- Open Access
Prosthetic abdominal wall hernia repair in emergency surgery: from polypropylene to biological meshes
World Journal of Emergency Surgery volume 3, Article number: 33 (2008)
The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have expanded and are now widely used in reparative surgery for abdominal wall hernias.
There are still difficulties to find correct indication for prosthetic implant in emergency hernia surgery: as a matter of fact there is still a great debate if to use non-absorbable prostheses in potentially or truly infected operating fields [e.g. after intestinal resections].
All these problems can be avoided with the use of absorbable prosthetic materials such as those composed of lactic acid polymers or lactic and glycolic acid copolymers: however, the use of these absorbable prosthesis exposes the patient to a rapid and inevitable hernia recurrence.
It is important to remember that prosthetic repair has been proven to have a significant less risk of recurrence than repair with direct sutures.
Recently, new "biologic" prosthetic materials have been developed and proposed for the clinical use in infected fields. These materials can be called "remodeling" for the way by which they are replaced after their placement within the patient. The "remodeling" process is made possible through a process of incorporation, where a reproduction of a site-specific tissue similar to the original host tissue is created.
In the last 30 years with the introduction of the "tension-free" techniques in hernia repair based on the use of alloplastic, nonabsorbable prosthetic materials, we have witnessed to a significant reduction in postoperative pain degree and incidence of hernia recurrences when confronted with the older nonprosthetic hernioplasties.
The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have hence expanded and are now widely used in reparative surgery for abdominal wall hernias [1, 2]. When implanted, these nonabsorbable materials –although extremely biocompatible-stimulate a foreign-bodies reaction within the host.
After the initial inflammatory phase, the reaction is followed by an intense deposition of nonspecific fibrotic tissue and concluded by a permanent encapsulation of the alloplastic material in the host's tissues.
If these are the physiopathological bases that explain the success of alloplastic nonabsorbable prosthetic materials in hernia surgery, they are also the reasons for not uncommon complications such as infections [3–7].
Nowadays there are still difficulties to find correct indication for prosthetic implant in emergency hernia surgery: as a matter of fact there is still a great debate if to use non-absorbable prostheses in potentially or truly infected operating fields [e.g. after intestinal resections] .
Any area in which surgery with a possible risk of bacterial contamination is performed [bowel resections, cholecystectomy, operations on bile duct, parastomal hernias, etc], is potentially at risk for prosthetic repair. On one side there is a common consensus on what should be done in frankly contaminated areas such as in peritonitis. In fact the opinion is not to position any kind of non absorbable prosthetic material due to a very high risk of infection [do not use non absorbable materials]. On the other side it is not demonstrated that there is an increased risk of contamination of the mesh in case that simultaneous operations on the digestive tract are performed. [potentially contaminated surgical fields].
Some authors report prosthetic repair of the abdominal wall after colonic resection [potentially contaminated surgical field] with good results [1–3]. Many other perform prosthetic inguinal hernia repair in emergencies in which intestinal resection has to be made [strangulated hernias, another potentially contaminated surgical field] [4–6].
All these problems can be avoided with the use of absorbable prosthetic materials such as those composed of lactic acid polymers or lactic and glycolic acid copolymers .
However, the use of these absorbable prosthesis exposes the patient to a rapid and inevitable hernia recurrence as these materials, once implanted, are attacked by an inflammatory reaction that, through a hydrolytic reaction, removes and digests the implanted prosthetic material completely. In this case, the high risk of hernia recurrence is explained by the complete dissolution of the prosthetic support .
It is important to remember that prosthetic repair has been proven to have a significant less risk of recurrence than repair with direct sutures .
It also possible to perform polypropylene prosthetic incisional hernia repairs in potentially contaminated areas, with a preventive preparation of the retromuscolar-preperitoneal space where in the prosthesis implantation: then the preperitoneal space is closed temporarily suturing the peritoneum to muscular fascia after inserting iodine gauze into it. Only after preparing this space the following emergency potentially contaminating operation can be performed. Great attention must be was given not to contaminate both the peritoneal cavity and the prosthetic implant site. 
It is very important to underline that in incisional hernia the success of the procedure can be guaranteed only by an accurate preparation of the preperitoneal space: perfect haemostasis, temporary closure of the space inserting iodine gauzes, local antibiotic treatment, washing of the cavity and accurate drainage .
In general preperitoneal repair permits to have a wide vision of the inguinal, crural, and spigelian region. The dissection of this space allows to position a wide mesh that repairs the entire region with less risk of recurrence. The peritoneum also isolates the peritoneal cavity from the mesh with less risk of contamination.
