Is Mesh Used For Children Hernia Repair

Ann R Coll Surg Engl. 2010 May; 92(4): 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 about countries and widely accustomed as superior to primary suture repair. As a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one can be difficult. This article outlines the general properties of meshes and factors to be considered when selecting 1.

MATERIALS AND METHODS

We performed a search of the medical literature from 1950 to i May 2009, as indexed by Medline, using the PubMed search engine (<http://world wide web.pubmed.gov>). To capture all potentially relevant articles with the highest caste of sensitivity, the search terms were intentionally broad. We used the following terms: 'mesh, pore size, strength, recurrence, complications, lightweight, properties'. Nosotros besides hand-searched the bibliographies of relevant articles and product literature to identify additional pertinent reports.

RESULTS AND CONCLUSIONS

The most of import properties of meshes were found to exist the type of filament, tensile strength and porosity. These determine the weight of the mesh and its biocompatibility. The tensile strength required is much less than originally presumed and light-weight meshes are thought to be superior due to their increased flexibility and reduction in discomfort. Big pores are also associated with a reduced gamble of infection and shrinkage. For meshes placed in the peritoneal cavity, consideration should besides be given to the risk of adhesion formation. A variety of blended meshes have been promoted to address this, merely none appears superior to the others. Finally, biomaterials such as acellular dermis have a place for apply in infected fields but have yet to prove their worth in routine hernia repair.

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

History

Until 1958, abdominal wall hernias were closed with chief suture repair. In 1958, Usher published his technique using a polypropylene mesh. This led to the Lichtenstein repair some xxx years afterward which popularised mesh for hernia repair. Currently, about one million meshes are used per year world-wide.¹ The benefits of meshes were accepted for many years merely the need for evidence-based medicine led to several trials designed to quantify their advantages. In 2002, the EU trialist collaboration analysed 58 randomised controlled trials and found that the employ of mesh was superior to other techniques. In item, they noted fewer recurrences and less postoperative pain with mesh repair.² Although these results are not accepted by all surgeons,^three meshes have at present almost replaced suture repair in the adult world.

The original logic backside using a mesh was very simple: the mesh was a fabric which could be used to reinforce the abdominal wall with the germination of scar tissue. It was expected that the best meshes would be those fabricated of very strong material and able to induce the nearly fibrosis. Unfortunately, this fibrotic reaction led to hurting and movement restriction and it presently became clear that this needed to be minimised. In order to exercise this, the surface expanse, and therefore strength, of the mesh had to be reduced. Calculations of intra-abdominal pressures proved that this would be possible without compromising mesh part. In fact, the tensile forcefulness of a mesh required to withstand the maximum intestinal pressure is just a tenth of that of most meshes (run across Fig. 2). This realisation led to the concept of lite-weight meshes.

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Comparing of mesh strength with abdominal wall pressures.

Lite-weight meshes were commencement introduced in 1998 (Vypro) and their superiority over the heavy-weight meshes is now widely accustomed. These meshes accept large pores (normally iii–5 mm) and a minor expanse. They stimulate a reduced inflammatory reaction and, therefore, have greater elasticity and flexibility.⁴ They also shrink less and have been shown to subtract pain later on Lichtenstein inguinal hernia repair. Unfortunately, despite these improvements, they continue to have complications such as recurrence, infection and adhesion formation. Thus, the search for an ideal mesh continues.

The difficulty of finding a single, 'ideal' mesh was best-selling by the development of blended meshes. These combine more than ane fabric and are the footing of most new mesh designs. The primary advantage of the blended meshes is that they can be used in the intraperitoneal space with minimal adhesion formation. Despite the vast selection of brands bachelor, most all these meshes keep to use 1 or other of 3 basic materials – Polypropylene, Polyester and ePTFE. These are used in combination with each other or with a range of boosted materials such as titanium, omega iii, monocryl, PVDF and hyaluronate. Contrary to the manufacturers' literature, information technology appears that none of these constructed materials is without disadvantages.⁵

The problems encountered with synthetic materials led to the development of biomaterials and it is appropriate that the history of meshes should conclude with the most physiologically based implants. These consist of an acellular collagen matrix derived from human dermis (Aderm) or porcine small intestine submucosa (Surgisis). The matrix allows soft tissue to infiltrate the mesh which somewhen becomes integrated into the torso by a process of remodelling. Unfortunately, this process likewise appears to lead to a rapid reduction in their mechanical strength, and concerns regarding this have restricted their use to infected environments (where i would usually use an absorbable synthetic material such every bit Vicryl).

