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Cite this article: Sherif RD, Jablonka EM, Burish NM, Torina PJ, Harmaty MA (2017) The Use of Lightweight, Large-Pore Polypropylene Mesh Onlay in the Repair of Contaminated Abdominal Wall Defects: a Single Center Experience. JSM Gen Surg Cases Images 2(2): 1028.

*Corresponding authorRami D. Sherif, Icahn School of Medicine at Mount Sinai, 50 East 98th Street, New York , NY 10029, USA, Tel: 716-359-0653; Email:

Submitted: 03 April 2017

Accepted: 25 May 2017

Published: 30 May 2017

Copyright© 2017 Sherif et al.

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Keywords•Hernia repair•contaminatedfield•Abdominal wall defect•Polypropylene mesh

Review Article

The Use of Lightweight, Large-Pore Polypropylene Mesh Onlay in the Repair of Contaminated Abdominal Wall Defects: A Single Center ExperienceRami D. Sherif2*, Eric M. Jablonka2, Nikki M. Burish3, Philip J. Torina2, and Marco A. Harmaty2

1Icahn School of Medicine at Mount Sinai, USA2Department of Surgery, Icahn School of Medicine at Mount Sinai, USA3Surgical Outcomes Analysis and Research, Harvard Medical School, USA

Abstract

Background: Most surgeons are reluctant to place synthetic mesh in contaminated abdominal wall repairs for fear of mesh infection. Biologic meshes are often used in this setting; however, these meshes lack the long-term durability of permanent, synthetic mesh. The authors present a single-center case series illustrating the safety and efficacy of the use of lightweight, large-pore polypropylene mesh in the repair of contaminated abdominal wall defects.

Methods: A retrospective review of patients who underwent abdominal wall reconstruction with lightweight, large-pore polypropylene mesh at a single institution between March 2009 and June 2015 was performed. Patient demographics, complications, and hernia recurrence rates were reported.

Results: Twenty patients were identified who underwent abdominal wall reconstruction with lightweight, large-pore polypropylene mesh in conjunction with a clean-contaminated (n=8), contaminated (n=10), or grossly infected (n=2) abdominal surgery. All meshes were placed overlying the anterior rectus sheath following fascial closure with either a unilateral or bilateral component separation. Thirteen patients had at least one risk factor for poor wound healing. Sixteen patients had uncomplicated post-operative courses. Of the four reported complications, two had seromas that resolved after needle aspiration, and two had superficial infections that resolved after a course of intravenous and oral antibiotics. Of note, the two patients categorized as infected cases maintained an uncomplicated course. There were no mesh infections, readmissions, mesh removals, or hernia recurrences.

Conclusions: In contaminated surgical fields, abdominal wall repair with lightweight, large-pore polypropylene mesh may be performed with minimal wound-related morbidity and successful reestablishment of abdominal wall integrity.

INTRODUCTIONComplex abdominal wall repair in contaminated surgical

fields is a problem that continues to challenge the reconstructive surgeon. Reinforcing abdominal wall repairs with the addition of a prosthetic mesh has proven to be a formidable defense against hernia recurrence, considered by many to be the “gold standard” [1]. Although it has been recently suggested that synthetic mesh use is a feasible option in selected contaminated procedures [2-6], placing a permanent prosthesis into a surgical field of compromised sterility continues to carry concern for developing post-operative surgical site infections. Recent history witnessed the emergence of biologic matrices as a once promising solution to replace synthetic meshes. While biologics have been thought to be inherently less susceptible to infection, tissue integration and replacement of the mesh leads to progressive weakening of the abdominal wall repair [4,7-9].