A systemic antibiotic therapy should be used as routine in these cases with higher risk of infection. Many studies have proven the validity of antibiotic chemotherapy in the prevention of postoperative infections after prosthetic repair of the abdominal wall . It is certain that both in non-complicated inguinal hernia and in abdominal wall hernia repairs the use of antibiotics can reduce significantly the number of infections. So particularly in operations in which we think that it is possible that enteric bacteria have contaminated the operating field we should use wide spectrum antibiotics that protect against gram + and gram – bacteria. There is no convincing evidence to suggest that the new-generation Cephalosporins are more effective than first-generation . Some Authors suggest in standard prosthetic repair single dose of ampicillin and sulbactam, others Authors first – second generation cephalosporine/amoxicillin and clavulanic acid and others single dose cephtriaxone .
Recently, new "biologic" prosthetic materials have been developed and proposed for the clinical use in infected fields. These materials can be called "remodeling" for the way by which they are replaced after their placement within the patient. The "remodeling" process is made possible through a process of incorporation, where a reproduction of a site-specific tissue similar to the original host tissue is created. The reconstructed tissue tends to resemble the original specific tissue that replaces, not only from the histological point of view, but also functionally. Although these new prosthetic materials are all essentially composed by an extracellular matrix deprived of its cellular components and substantially differs only in relation to the source from which the extracellular matrix is obtained, whether it be either a porcine small intestine submucosa or the cadaveric human derma, or something else [9, 10], they can be further subdivided in two categories: those totally remodeling that are completely substituted by a new created tissue and those partially remodeling that due to a cross-linking process don't disappear completely. The introduction of such materials in clinical practice has provided a new perspective for abdominal wall defect repair in contaminated surgical fields.
In this respect the patient can incorporate the prosthetic material by reconstructing "from himself" the specific damaged tissue and, in particular, recreate a mature "neofascia" that has a normal supportive and contenitive function. Even in the case of the abdominal wall reconstruction, the extracellular matrix implanted into the host has a direct upholding function only initially. Subsequently, it comes to be vascularized and colonized from the host cells that remodel its form until the reconstruction of a new and mature fascia is complete. Finally, this mature structure restores the original supportive and upholding function of the abdominal wall [11, 12].
Although many of these products are purchased with indication for hernia repair and soft tissues reconstruction, only few of them have been reported in literature to have a clinical recognized use: among the partially remodeling the porcine dermal collagen [13–16] and among the totally remodeling the acellular extracellular matrix  the acellular cadaveric dermis [18–20] and the porcine small intestine submucosa [21–30].
Results of long-term studies are no longer available, especially in which they regard hernia recurrences when compared to the non-absorbable materials [some Authors reported an higher recurrent hernia incidence compared to polypropylene but these data were non confirmed].
It is already possible however, to identify clear indications to the use of this biomaterial when considering its peculiarities in the emergency hernia repair of infected or potentially infected fields or in patients with high risk of infection of the non-absorbable prosthesis [i.e. immune-depressed subject] [31–50].
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM: The tension-free hernioplasty. Am J Surg. 1989, 157: 188-93. 10.1016/0002-9610(89)90526-6.
Collaboration EH: Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg. 2000, 87: 854-9. 10.1046/j.1365-2168.2000.01539.x.
Campanelli G, Nicolosi FM, Pettinari D, Avesani EC: Prosthetic repair, intestinal resection, and potentially contaminated areas: safe and feasible?. Hernia. 2004, 8 (3): 190-2. Epub 2004 Jun 16. 10.1007/s10029-004-0242-5.
Birolini C, Utiyama EM, Rodrigues AJ Jr, Birolini D: Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use?. J Am Coll Surg. 2000, 191 (4): 366-72. 10.1016/S1072-7515(00)00703-1.
Pans A, Deasive C, Jacquet N: Use of preperitoneal prosthesis for strangulated groin hernia. Br J Surg. 1997, 84 (3): 310-2. 10.1002/bjs.1800840307. Wysocki A, Pozniczek M, Krzywon J, Bolt L: Use of polypropylene prostheses for strangulated inguinal and incisional hernias. Hernia 2001, 5(2): 105–6
Alaedeen DI, Lipman J: The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields. Hernia. 2006, 11 (1): 41-45. 10.1007/s10029-006-0164-5.
Falagas ME, Kasiakou SK: Mesh-related infections after hernia repair surgery. Clin Microbiol Infect. 2005, 11: 3-8. 10.1111/j.1469-0691.2004.01014.x.
Dayton MT, Buchele BA, Shirazi SS, Hunt LB: Use of an absorbable mesh to repair contaminated abdominal-wall defects. Arch Surg. 1986, 121: 954-60.
Record RD, Hillegonds D, Simmons C: In vivo degradation of 14C-labeled small intestinal submucosa [SIS] when used for urinary bladder repair. Biomaterials. 2001, 22: 2653-9. 10.1016/S0142-9612(01)00007-2.