It is articulate that the evolution of meshes is not yet complete and the ideal mesh has even so to exist found. Equally no such mesh exists, this article outlines the properties to exist considered when choosing a suitable implant from the many bachelor.

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://world wide web.pubmed.gov>). To capture all potentially relevant manufactures with the highest degree of sensitivity, the search terms were intentionally broad. We used: 'mesh, pore size, force, recurrence, complications, lightweight, properties'. We as well mitt-searched the bibliographies of relevant manufactures and product literature to identify additional pertinent reports.

Mesh properties

TENSILE STRENGTH

The tension placed on the abdominal wall can be calculated past the police of Laplace which states that (Fig. one): 'in an elastic spherical vessel (belly), the tension, pressure, wall thickness and diameter are related by: Tension = (Bore × Pressure)/(iv × Wall thickness)'.

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

The maximum intra-abdominal pressures generated in healthy adults occur whilst coughing and jumping (Fig. 2). These are estimated to exist virtually 170 mmHg.^vi Meshes used to repair large hernias, therefore demand to withstand at least 180 mmHg before bursting (tensile strength up to 32 North/cm). This is easily achieved as fifty-fifty the lightest meshes will withstand twice this pressure without bursting (for example, burst pressure level of Vypro = 360 mmHg⁷). 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 75 μm in order to allow infiltration by macrophages, fibroblasts, blood vessels and collagen. Meshes with larger pores allow increased soft tissue in-growth and are more flexible considering of the avoidance of granuloma bridging. Granulomas unremarkably grade around individual mesh fibres as part of the foreign body reaction. Bridging describes the process whereby individual granulomas become confluent with each other and encapsulate the entire mesh (Fig. three). This leads to a stiff scar plate and reduced flexibility. It occurs in meshes with small pores of less than 800 μm.

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Granulomas forming around individual mesh fibres and bridging where individual granulomas go confluent with each other and encapsulate the unabridged mesh.

WEIGHT

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

Heavy-weight meshes use thick polymers, accept small-scale pore sizes and high tensile strength. These meshes typically weigh 100 chiliad/thou² (1.5 one thousand for ten × 15 cm mesh). The strength is derived from a big mass of material, which activates a profound tissue reaction and dense scarring.

Light-weight meshes are composed of thinner filaments and have larger pores (> 1 mm). Their weight is typically 33 g/m² (0.5 g for ten × 15 cm mesh). They initiate a less pronounced foreign body reaction and are more elastic. Despite a reduced tensile forcefulness, they can still withstand pressures above the maximum abdominal pressure of 170 mmHg (minimum tensile strength 16 N/cm).

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

REACTIVITY/BIOCOMPATIBILITY

Modernistic biomaterials are physically and chemically inert. They are generally stable, non-immunogenic and non-toxic. Despite this, they are non biologically inert.⁷ A strange body reaction is triggered past their presence. This involves inflammation, fibrosis, calcification, thrombosis and formation of granulomas. Information technology is very different from the physiological wound healing of suture repair.^nine

The foreign trunk reaction is adequately uniform regardless of the type of foreign material, but the extent of the reaction is affected by the amount of material present. Thus pore size is in one case again the determining factor for meshes. As described to a higher place, meshes with small-scale pores develop strong scar plates which are avoided in meshes with larger pores where there is a gap between the granulomas.