An ideal mesh for repairing contaminated abdominal

wall defects would have the long-lasting, high-tensile strength properties of a synthetic prosthesis and the ability to resist infection of a biologic mesh. Lightweight, large-pore polypropylene mesh (LP-PP) [PROLENETM Soft Polypropylene Mesh, Ethicon Endo-Surgery, Inc., Cincinnati, OH] represents a newer generation synthetic mesh that is advocated to achieve both of the aforementioned goals. LP-PP mesh is a lightweight mesh characterized by high tensile strength and vigorous tissue in-growth. The mesh is woven with larger interstices (2.4mm pore-size) that theoretically allow for faster host tissue incorporation when compared to medium- and heavy-weight meshes. This results in diffuse internal migration of inflammatory cells responsible for clearing bacterial contamination [10,11]. Not only has it been associated with less postoperative pain, increased patient satisfaction, and improved abdominal wall physiology, but LP-PP is likely the most ideal synthetic mesh to resist infection [10,12-20].

In this article, the authors present their experience using

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LP-PP mesh in the on lay position during cases of contaminated abdominal wall reconstruction in conjunction with the component separation technique. The aim of this study is to support the safe and reliable use of the LP-PP mesh as a permanent synthetic mesh option for abdominal wall repair in contaminated surgical fields.

PATIENTS AND METHODSStudy design

A single-center, retrospective analysis of patients who underwent abdominal wall reconstruction with LP-PP mesh was performed. Data was extracted from the center’s electronic medical charting system. All cases that were categorized as clean-contaminated, contaminated, and infected were included in accordance with the Centers for Disease Control and Prevention wound class [21]. Cases where an additional non-PP mesh or biologic matrix was also used were excluded. Patient demographics, level of surgical field contamination, concomitant surgeries, repair technique and surgical outcomes were reviewed. Patients were evaluated for hematoma, seroma, wound dehiscence, wound infection, acute and chronic mesh infection, mesh removal and hernia recurrence. Surgical-site infections were as defined by the Centers for Disease Control and Prevention and determined by clinical suspicion or wound culture. Recurrent hernia was diagnosed by clinical examination and/or computed tomographic imaging during the follow-up period.

The authors adhered to the STROBE standardized reporting guidelines for cohort studies. The Icahn School of Medicine at Mount Sinai Institutional Review Board, in accordance with the Mount Sinai Hospital’s Federal Wide Assurances to the Department of Health and Human Services, approved this study.

Operative techniqueAll patients, except those with ongoing wound infection,

received timely pre-operative intravenous antibiotics to cover both skin and enteric flora (i.e., 1-2g IV cefazolin and 500mg IV metronidazole). Patients who had an ongoing wound infection received the recommended intravenous antibiotics from the time of admission.

In all cases, complete fascial closure was achieved either with or without a myofascial component separation. Component separation was performed by releasing the external oblique muscle at its aponeurotic insertion along the semilunaris line from the costal margin to the pubis to allow for midline mobilization of the fascial edges. Bilateral component separation was performed when a unilateral release did not adequately allow tension-free fascial approximation.

Following fascial closure, LP-PP mesh was placed overlying the anterior rectus fascia in an onlay fashion. All meshes were soaked for 2 minutes in a solution consisting of 50,000 Units of bacitracin in 1L of normal saline prior to inset. The same solution was used to irrigate the abdomen before mesh placement and again prior to skin closure. The mesh was secured around the periphery with interrupted 2-0 PDS sutures. The same suture was used for quilting over the anterior rectus fascia. If a concomitant abdominal surgery necessitated creation of a stoma, a wide patch of skin and subcutaneous abdominal tissue in this location was left attached over the ipsilateral rectus muscle when possible. This maneuver helped to keep the bowel from contacting the LP-

PP mesh during later passage of the stoma from the abdominal cavity to the skin. The mesh was then altered in order to accommodate (Figure 1). A layered skin closure (i.e., interrupted 0-vicryl sutures in scarpa’s fascia, interrupted deep dermal 3-0 monocryl sutures and a running subcuticular 4-0 monocryl suture) was performed over 2 drains placed in the sub-scarpal plane and above the LP-PP mesh. When required, stoma creation was performed by the general surgery team. Stoma passage was carried through the preserved path of non-undermined abdominal skin and subcutaneous tissue, when present.

