Mesh Type With Ventral Hernia Repair: A Systematic Review and Meta-analysis of Randomized Trials.

INTRODUCTION: Synthetic mesh is widely utilized for clean ventral hernia repair; however, it is unclear if synthetic mesh provides the same benefits with high-risk patients or during contaminated cases. Many surgeons use biologic mesh in these settings, but there is little evidence to support this practice. Our objective was to compare the clinical outcomes of utilizing biologic mesh versus synthetic mesh during ventral hernia repair. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a review of the literature was conducted using Cochrane library, EMBASE, Clinicaltrials.gov, and PubMed for randomized controlled trials published that compared biologic versus synthetic mesh during ventral hernia repair. The primary outcome was major complications defined as deep or organ space surgical site infection, reoperations, and hernia recurrences. RESULTS: Of 1889 manuscripts screened, four publications were included. The four studies included a total of 758 patients, with 381 receiving biologic mesh and 377 receiving synthetic mesh. Compared to biologic mesh, synthetic mesh had lower rates of major complications (38.6% versus 23.4, risk ratio = 0.55, 95% confidence interval = 0.35 to 0.86, P = 0.009) and hernia recurrence (24.5 % versus 10.3%, risk ratio = 0.44, 95% confidence interval = 0.28 to 0.69, P = 0.004). In addition, there was a lower percentage of surgical site infection and reoperation in the synthetic mesh group. CONCLUSIONS: Contrary to current surgical teaching, placement of permanent synthetic mesh into a contaminated field yielded rates of complications that were comparable or reduced compared to biologic mesh.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

A 13-year experience with biologic and biosynthetic absorbable mesh reinforced laparoscopic paraesophageal hernia repair.

BACKGROUND: Mesh reinforced cruroplasty during laparoscopic paraesophageal hernia repair remains controversial due to wide variation in surgical technique and mesh composition. This study aims to review outcomes and rates of recurrence following laparoscopic paraesophageal hernia repair (LPEHR) with mesh reinforced cruroplasty utilizing absorbable mesh at a single institution. METHODS: A retrospective review of all patients who underwent LPEHR with mesh was performed. Medical records were reviewed for patient reported, radiographic or endoscopic evidence of recurrence, defined as > 2 cm of vertical intrathoracic stomach. If no studies were available for review, patients were considered to have no recurrence. Outcomes and mesh-related complications were also reviewed. RESULTS: Between 10/2008 and 9/2021, 473 patients underwent LPEHR with absorbable mesh; 1.3% type 2 hernias, 86.0% type 3 hernias, 12.7% type 4 hernias. Three types of mesh were used: initially biologic mesh (n = 83), then heavyweight synthetic bioabsorbable mesh (n = 261), and finally lightweight synthetic bioabsorbable mesh (n = 111). There were no significant differences in age, ASA, BMI, gender, smoking status, chronic steroid use, preoperative acid suppression, hernia type, or recurrent hernia between groups. There were no significant differences in 30-day postoperative outcomes. Reflux Symptom Index, GERD-HRQL, and Dysphagia Scores at 1- and 2-year postoperative timepoints were not significantly different. The overall recurrence rate was 16.7%, with no significant differences in recurrence rates between biologic, heavyweight or lightweight biosynthetic absorbable mesh through 2 years after surgery. A shorter median time to recurrence (10 months, p = 0.016) was seen in the lightweight group. CONCLUSION: LPEHR with absorbable mesh reinforced cruroplasty is feasible and safe, with equivalent patient-reported outcomes, including dysphagia, up to 2-years postop regardless of mesh choice. No significant differences in recurrence rates between biologic, heavyweight, or lightweight synthetic bioabsorbable mesh were seen up to 2 years after LPEHR.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis.

AIM: Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE. METHOD: The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed. RESULTS: A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75). CONCLUSION: Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer.

AIM: Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer. METHODS: We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses. RESULTS: Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £1,706 (£1,692 to £1,720) (stage I) and £684 (£678 to £690) (stage IV) for synthetic versus no mesh, and £2,038 (£1,997 to £2,079) (stage I) and £1,671 (£1,653 to £1,689) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.95 for stages I-III and ≥0.93 for stage IV. [Correction added on 05 October 2021 after first online publication: The estimation of health outcomes (QALYs) for all three interventions evaluated (synthetic mesh; biologic mesh; no mesh) have been corrected in this version.] CONCLUSIONS: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.

Mesh-related complications in paraoesophageal repair: a systematic review.