Meshes as well appear to alter collagen composition. During normal scar healing, the initial, immature, type III collagen is rapidly replaced by stronger, blazon I collagen. This process is delayed in the presence of a strange body such as a mesh. The upshot is a much lower ratio of type I/III collagen, leading to reduced mechanical stability.⁷ ^, ^nine ^, ¹⁰ This effect occurs regardless of the type of mesh used, although the amount of collagen laid down is higher in microporous meshes.

ELASTICITY

The natural elasticity of abdominal wall at 32 Northward/cm is about 38%. Light-weight meshes accept an elasticity of almost 20–35% elasticity at 16 N/cm.⁷ Heavy-weight meshes take but half this elasticity (4–xvi% at sixteen N/cm) and tin can restrict intestinal distension.

CONSTITUTION

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

SHRINKAGE

Shrinkage occurs due to wrinkle of the scar tissue formed around the mesh. Scar tissue shrinks to about 60% of the former surface surface area of the wound.⁷ The smaller pores of heavy-weight meshes lead to more than shrinkage due to the formation of a scar plate (Fig. four).

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Shrinkage properties of different meshes. Prolene shrinks 75–94%, PTFE shrinks 40–l%, Vypro 2 shrinks 29%, Ultrapro shrinks < five%, and Sofradim shrinks < five%.

Complications of meshes

Most complications are simply a reflection of the properties 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 good contour for adhesion risk but a high risk of infection. Incontrast, Polypropylene meshes are durable and have a depression infection risk merely they take little flexibility and a loftier adhesion hazard. The main factors to consider in relation to complications are outlined below.

INFECTION Take chances

Mesh infection is feared because it is difficult to eradicate without removing the mesh and tin can become clinically apparent many years after implantation.^xi Mesh infection remains about 0.ane–three%,¹² ^, ¹³ although this is obviously college in the infected fields, for case, in parastomal hernia repair.

Although widely skillful, in that location is no evidence that routine prophylaxis with antibiotics confers any protection against infection. In contrast there is some testify that the infection risk can be lowered by impregnating meshes with antiseptics.^xiv

The risk of infection is mainly determined by the type of filament used and pore size. Microporous meshes (for example, ePTFE) are at higher risk of infection because macrophages and neutrophils are unable to enter pocket-size pores (< 10 μm). This allows bacteria (< 1 μm) to survive unchallenged within the pores. A like problem applies to multifilament meshes. The meshes at lowest risk of infection are, therefore, those made with monofilament and containing pores greater than 75 μm. Eradication of infection in such meshes can exist achieved without their removal.^xv

ADHESION RISK

The popularisation of laparoscopic intraperitoneal mesh placement has led to increasing concern regarding mesh-related adhesions. Adhesions result from the fibrin exudates that follow any kind of trauma. These exudates form temporary adhesions until the fibrinolytic system 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, simply their extent is determined past pore size, filament construction and area. Heavy-weight meshes induce an intense fibrotic reaction which ensures strong adherence to the intestinal wall simply also causes dense adhesions. In contrast, microporous ePTFE does not allow tissue in-growth. It has a very depression hazard of adhesion formation, just is unable to attach strongly to the abdominal wall.

These two extremes illustrate the difficulty of producing a mesh which volition attach well to the abdominal wall merely non to the bowel. Composite meshes aim to do this past providing an additional surface which can exist safely placed in contact with bowel whilst peritoneal mesothelial cells grow over the mesh. Information technology takes upwards to 7 days to regenerate peritoneum; however, once formed, it should preclude adhesion formation to the mesh. Until recently, the standard composite mesh was a PP/ePTFE mix, but there are now a big variety of substances bachelor, including PVDF, cellulose and omega-3 fatty acids. Unfortunately, at that place is evidence to suggest that most of these only forestall adhesion germination in the brusk term and the outcome is diminished subsequently thirty days.¹⁶ In some types, it is also 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 greatly betwixt studies, but almost describe a reduction in the rate of recurrence by at least one-half when using a mesh (for example, for incisional hernias this is reduced from 17–67% to one–32%).^xviii ^– ²³ In nearly all cases, recurrent herniation occurs at the edges of meshes. This is ordinarily due to inadequate fixation, or underestimation of shrinkage of the mesh, at the original operation. There is little prove that recurrence is related to the type of mesh used,⁵ although it has been proposed that light-weight meshes have a higher hazard due to their increased flexibility and movement.^seven Other known risk factors include postoperative infection, seroma and haematoma.

