth. It has a very low risk of adhesion formation, only is unable to adhere strongly to the abdominal wall.

These two extremes illustrate the difficulty of producing a mesh which will adhere well to the abdominal wall but non to the bowel. Composite meshes aim to do this by providing an boosted surface which can be safely placed in contact with bowel whilst peritoneal mesothelial cells grow over the mesh. It takes up to 7 days to regenerate peritoneum; however, once formed, it should prevent adhesion germination to the mesh. Until recently, the standard composite mesh was a PP/ePTFE mix, just there are now a large multifariousness of substances available, including PVDF, cellulose and omega-3 fatty acids. Unfortunately, at that place is evidence to advise that most of these only forbid adhesion germination in the brusque term and the effect is diminished afterward xxx days.¹⁶ In some types, information technology is besides possible for the layers to separate and become adherent to bowel.¹⁷

RECURRENCE

The use of meshes is thought to reduce dramatically the incidence of hernia recurrence. Quoted rates vary profoundly between studies, merely near describe a reduction in the rate of recurrence by at least half when using a mesh (for case, for incisional hernias this is reduced from 17–67% to 1–32%).^{18 – 23} In nearly all cases, recurrent herniation occurs at the edges of meshes. This is commonly due to inadequate fixation, or underestimation of shrinkage of the mesh, at the original operation. In that location is little evidence that recurrence is related to the blazon of mesh used,^five although information technology has been proposed that light-weight meshes accept a higher risk due to their increased flexibility and move.^vii Other known take chances factors include postoperative infection, seroma and haematoma.

Ii-thirds of recurrences occur after 3 years (median, 26 months).²⁴ This suggests that a technical mistake is unlikely to be the only cause of recurrence and defective collagen synthesis may be equally important. All meshes cause a foreign body reaction which has an consequence on the ratio of Type I and Three collagen synthesised.^{seven , 9} Changes in this ratio bear upon both tensile strength and mechanical stability and may increase the risk of recurrence. Altered ratios of collagen tin can be seen within fibroblasts located at the edges of recurrent hernias.^{7 , nine , 22} Information technology is not clear if the type of mesh used has any effect on this.

Hurting

Meshes are associated with a reduced risk of chronic pain compared to suture repair. This is thought to be related to the power to employ tension-gratuitous technique rather than the mesh itself.¹⁹ Notwithstanding, hurting remains a serious complication of mesh repair and can occur for a diversity of reasons. With regards to acute postoperative pain, there is little difference in the type of mesh used. Chronic pain post-obit hernia repair has gained increased recognition, with a quoted risk of over 50%.^{25 , 26} When it starts in the immediate postoperative period, information technology is usually due to nerve damage at the time of performance. In dissimilarity, hurting due to foreign torso reaction (FBR) typically presents subsequently one year. Explants removed for chronic pain are plant to take nerve fibres and fascicles around the strange body granulomata within the mesh. Neuromas tin can also be found at the interface of mesh and host tissue suggesting mechanical destruction of fretfulness by mesh. Information technology follows that meshes with small pores and greater FBR, volition cause college rates of chronic hurting. This is supported by nearly studies,^{27 , 28} although disputed past some.^{29 , 30} Some authors take besides suggested that absorbable meshes may have a part in reducing chronic pain.²⁶

MESH DEGRADATION

Degradation of meshes is rare and mainly seen in polyester meshes.³¹ Degradation may be due to hydrolysis, resulting in brittleness and loss of mechanical forcefulness. Calcification can besides occur only has only been documented in meshes with small pores.³²

SEROMA

Seromas develop with any mesh type but those with larger pores may be less probable to do so.³³

Which mesh should surgeons use?

When choosing a mesh (Tables 1–three), the surgeon must consider the context in which it is to be used. In most situations, one should look for a light-weight mesh, with big pores and minimal surface surface area. Ideally, information technology should consist of a monofilament. A polypropylene or polyester mesh is, therefore, unremarkably suitable (for instance, Paritiene Low-cal, Optilene, Mersilene). These meshes will be more than comfortable and take a lower gamble of infection. If the mesh is to exist placed inside the peritoneal crenel, an effort should be fabricated to minimise adhesions by choosing a hybrid mesh with an absorbable surface. Despite manufacturers' claims, the differences between the various types of these are unproven and it is currently difficult to recommend a unmarried cloth. In infected wounds, an absorbable mesh is preferred, for example, polyglactin (Vicryl) or polyglycolic (Dexon). Biomaterials may also exist useful in this situation if the additional toll can be justified. Finally, the surgeon should not forget that the way the mesh is placed is as of import equally the blazon of mesh used. If a mesh is too small or fixed under tension, there will exist complications any its textile. Despite the new implants available, surgical skill yet has a office in preventing hernia recurrence!