All patients received peri-operative IV antibiotics until hospital discharge. Patients with closed suction drains in place upon discharge remained on oral antibiotics until drain removal.

RESULTSBetween March 2009 and June 2015, 20 patients were

identified who underwent abdominal wall reconstruction with an LP-PP mesh on lay in conjunction with a clean contaminated (n=8), contaminated (n=10), or grossly infected (n=2) surgical field. Eleven patients were male and 9 were female. The average age was 56 years (range: 22-81).Average ASA score was 3 (+/- 0.7) and average BMI was 25.4 (+/- 5.6).The patients underwent a variety of concomitant abdominal surgeries that are listed in (Table 1). The average follow-up was 14.5 months with 83% and 63% follow-up rates at one month and six months, respectively.

Thirteen patients had at least one risk factor for poor wound healing (Table 2). Sixteen patients had uncomplicated post-operative courses. Of the four patients who experienced a complication, two developed seromas that resolved after needle aspiration in the office. The remaining two patients had superficial infections that resolved after a course of intravenous and oral

Figure 1 Lightweight, large-pore polypropylene (LP-PP) mesh placement with bilateral myofascial component separation and stoma creation: The external oblique muscles are released at the aponeurotic insertions along the semilunar lines, allowing for midline fascial approximation. LP-PP mesh is placed over the rectus fascia and secured around the periphery along the released external oblique tendons. The mesh is altered to accommodate passage of a stoma and then further secured with quilting sutures.

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antibiotics. One of the two superficial infections was of the prior stoma site. Of note, the two patients categorized as “infected” cases maintained an uncomplicated post-operative course. There were no acute or chronic mesh infections, readmissions, mesh removals, or hernia recurrences (Table 3).

DISCUSSIONRecent studies have suggested that the use of synthetic

mesh in clean-contaminated and selected contaminated abdominal wall repairs may be safer than once thought [2-6]. Most of the studies supporting such claims included a variety of polypropylene-based mesh types (i.e., light-, medium-, and heavy-weight) placed in various positions (i.e., onlay, sublay, and retro-rectus) relative to the abdominal wall. To our knowledge,

the current study is the first to evaluate the safety of lightweight large-pore polypropylene mesh as a reinforcing on lay prosthesis in contaminated abdominal wall reconstruction. Eighty percent of the patients in our series maintained an uncomplicated post-operative course and there were no mesh infections, mesh removals, or hernia recurrence reported during the follow-up period. Given the overall low major morbidity rates, the current study continues to challenge the perception that contaminated hernias should be repaired with expensive biologic matrices.

In 1958, Francis Usher published a landmark paper in which he developed and utilized a polypropylene (PP) mesh for reinforcing inguinal and incisional hernias [22]. This seminal study heralded a new age of mesh repair, prompting a number of studies over the following half-century describing a wide variety of meshes and comparative efficacies. It was not until 2004 that a Dutch group led by Jacobus Burger published the long-term results of a definitive randomized controlled trial comparing primary suture repair to mesh repair of incisional hernias. Jacobus left little room for doubt, concluding, “suture repair of incisional hernias should be completely abandoned”[1]. Thus, the gold standard of mesh repair for hernias was established.

The variety of available meshes has since grown rapidly, leading to many scrutinizing debates over which mesh material provides the best abdominal wall reinforcement. The early rise of synthetic meshes was marred by studies reporting their vulnerability to bacterial inoculation [23]. Recently, biologic matrices have been touted as an alternative reinforcing material that is thought to carry a safer risk profile. The appeal of such biocompatible implants lies in their inherent ability to quickly integrate into the host allowing them to withstand infection [7,8].

However, the past few years has seen a growing criticism directed toward the justification of using biologic matrices in contaminated abdominal wall repairs. A recent systematic literature review reported outcomes after abdominal wall reinforcement using either synthetic non-absorbable or biologic prosthetics. In contaminated fields, wound infection rates were actually found to be similar with hernia recurrence rates of 3.2% and 27.2% for non-absorbable synthetic and biologics, respectively [24]. Despite the biologic meshes’ ability to evade infection, the collagen proteases released by bacteria within the

Table 1: Concomitant abdominal surgeries stratified by wound classification.