Hodde J: Naturally occurring scaffolds for soft tissue repair and regeneration. Tissue Eng. 2002, 8: 295-308. 10.1089/107632702753725058.
Sipe JD: Tissue engineering and reparative medicine. Ann NY Acad Sci. 2002, 961: 1-9.
Vacanti JP, Langer R: Tissue engineering: the design and fabrication of living replacement devices for surgical reconstruction and transplantation. Lancet. 1999, 354 (Suppl 1): SI32-4.
Langer R, Vacanti JP: Tissue engineering. Science. 1993, 260: 920-6. 10.1126/science.8493529.
Hiles M, Hodde J: Tissue engineering a clinically useful extracellular matrix biomaterial. Int Urogynecol J. 2006, 17: S39-S43. 10.1007/s00192-006-0104-z.
Hodde J: Extracellular matrix as a bioactive material for soft tissue reconstruction. ANZ J Surg. 2006, 76 (12): 1096-100. 10.1111/j.1445-2197.2006.03948.x.
Parker DM, Armstrong PJ, Frizzi JD, North JH: Porcine dermal collagen [Permacol] for abdominal wall reconstruction. Curr Surg. 63: 255-258. 10.1016/j.cursur.2006.05.003.
Ma SZ, Li XH, Hu J: Acellular extracellular matrix for inguinal hernia repair. Hernia. 2006, 10: 229-231. 10.1007/s10029-006-0071-9.
Buinewicz B, Rosen B: Acellular cadaveric dermis [AlloDerm]: a new alternative for abdominal hernia repair. Ann Plast Surg. 2004, 52: 188-194. 10.1097/01.sap.0000100895.41198.27.
Espinosa-de-los-Monteros A, de la Torre JI, Marrero I, Andrades P, Davis MR, Vásconez LO: Utilization of human cadaveric acellular dermis for abdominal hernia reconstruction. Ann Plast Surg. 2007, 58 (3): 264-7. 10.1097/01.sap.0000254410.91132.a8.
Lipman J, Medalie D, Rosen MJ: Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach. Am J Surg. 2008, 195 (1): 84-8. 10.1016/j.amjsurg.2007.02.017.
Ansaloni L, Catena F, D'Alessandro L: Prospective randomized, double-blind, controlled trial comparing Lichtenstein's repair of inguinal hernia with polypropylene mesh versus Surgisis gold soft tissue graft: preliminary results. Acta Biomed. 2003, 74 (Suppl 2): 10-14.
Edelman DS: Laparoscopic herniorraphy with porcine SIS: a preliminary study. JSLS. 2002, 6: 203-205.
Ansaloni L, Catena F, Gagliardi S, Gazzotti F, D'Alessandro L, Pinna AD: Hernia repair with porcine small-intestinal submucosa. Hernia. 2007, 11 (4): 321-6. 10.1007/s10029-007-0225-4.
Gagliardi S, Ansaloni L, Catena F, Gazzotti F, D'Alessandro L, Pinna AD: Hernioplasty with Surgisis[R] Inguinal Hernia Matrix [IHM]trade mark. Surg Technol Int. 2007, 16: 128-33.
Napolitano L, Di Bartolomeo N, Aceto L, Waku M, Innocenti P: Use of prosthetic materials in incisional hernias: our clinical experience. G Chir. 2004, 25 (4): 141-5.
Rauth TP, Poulose BK, Nanney LB, Holzman MD: A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa – implications for patch repair in ventral herniorrhaphy. J Surg Res. 2007, 143 (1): 43-9. 10.1016/j.jss.2007.03.079.
Edelman DS, Selesnick H: "Sports" hernia: treatment with biologic mesh [Surgisis]: a preliminary study. Surg Endosc. 2006, 20 (6): 971-3. 10.1007/s00464-005-0281-8.
Edelman DS, Hodde JP: Bioactive prosthetic material for treatment of hernias. Surg Technol Int. 2006, 15: 104-8.
Fine AP: Laparoscopic repair of inguinal hernia using Surgisis mesh and fibrin sealant. JSLS. 2006, 10 (4): 461-5.
Ansaloni L, Cambrini P, Catena F, Di Saverio S, Gagliardi S, Gazzotti F, Hodde JP, Metzger DW, D'Alessandro L, Pinna AD: Immune response to small intestinal submucosa [surgisis] implant in humans: preliminary observations. J Invest Surg. 2007, 20 (4): 237-41. 10.1080/08941930701481296.
Saettele TM, Bachman SL, Costello CR, Grant SA, Cleveland DS, Loy TS, Kolder DG, Ramshaw BJ: Use of porcine dermal collagen as a prosthetic mesh in a contaminated field for ventral hernia repair: a case report. Hernia. 2007, 11 (3): 279-85. 10.1007/s10029-006-0186-z.
