Michael J Rosen1. 1. Case Medical Center, University Hospitals of Cleveland, Department of General Surgery, Cleveland, OH 44106, USA.
Abstract
INTRODUCTION: The ideal prosthetic material for ventral hernia repair has yet to be described. Each prosthetic material has unique advantages and disadvantages in terms of tissue ingrowth, adhesion formation, and shrinkage profiles. Polyester-based mesh has shown minimal shrinkage and excellent tissue ingrowth in animal models. However, the macroporous, braided nature of this material has raised several concerns regarding the incidence of infections, fistulas, and bowel obstructions. We have reviewed our experience with polyester-based mesh for the repair of ventral hernias. METHODS: All patients undergoing ventral hernia repair at the Case Comprehensive Hernia Center at University Hospitals of Cleveland from December 2005 to April 2008 were included. Laparoscopic cases underwent intraperitoneal placement of a polyester-based mesh with a collagen hydrogel anti-adhesive barrier. The mesh was sized for at least 4 cm of fascial overlap, and transfascial fixation sutures and titanium spiral tacks were used routinely to secure the mesh to the abdominal wall. Those cases deemed inappropriate for laparoscopic ventral hernia repair underwent open repair. Open ventral hernia repairs were performed using a retrorectus repair, placing the mesh in an extraperitoneal position. Unprotected polyester mesh was used in these cases. Pertinent data included patient demographics, surgical details, postoperative outcomes, and long-term follow-up evaluation. RESULTS: During the study period 109 patients underwent ventral hernia repair with polyester mesh. Seventy-nine patients had a laparoscopic repair, and 30 patients had an open repair. The mean age was 57 years, with a mean body mass index of 33 kg/m(2), and American Society of Anesthesia score of 2.6. The patients had undergone 2.1 prior abdominal surgical procedures, and 42 patients had recurrent hernias. Surgical details for the laparoscopic repair and open repair were as follows: mean defect size, 116 versus 403 cm(2); mesh size, 367 versus 1,055 cm(2); and surgical times, 132 versus 170 minutes, respectively. The average hospital stay was 4.2 days for the laparoscopic repair and 5.8 days for the open repair groups. With a mean follow-up period of 14 months (range, 2-28 mo) in the laparoscopic repair group, 1 patient (1.4%) developed a mesh infection (with a history of a prior methicillin-resistant Staphylococcus aureus mesh infection), 1 patient (1.4%) developed a small-bowel obstruction remote to the mesh on re-exploration, and there were no fistulas. With a mean follow-up period of 11 months (range, 2-21 mo) in the open repair group, 3 wound infections (13%) occurred, 2 involved the mesh, which was salvaged with local wound care in 1, and required partial mesh resection in the other, and there were no bowel obstructions or fistulas during the follow-up evaluation. CONCLUSIONS: This study shows that in this complex group of patients, polyester mesh placed during ventral hernia repair results in acceptable infection rates, and no direct bowel complications or fistulas. Given the macroporous nature of the mesh, each case of infection was treated successfully with local wound measures or partial mesh resection. Polyester-based meshes with an anti-adhesive barrier appear safe for intraperitoneal placement.
INTRODUCTION: The ideal prosthetic material for ventral hernia repair has yet to be described. Each prosthetic material has unique advantages and disadvantages in terms of tissue ingrowth, adhesion formation, and shrinkage profiles. Polyester-based mesh has shown minimal shrinkage and excellent tissue ingrowth in animal models. However, the macroporous, braided nature of this material has raised several concerns regarding the incidence of infections, fistulas, and bowel obstructions. We have reviewed our experience with polyester-based mesh for the repair of ventral hernias. METHODS: All patients undergoing ventral hernia repair at the Case Comprehensive Hernia Center at University Hospitals of Cleveland from December 2005 to April 2008 were included. Laparoscopic cases underwent intraperitoneal placement of a polyester-based mesh with a collagen hydrogel anti-adhesive barrier. The mesh was sized for at least 4 cm of fascial overlap, and transfascial fixation sutures and titanium spiral tacks were used routinely to secure the mesh to the abdominal wall. Those cases deemed inappropriate for laparoscopic ventral hernia repair underwent open repair. Open ventral hernia repairs were performed using a retrorectus repair, placing the mesh in an extraperitoneal position. Unprotected polyester mesh was used in these cases. Pertinent data included patient demographics, surgical details, postoperative outcomes, and long-term follow-up evaluation. RESULTS: During the study period 109 patients underwent ventral hernia repair with polyester mesh. Seventy-nine patients had a laparoscopic repair, and 30 patients had an open repair. The mean age was 57 years, with a mean body mass index of 33 kg/m(2), and American Society of Anesthesia score of 2.6. The patients had undergone 2.1 prior abdominal surgical procedures, and 42 patients had recurrent hernias. Surgical details for the laparoscopic repair and open repair were as follows: mean defect size, 116 versus 403 cm(2); mesh size, 367 versus 1,055 cm(2); and surgical times, 132 versus 170 minutes, respectively. The average hospital stay was 4.2 days for the laparoscopic repair and 5.8 days for the open repair groups. With a mean follow-up period of 14 months (range, 2-28 mo) in the laparoscopic repair group, 1 patient (1.4%) developed a mesh infection (with a history of a prior methicillin-resistant Staphylococcus aureus mesh infection), 1 patient (1.4%) developed a small-bowel obstruction remote to the mesh on re-exploration, and there were no fistulas. With a mean follow-up period of 11 months (range, 2-21 mo) in the open repair group, 3 wound infections (13%) occurred, 2 involved the mesh, which was salvaged with local wound care in 1, and required partial mesh resection in the other, and there were no bowel obstructions or fistulas during the follow-up evaluation. CONCLUSIONS: This study shows that in this complex group of patients, polyester mesh placed during ventral hernia repair results in acceptable infection rates, and no direct bowel complications or fistulas. Given the macroporous nature of the mesh, each case of infection was treated successfully with local wound measures or partial mesh resection. Polyester-based meshes with an anti-adhesive barrier appear safe for intraperitoneal placement.