2-thirds of recurrences occur later iii years (median, 26 months).²⁴ This suggests that a technical error is unlikely to be the only cause of recurrence and defective collagen synthesis may be equally of import. All meshes cause a foreign torso reaction which has an outcome on the ratio of Type I and 3 collagen synthesised.⁷ ^, ^ix Changes in this ratio impact both tensile force and mechanical stability and may increase the take chances of recurrence. Altered ratios of collagen tin can exist seen within fibroblasts located at the edges of recurrent hernias.^seven ^, ⁹ ^, ²² It is not articulate if the type of mesh used has any outcome on this.

Pain

Meshes are associated with a reduced risk of chronic pain compared to suture repair. This is idea to exist related to the power to use tension-free technique rather than the mesh itself.^nineteen Nevertheless, hurting remains a serious complexity of mesh repair and can occur for a diversity of reasons. With regards to astute postoperative pain, in that location is little deviation in the blazon of mesh used. Chronic pain following hernia repair has gained increased recognition, with a quoted risk of over 50%.²⁵ ^, ²⁶ When it starts in the immediate postoperative period, it is usually due to nerve damage at the time of operation. In contrast, hurting due to foreign body reaction (FBR) typically presents subsequently 1 yr. Explants removed for chronic pain are found to have nervus fibres and fascicles around the foreign body granulomata within the mesh. Neuromas tin can also be found at the interface of mesh and host tissue suggesting mechanical devastation of nerves by mesh. It follows that meshes with small pores and greater FBR, will crusade higher rates of chronic pain. This is supported by most studies,²⁷ ^, ²⁸ although disputed past some.²⁹ ^, ³⁰ Some authors take also suggested that absorbable meshes may accept a office in reducing chronic pain.²⁶

MESH DEGRADATION

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

SEROMA

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

Which mesh should surgeons utilize?

When choosing a mesh (Tables one–iii), the surgeon must consider the context in which it is to be used. In most situations, i should expect for a light-weight mesh, with large pores and minimal surface area. Ideally, it should consist of a monofilament. A polypropylene or polyester mesh is, therefore, usually suitable (for example, Paritiene Light, Optilene, Mersilene). These meshes volition exist more comfortable and have a lower take chances of infection. If the mesh is to be placed inside the peritoneal cavity, an attempt should be made to minimise adhesions past choosing a hybrid mesh with an absorbable surface. Despite manufacturers' claims, the differences between the various types of these are unproven and information technology is currently difficult to recommend a unmarried fabric. In infected wounds, an absorbable mesh is preferred, for example, polyglactin (Vicryl) or polyglycolic (Dexon). Biomaterials may also be useful in this situation if the additional price tin be justified. Finally, the surgeon should non forget that the manner the mesh is placed is as important equally the type of mesh used. If a mesh is too small or fixed under tension, there volition be complications whatever its material. Despite the new implants available, surgical skill still has a part 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–ninety days)	Medium weight 56 g/grand²	Absorbable meshes primarily used in infected fields

Dexon (Syneture)	Polyglycolic	Medium 0.75mm	Yep, fully (60–90 days)
Safil (B-Baun)

*Multifilament and monofilament*
Marlex (BARD)	Polypropylene	Small to medium 0.viii mm	No	Heavy-weight average 80–100 g/m²	Traditional heavy meshes with small-scale pores and little stretch. Not used in extraperitoneal spaces equally they produce dense adhesions. Depression infection risk
3D Max (BARD)
Polysoft (BARD)
Prolene (Ethicon)
Surgipro (Autosuture)
Prolite (Atrium)
Trelex (Meadox)
Atrium (Atrium)
Premilene (B-Braun)
Serapren (smooth)
Parietene (Covidien)