Wound Classification Number (n=20)Clean-contaminated 8

Ileostomy 1Small bowel resection 1

Bladder surgery 1Parastomal hernia 1Enterotomy repair 1

Gynecologic 1Liver resection 1

Cholecystectomy 1Contaminated 10

Colostomy 2Colostomy reversal 2

ECF takedown 1Ileocolic anastomosis 1

Colon resection 2Pelvic Exenteration 1

Open Wound 1Infected 2

Subphrenic abscess 1Explantation of infected mesh 1

Table 2: Factors impacting on wound healing.

Risk FactorClean-

contaminated cases (n=8)

Contaminated cases (n=10)

Infectedcases (n=2)

BMI*

>30 5 3 0

Diabetes 2 3 0

CAD** 3 4 0

COPD*** 0 2 0

Tobacco

Current 0 0 0

Former 0 3 0

Kidney disease 1 1 0Immuno-compromised 4 4 0

*BMI: body mass index, **CAD: coronary artery disease; ***COPD: chronic obstructive pulmonary disease

Table 3: Patient Outcomes.

Complications Number (n=20)

Overall 4

Clean-contaminated 3/8

Contaminated 1/10

Infected 0/2

Infection 2

Superficial 2

Mesh 0

Wound dehiscence 0

Seroma 2

Hematoma 0

Mesh removal 0

Hernia recurrence 0

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wound may weaken the dermal matrix construct, thus leading to abdominal wall eventration and eventual hernia recurrence [7,8]. A recent report by Rosen et al. demonstrated that over half of hernias repaired with biologics recur by 3 years [25], while recurrence rates with synthetic meshes approach only 25 percent for that same time period [5]. The body of surgeons supporting the use of biologic matrices is narrowing rapidly, furthering the need for data supporting the reliable and safe use of permanent synthetic mesh in abdominal wall repairs at every level of contamination.

Synthetic PP meshes undoubtedly maintain an acceptable tensile strength that biologics appear to lose over time [23]. Their use in contaminated repairs has often been avoided due to the perpetuated fear of developing an infection that would necessitate subsequent mesh removal. In several retrospective studies, infection was among the most common reasons for mesh explantation, suggesting that PP mesh should be used with caution, particularly in the setting of intra-abdominal contamination [23,26,27].

As early as 2000, Birolini and colleagues from Brazil challenged this long-standing belief when they published their series of 20 patients undergoing elective colorectal surgery and concomitant hernia repair with a PP mesh on lay. With 2-year follow-up in all patients, they reported 1 superficial skin infection, 1 deep wound infection, and 1 patient with a draining sinus, which healed after partial excision of a small area of unincorporated mesh. Birolini concludes his paper with a definitive statement disagreeing with authors who contraindicate mesh use in contaminated operations. He advocates strongly for the use of synthetic meshes in the treatment of incisional hernias even in high risk patients. This is especially evident in the one patient in his study who developed intraperitoneal sepsis from bowel necrosis who still developed healthy granulation tissue infiltrating the mesh without any subcutaneous infection, thus showing successful incorporation of the mesh [12,28]. Soon after, in 2002, Kelly and Behman also evaluated the impact of PP mesh placement in contaminated fields on wound morbidity, hernia recurrence, and mortality. In their series of 24 patients, they demonstrated that the use of such meshes in contaminated operative fields resulted in minimal wound morbidity. Over the next several years, other investigators continued to share their successful experience with PP mesh in contaminated repairs [6,12,29].