Smart N, Immanuel A, Mercer-Jones M: Laparoscopic repair of a Littre's hernia with porcine dermal collagen implant [Permacol]. Hernia. 2007, 11 (4): 373-6. 10.1007/s10029-007-0197-4.
Shaikh FM, Giri SK, Durrani S, Waldron D, Grace PA: Experience with porcine acellular dermal collagen implant in one-stage tension-free reconstruction of acute and chronic abdominal wall defects. World J Surg. 2007, 31 (10): 1966-75. 10.1007/s00268-007-9174-4.
Liyanage SH, Purohit GS, Frye JN, Giordano P: Anterior abdominal wall reconstruction with a Permacol implant. J Plast Reconstr Aesthet Surg. 2006, 59 (5): 553-5. 10.1016/j.bjps.2005.06.008.
Gupta A, Zahriya K, Mullens PL, Salmassi S, Keshishian A: Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm. Hernia. 2006, 10 (5): 419-10.1007/s10029-006-0130-2.
Albo D, Awad SS, Berger DH, Bellows CF: Decellularized human cadaveric dermis provides a safe alternative for primary inguinal hernia repair in contaminated surgical fields. Am J Surg. 2006, 192 (5): e12-7. 10.1016/j.amjsurg.2006.08.029.
Schuster R, Singh J, Safadi BY, Wren SM: The use of acellular dermal matrix for contaminated abdominal wall defects: wound status predicts success. Am J Surg. 2006, 192 (5): 594-7. 10.1016/j.amjsurg.2006.08.017.
Alaedeen DI, Lipman J, Medalie D, Rosen MJ: The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields. Hernia. 2007, 11 (1): 41-5. 10.1007/s10029-006-0164-5.
Kim H, Bruen K, Vargo D: Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg. 2006, 192 (6): 705-9. 10.1016/j.amjsurg.2006.09.003.
Diaz JJ, Guy J, Berkes MB, Guillamondegui O, Miller RS: Acellular dermal allograft for ventral hernia repair in the compromised surgical field. Am Surg. 2006, 72 (12): 1181-8.
Patton JH, Berry S, Kralovich KA: Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg. 2007, 193 (3): 360-3. 10.1016/j.amjsurg.2006.09.021.
Bellows CF, Albo D, Berger DH, Awad SS: Abdominal wall repair using human acellular dermis. Am J Surg. 2007, 194 (2): 192-8. 10.1016/j.amjsurg.2006.11.012.
Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, Ponsky J: Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes?. J Am Coll Surg. 2007, 205 (5): 654-60. 10.1016/j.jamcollsurg.2007.06.012. Epub 2007 Sep 14
Franklin ME, Gonzalez JJ, Michaelson RP, Glass JL, Chock DA: Preliminary experience with new bioactive prosthetic material repair of hernias in infected fields. Hernia. 2002, 6: 171-174. 10.1007/s10029-002-0078-9.
Franklin ME, Gonzalez JJ, Glass JL: Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up. Hernia. 2004, 8: 186-189.
Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H: Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg. 2005, 140: 549-560. 10.1001/archsurg.140.6.549.
Catena F, Ansaloni L, Leone A, De Cataldis A, Gagliardi S, Gazzotti F, Peruzzi S, Agrusti S, D'Alessandro L, Taffurelli M: Lichtenstein repair of inguinal hernia with Surgisis inguinal hernia matrix soft-tissue graft in immunodepressed patients. Hernia. 2005, 9: 29-31. 10.1007/s10029-004-0273-y.
Catena F, Ansaloni L, Gazzotti F, Gagliardi S, Di Saverio S, D'Alessandro L, Pinna AD: Use of porcine dermal collagen graft [Permacol] for hernia repair in contaminated fields. Hernia. 2007, 11 (1): 57-60. 10.1007/s10029-006-0171-6.
Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H: Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg. 2005, 140 (6): 549-62. 10.1001/archsurg.140.6.549.
Treviño JM, Franklin ME, Berghoff KR, Glass JL, Jaramillo EJ: Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques. Hernia. 2006, 10 (3): 253-7. 10.1007/s10029-006-0085-3.
The authors declare that they have no competing interests.
GC participated in the design of the paper, FC conceived the paper, and participated in its design and coordination., LA conceived the paper, and participated in its design and coordination. All authors read and approved the final manuscript.
About this article
Cite this article
Campanelli, G., Catena, F. & Ansaloni, L. Prosthetic abdominal wall hernia repair in emergency surgery: from polypropylene to biological meshes. World J Emerg Surg 3, 33 (2008). https://doi.org/10.1186/1749-7922-3-33
- Hernia Repair
- Prosthetic Material
- Parastomal Hernia
- Abdominal Wall Hernia
- Preperitoneal Space