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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Majumder A, Winder JS, Wen Y, Pauli EM, Belyansky I, Novitsky YW. Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs. Surgery. 2016;160(4):828-838.

Commentary by: Gregory A. Dumanian, MD, FACS, and Lauren Mioton Connor, MD

The authors reported a study analyzing the complications associated with biologic mesh compared to those of synthetic mesh in contaminated hernia repairs. The results of this study add to the mounting evidence that hernia repairs with biologic mesh have higher rates of postoperative complications and offer less durable repairs vs. those repaired with synthetic mesh.1 The reasoning for this outcome focuses on the preserved strength of synthetic mesh and possible stretching and loss of tensile strength shown with biologic mesh. Biologic mesh may further weaken in contaminated cases after the collagen-based cadaveric dermis encounters collagenase producing bacteria. Differences in infection rates could relate to improved porosity and decreased total foreign material found in synthetics as opposed to biologic meshes.

This study demonstrated how difficult it is to relate the postoperative course of a patient to a specific isolated element of a procedure. There were a number of factors, including patient comorbidities, hernia size, and variances in operative technique that could impact complications independent of the type of mesh. Specifically, the patient populations were not randomized, and thus, subtle variances could have led patients with worse levels of contamination to be treated with biologics over prosthetics. Additionally, the study failed to address hernia size or specify if and when bridging mesh was utilized—important factors when analyzing hernia recurrence and the factors impacting it.2 Patients who underwent hernia repairs with biologics also had a higher average BMI than those with prosthetic mesh, which, after Bonferroni correction for multiple observations, proves to be a statistically significant difference. Additionally, the longer length of hospital stays seen with biologic mesh patients could have been due to patient management issues rather than problems relating to the hernia repair itself. Perhaps the biologics were used prior to the ERAS protocols now so commonly utilized. The methodology of this study in detecting all hernia recurrences was not optimal, but speaks to the complex tertiary referral nature of these medical centers. Namely, the authors mentioned that some recurrences were documented via follow-up survey alone. This allowed for patient reported bias and could have led to slightly higher recurrence rates in one or both populations. The average follow-up for each population was not specified, rather, a range was provided. A truncated follow-up period in many of these patients could have correlated to missed hernia recurrences.

Even with the knowledge that hernia repairs using biologic mesh carry higher complication rates than those done with prosthetic mesh, the use of biologic mesh is still common practice. The reason for this, though not a focus of this manuscript, is the expected difficulty of salvage of the infected mesh case. While biologic meshes may melt away in the face of persistent contamination, permanent meshes often must be completely removed. Surgeons seem willing to risk a hernia recurrence in the long term if they can avoid the possibility of having an infected prosthetic mesh requiring explantation.

The authors of this study should be commended for their work. They captured a large patient population for analysis; there are over thirty studies thus far analyzing the effects of biologic and/or synthetic mesh durability specifically in contaminated fields, and most involve less than 50 patients.3 Most importantly, their work brings the ever-important discussion of risk-benefit analysis in surgery to the forefront. While the continued use of biologics in contaminated hernia cases may be driven by the desire to avoid a difficult secondary procedure, prosthetic mesh repairs offer a robust and safe option for most patients.

References

  1. Souza J, Dumanian GA. Routine use of bioprosthetic mesh is not necessary: A retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair. Surgery. 2013;153(3):393-9.
  2. Giordano S, Garvey PB, Baumann DP, et al. Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: A propensity score analysis. Surgery. 2016 Oct 31. Epub ahead of print.
  3. Lee L, Mata J, Landry T, et al. A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields. Surg Endosc. 2014;28(9):2531-46.