It is thought that the ideal PP mesh should be manufactured with large pore sizes to expedite tissue integration and to provide less surface area for bacterial adherence [10,12]. This idea led to a shift away from the traditional heavy-weight microporous PP meshes to using newer mid- and light-weight macroporous meshes (i.e., LP-PP mesh). Animal studies began to provide evidence in support of this theory. In 2012, Deerenberg et al., implanted seven commercially available meshes into artificially created contaminated abdominal environments by inducing peritonitis in rat models. They found that the macroporous synthetic PP meshes can resist infection equally as well as a biological collagen mesh in contaminated settings [30]. Diaz-Godoy and colleagues then set out to identify the ideal PP mesh to use in contaminated fields by comparing meshes with differing pore-size diameters in a rabbit appendiceal puncture-aspiration model. None of the rabbits that received very-large-pore PP mesh (3.6mm) developed an SSI, compared with a 30% and 33% rate of infection in the medium-pore (0.8mm) and large-pore (1.5mm)

PP mesh groups, respectively [10].

The following year, Carbonell and colleagues published their 100 patient series of retromuscular placement of lightweight, wide-pore, PP mesh in clean-contaminated and contaminated hernia repair. The 30-day surgical site infection rate was 7.1% and 19% for clean-contaminated and contaminated cases, respectively, with only 4% (n=4) eventually requiring mesh removal [31]. That same year, Souza and Dumanian published a retrospective review of 100 consecutive midline cases of incisional hernia repair using an uncoated, mid-weight, PP, intra-abdominal underlay with an emphasis on complications. Their results found no enterocutaneous fistulae formation or infections requiring mesh removal in potentially contaminated fields [3,32].

The results of our review encourage the use of LP-PP mesh as a safe and effective permanent synthetic mesh option for abdominal wall reconstruction in contaminated surgical fields. The high tensile strength and macroporous structure allows fibrous scar tissue to surround the polypropylene fibers, incorporating the mesh into the abdominal wall for a well-integrated, durable repair [23]. Although the mechanical strength of LP-PP is less than that of the medium-or heavy-weight materials, they have been shown to provide more than enough tensile strength to withstand the major forces the abdominal wall endures during strenuous activities such as coughing and jumping [9]. It is well known that hernia recurrence rates are higher for onlay mesh positioning compared to sublay [25]. We chose to place the mesh as a reinforcing onlay for two reasons: to theoretically keep the mesh better protected from the intra abdominal source of contamination and to facilitate easier removal if warranted. A majority of patients in our series (n=16) maintained an uncomplicated post-operative course. All four complications reported were minor and resolved with minimal intervention. Interestingly, there were no complications reported for the two cases classified as “infected”. There were no mesh infections, readmissions, mesh removals, or hernia recurrences noted at an average follow-up period of 14.5 months.

The strength of the study includes all surgeries being performed by the same two-surgeon team at a single institution. This study is not without its limitations. The small sample size and retrospective nature makes it difficult to draw conclusions of statistical significance. One other limitation is the longer timeframe over which the retrospective review was conducted. Practice patterns change rapidly in surgery and it is possible that standards in care underwent some changes over the time that this review was completed. Given the compelling positive results, however, this study provides meaningful data in support for the use of lightweight, large-pore polypropylene meshin the onlay position during contaminated abdominal wall reconstruction.

CONCLUSIONThe development of more durable, inert, and infection-

resistant meshes is paving the way to an ideal surgical method for reinforcing abdominal wall repairs. Although further clinical studies comparing the safety and efficacy of PP mesh types against one another are needed, we believe that LP-PP mesh in the onlay position can provide the long-term, high-tensile strength of traditional PP mesh with an improved resistance to developing infection. Lightweight, large-pore polypropylene mesh secured over the abdominal fascial closure during

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contaminated abdominal wall reconstruction is liable method to help the reconstructive surgeon safely obtain durable closure with acceptable minor risk to the patient.

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Sherif RD, Jablonka EM, Burish NM, Torina PJ, Harmaty MA (2017) The Use of Lightweight, Large-Pore Polypropylene Mesh Onlay in the Repair of Con-taminated Abdominal Wall Defects: a Single Center Experience. JSM Gen Surg Cases Images 2(2): 1028.

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