Parietene Light (Covidien)		Large 1.0–3.6 mm		Light/medium weight 36–48g/k²	Traditional meshes but lighter, with larger pores
Optilene (B-Baun)

*Multi*
Mersilene (Ethicon)	Polyester	Big 1–2 mm	No	Medium weight ∼xl g/1000²	Depression infection risk and ?less inflammatory response than PP. Long-term deposition may be a problem³⁰

*Foil*
Goretex (Gore)	ePTFE	Very minor 3 μm	No	Heavyweight	Smooth and stiff. Not a true mesh simply multilaminar patch. Microporous. High infection risk

Table three

Composite meshes (for intraperitoneal use)

Type of mesh		Pore size	Absorbable	Weight	Comments
*Multi*
Vypro, Vypro II (Ethicon)	Prolypropylene/PG910	Large > 3 mmm	Partially (42 days)	Lite-weight 25 & 30 g/chiliadⁱⁱ	First light-weight meshes with large pores. Vypro non strong enough for incisional hernias (utilise Vypro II)

Gortex Dual Mesh & Dual Mesh Plus (Gore)	ePTFE	Very small iii/22 μm	No	Heavy-weight	Dissimilar sized pores for each side. Dual Mesh Plus is impregnated with antiseptic to minimise infection

Parietex (Covidien)	Polyester/collagen	Large > 3 mm	Partially (20 days)	Medium weight 75 thou/mⁱⁱ	Bovine collagen coating and anti-adhesion flick of polyethylene glycol and glycerol. ?Only short-term do good for anti-adhesional property^sixteen

*Mono*
Composix EX Dulex (BARD)	Polypropylene/ePTFE	Medium 0.8 mm	No	Light-weight	Two distinct surfaces, overlap of ePTFE stops adhesions at the edges

Proceed (Ethicon)	Polypropylene/cellulose (ORC)	Big	Partially (< 30 days)	Light-weight 45 g/m²	3-layer laminate with PP; oxidised cellulose (absorbable) and polydioxanone film (not absorbed)

Dynamesh IPOM (FEG Textiltechnik)	Prolypropylene/PVDF	Large one–2 mm	Partially	Medium weight lx one thousand/chiliad²	PVDF causes minimal foreign body reaction

Sepramesh (Genzyme)	Prolypropylene/sodium	Large 1–2 mm	Partially (< thirty days)	Heavy-weight 102 1000/thou²	Seprafilm turns to gel in 48 h and remains on mesh for 1 calendar week to let re-epithelisation. ?Simply brusk-term benefit for anti-adhesional property hyaluronate¹⁶

Ultrapro (Ethicon)	Polypropylene/polyglecaprone (Monocryl)	Large > three mm	Partially (< 140 days)	Light-weight 28 g/kⁱⁱ	Monocryl has a combination of polymers; east-caprolactone, which is malleable and polyglycolide, which is stiff. Less inflammatory response than Vicryl

Ti-mesh (GfE)	Polypropylene/titanium	Large > 1 mm	No	Light-weight and actress-low-cal 16 & 35 g/m^two	Possibly has a reduced inflammatory response compared to other meshes (?biologically inert)³⁴

C-Qur (Atrium)	Polypropylene/omega 3	Large > 1 mm	Partially (∼120 days)	Medium-weight fifty g/m²	Omega 3 from fish oils ?But curt-term benefit for anti-adhesional holding^xvi

Table ii

Types of mesh: Biomateria

Type of mesh		Comments
Surgisis (Melt)	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. Tin be used in contaminated wounds
Fortagen (Organogenesis)

Alloderm (Lifecell)	Human acellular dermis
Flex Hard disk drive (J&J)
AlloMax (Davol)

Collamend (Davol)	Xenogenic acellular dermis (porcine/bovine)
Strattice (LifeCell)
Permacol (TSL)
XenMatriX (Brennen)
SurgiMend (TEI)

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