Evolution and advances in laparoscopic ventral and incisional hernia repair

Table 1 Advantages and disadvantages of permanent synthetic mesh materials (polyester and polypropylene)

Advantages	Disadvantages
Permanent synthetic mesh, either woven or knit	Risk contraction, chronic inflammation, stiff abdominal wall, chronic pain especially with heavy weight PP
Provides strength by stimulating inflammation and abdominal wall ingrowth	PE with possible higher infection and recurrence vs PP
PE has less contraction than PP	Should not be placed in contact with bowel as inflammatory response increases adhesions to viscera
Lightweight PP has less foreign body response, more pliable, more ingrowth[25]	Increased risk of fistula, bowel obstruction, and re-operative complications[26]
Sometimes able to salvage lightweight mesh after infection due to improved antibiotic penetration[25]	Enterotomy and/or bowel resection upon re-operation are almost four times greater with prior use of mesh, with most of these being uncoated mesh[27]

PE: Polyester; PP: Polypropylene.

Table 2 Advantages and disadvantages of commonly used composite meshes

Mesh	Abdominal wall side/visceral side	Advantages	Disadvantages
Composite meshes[24]	Permanent mesh/anti-adhesion barrier	Permanent mesh for inflammation, fibrosis, and abdominal wall ingrowth and strength	No level I evidence of the superiority of one mesh over another. Some differences have been noted in animal models, although adhesion prevention is similar for most[28]. A multi-center, human study is underway to better determine the characteristics of these composite meshes (NCT01355939)[29]
		Visceral side designed to prevent adhesion related complications
Dualmesh[25]	Micropore ePTFE/Macropore ePTFE	Minimal inflammatory reaction[22]	PTFE has higher rates of bacterial adherence and less resistant to colonization[31,32]
		Adhesions less tenacious than all other meshes[24,30]	Higher risk of explantation in open cases (14.2%), but not laparoscopic cases (4.6%)[32]
		Less adhesiolysis time/mesh surface area compared to composix[24]	Limited fibrous tissue ingrowth and incorporation[22]
Composix™[25]	PP/ePTFE	PP thought to promote better ingrowth and inflammation	Adhesions predominately found due to mesh eversion at periphery[24]
			Possible increased infection risk (8% in one series)[33]
Parietex[30]	PET/type I collagen, polyethylene glycol, and glycerol	United States evaluation showed adhesions in 18% of patients, vs 77% when uncoated PE was used	Collagen film absorbed quickly (20 d)[34]
Proceed[30]	PP encapsulated by PDS/oxidized regenerated cellulose	Lightweight, macro-porous mesh[34]	Incomplete peritoneal mesothelialization over graft
			Induced dense adhesions in rabbit models[35]
C-QUR[30]	PP/omega 3 fatty acid gel	Less contracture in rabbit model[30]	Poor incorporation strength in rat model[28]
Sepramesh[25]	PP/sodium haluronate and carboxy - methylcellulose	Low adhesion coverage and good incorporation[28]	Inflammation induces breakdown of the coating, resulting in delayed adhesion formation[28]

ePTFE: Expanded polytetrafluoroethylene; PDS: Polydioxanone; PE: Polyester; PET: Polyethylene terephthalate; PP: Polypropylene.

Table 3 Advantages and disadvantages of newly developed meshes

Name	Materials	Properties	Current research
BioA® Tissue Reinforcement by Gore®[36,37]	3D matrix copolymer of polyglycolic acid and trimethyl carbonate	Absorbed in 6 mo	Prospective, observational study (NCT01325792) to evaluate single-staged open ventral incisional hernia repair with midline reinforcement in clean contaminated and contaminated wounds. Early one-year results demonstrated a hernia recurrence rate of 14% and an 18% infection rate[36]
TIGR® Matrix by Novus Scientific[38]	Knit mesh of fast absorbing and slow absorbing glycolide, lactide, and trimethylene carbonate fibers	First fiber retains strength for 1-2 wk	One case report of onlay use for open ventral hernia repair[38]
		Second fiber retains strength for 6-9 mo	Currently three-year safety and performance study showing use for inguinal hernia repairs in humans[40]
		Stimulates neovascularization and a high level of type I collagen ingrowth
		Absorbed in 3 yr
Phasix™ mesh by Bard[39]	Monofilament, knit mesh of poly-4-hydroxybutyrate	Minimal absorption in 12-26 wk	Launched in 2013 and currently there are no published results in human subjects
		Porcine model shows 18% strength than natural abdominal wall at 48 wk
		Manufacturer claims hernia repair support for 12-18 mo
Titanized mesh[41]	PP mesh with relatively inert titanium coating	Retains strength of PP mesh	Lower analgesic use (1.6 d vs 6.1 d, P < 0.001) and a quicker return to baseline activity (6.9 d vs 9.7 d, P < 0.001) when compared to parietex mesh. Also less postoperative pain at 1 mo, but no difference at 6 mo
		Titanium retards inflammation and decreases foreign body reaction[42]
Progrip by Covidien[43]	Self gripping PP mesh with small, absorbable hooks	Promotes abdominal wall adhesion, prevents migration, and decreases the number of tack or sutures fixation points	Has been used in laparoscopic inguinal, ventral, and incisional hernia repairs
			One study asserts less postoperative pain after laparoscopic inguinal hernia repair, but another shows no difference with open repair[43,44]
			Operative times may be less

PP: Polyethylene.