Table ane

Types of mesh: Multi, mulifilament and monofilament, foil

Type of mesh		Pore size	Absorbable	Weight	Comments
Multi
Vicryl (Ethicon)	Polyglactin	Small 0.4 mm	Yeah, fully (60–90 days)	Medium weight 56 chiliad/m2	Absorbable meshes primarily used in infected fields
Dexon (Syneture)	Polyglycolic	Medium 0.75mm	Yes, fully (60–90 days)
Safil (B-Baun)
Multifilament and monofilament
Marlex (BARD)	Polypropylene	Small to medium 0.8 mm	No	Heavy-weight boilerplate eighty–100 g/grandii	Traditional heavy meshes with small pores and picayune stretch. Non used in extraperitoneal spaces as they produce dense adhesions. Low infection take chances
3D Max (BARD)
Polysoft (BARD)
Prolene (Ethicon)
Surgipro (Autosuture)
Prolite (Atrium)
Trelex (Meadox)
Atrium (Atrium)
Premilene (B-Braun)
Serapren (smooth)
Parietene (Covidien)
Parietene Lite (Covidien)		Big i.0–3.6 mm		Lite/medium weight 36–48g/m2	Traditional meshes only lighter, with larger pores
Optilene (B-Baun)
Multi
Mersilene (Ethicon)	Polyester	Big 1–2 mm	No	Medium weight ∼twoscore g/m2	Low infection adventure and ?less inflammatory response than PP. Long-term degradation may be a problemthirty
Foil
Goretex (Gore)	ePTFE	Very small-scale iii μm	No	Heavyweight	Smooth and strong. Not a true mesh simply multilaminar patch. Microporous. High infection chance

Table three

Composite meshes (for intraperitoneal utilise)

Blazon of mesh		Pore size	Absorbable	Weight	Comments
Multi
Vypro, Vypro 2 (Ethicon)	Prolypropylene/PG910	Large > 3 mmm	Partially (42 days)	Calorie-free-weight 25 & 30 g/m2	First light-weight meshes with large pores. Vypro not strong enough for incisional hernias (use Vypro Two)
Gortex Dual Mesh & Dual Mesh Plus (Gore)	ePTFE	Very small three/22 μm	No	Heavy-weight	Unlike sized pores for each side. Dual Mesh Plus is impregnated with clarified to minimise infection
Parietex (Covidien)	Polyester/collagen	Large > 3 mm	Partially (xx days)	Medium weight 75 g/thou2	Bovine collagen coating and anti-adhesion pic of polyethylene glycol and glycerol. ?Only short-term benefit for anti-adhesional property16
Mono
Composix EX Dulex (BARD)	Polypropylene/ePTFE	Medium 0.8 mm	No	Light-weight	2 singled-out surfaces, overlap of ePTFE stops adhesions at the edges
Continue (Ethicon)	Polypropylene/cellulose (ORC)	Big	Partially (< thirty days)	Light-weight 45 g/10002	3-layer laminate with PP; oxidised cellulose (absorbable) and polydioxanone film (not captivated)
Dynamesh IPOM (FEG Textiltechnik)	Prolypropylene/PVDF	Large 1–two mm	Partially	Medium weight 60 g/m2	PVDF causes minimal strange trunk reaction
Sepramesh (Genzyme)	Prolypropylene/sodium	Big i–ii mm	Partially (< 30 days)	Heavy-weight 102 g/mtwo	Seprafilm turns to gel in 48 h and remains on mesh for 1 week to allow re-epithelisation. ?Just short-term benefit for anti-adhesional property hyaluronatexvi
Ultrapro (Ethicon)	Polypropylene/polyglecaprone (Monocryl)	Large > iii mm	Partially (< 140 days)	Light-weight 28 g/m2	Monocryl has a combination of polymers; east-caprolactone, which is malleable and polyglycolide, which is potent. Less inflammatory response than Vicryl
Ti-mesh (GfE)	Polypropylene/titanium	Big > ane mm	No	Low-cal-weight and actress-low-cal 16 & 35 k/one thousandii	Perhaps has a reduced inflammatory response compared to other meshes (?biologically inert)34
C-Qur (Atrium)	Polypropylene/omega three	Big > 1 mm	Partially (∼120 days)	Medium-weight 50 1000/m2	Omega 3 from fish oils ?Only short-term benefit for anti-adhesional propertysixteen

Tabular array 2

Types of mesh: Biomateria

Type of mesh		Comments
Surgisis (Cook)	Porcine (small intestine submucosa)	Readily colonised past host and forms scaffold for repair and remodelling of ECM. Strong at commencement but loss of strength with remodelling. Can be used in contaminated wounds
Fortagen (Organogenesis)
Alloderm (Lifecell)	Human being acellular dermis
Flex Hd (J&J)
AlloMax (Davol)
Collamend (Davol)	Xenogenic acellular dermis (porcine/bovine)
Strattice (LifeCell)
Permacol (TSL)
XenMatriX (Brennen)
SurgiMend (TEI)

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025220/

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