BACKGROUND: Paraoesophageal hernias (PEH) have a high recurrence rate, prompting surgeons to consider the use of mesh reinforcement of the hiatus. The risks and benefits of mesh augmentation in PEH repair are debated. Mesh-related complications including migration and erosion are considered in this publication. DESIGN: A systematic literature review of articles published between 1970 and 2019 in Medline, OVID, Embase, and Springer database was conducted, identifying case reports, case series and observational studies of PEH repair reporting mesh-related complications. RESULTS: Thirty-five case reports/series of 74 patients and 20 observational studies reporting 75 of 4200 patients with mesh complications have been included. The incidence of mesh-related erosions in this study is 0.035%. PTFE, ePTFE, composite and synthetic meshes were frequently associated with mesh erosion requiring intervention. Complete erosions are often managed endoscopically while partial erosions may require surgery and resection of the oesophagus and/or stomach. CONCLUSIONS: Mesh-related complication is rare with dysphagia a common presenting feature. Mesh erosion is associated with synthetic mesh more frequently in the reported literature. A mesh registry with long-term longitudinal data would help in understanding the true incidence of mesh-related complications.

Hernia recurrence and infection rate in elective complex abdominal wall repair using biologic mesh.

BACKGROUND: Elective complex ventral hernia repairs, done using synthetic mesh in patients with comorbidities, can result in mesh related complications such as hernia recurrence or infection. We studied hernia recurrence and surgical site occurrences after elective complex repairs in predominately clean cases using biologic mesh and examined the impact of several comorbidities. METHODS: A retrospective chart review was completed on patients who underwent elective repair with biologic mesh in clean/clean-contaminated settings between 2012 and 2015 with a minimum of 1-year follow-up. Multiple comorbid conditions, including diabetes, chronic obstructive pulmonary disease, steroid use, smoking history and previous hernia repairs were identified. Post-operative complications including recurrence and infections were ruled out by computed tomography, clinical exam, and/or by telephone survey. RESULTS: 40 patients were identified. 85% (n = 34) had class 1 wounds. 25% (n = 10) experienced a hernia recurrence. 10% (n = 4) of patients developed postoperative infection, none required mesh explantation or re-operation. No statistically significant association was found between the comorbidities assessed and recurrence/infection rates. CONCLUSIONS: We present the first study analyzing clinical outcomes of complex ventral hernia repairs using biologic mesh in predominately clean settings. This study being non-comparative limits definitive conclusions, but our aim is to add to the growing literature on biologic mesh to help future researchers performing comparative trials of synthetic versus biologic meshes.

Single-center ventral hernia repair with porcine dermis collagen implant.

INTRODUCTION: This study aims to evaluate the outcomes and utilization of porcine acellular dermal collagen implant (PADCI) during VHR at a large tertiary referral center. METHODS: Records of 5485 patients who underwent VIHR from June 1995 to August 2014 were retrospectively reviewed to identify patients >18 years of age who had VIHR with PADCI reinforcement. Use of multiple mesh reinforcement products, inguinal hernias, and hiatal hernias were exclusion criteria. The primary outcome was hernia recurrence, and secondary outcomes were early complications and surgical site occurrences (SSOs). Uni- and multivariate analyses assessed risk factors for recurrence after PADCI reinforced VIHR. RESULTS: There were 361 patients identified (54.5% female, mean age of 56.7 ± 12.5 years, and mean body mass index (BMI) of 33.0 ± 9.9 kg/m2). Hypertension (49.5%), diabetes (24.3%), and coronary artery disease (14.4%) were the most common comorbidities, as was active smoking (20.7%). Most were classified as American Association of Anesthesiologists (ASA) Class 3 (61.7%). Hernias were distributed across all grades of the ventral hernia working group (VHWG) grading system: grade I 93 (25.7%), grade II 51 (14.1%), grade III 113 (31.3%), and grade IV 6 (1.6%). Most VIHR were performed from an open approach (96.1%), and were frequently combined with concomitant surgical procedures (47.9%). Early postoperative complications (first 30 days) were reported in 39.0%, with 71 being SSO. Of the 19.7% of patients with SSO, there were 31 who required procedural intervention. After a mean follow-up of 71.5 ± 20.5 months, hernia recurrence was documented in 34.9% of patients. Age and male gender were predictors of recurrence on multivariate analysis. CONCLUSION: To the best of our knowledge, this is the largest retrospective single institutional study evaluating PADCI to date. Hernias repaired with PADCI were frequently in patients undergoing concomitant operations. Reinforcement with PADCI may be considered a temporary closure, with a relatively high recurrence rate, especially among patients who are older, male, and undergo multiple explorations in a short perioperative period.

Comparison of biological and alloplastic meshes in ventral incisional hernia repair.

PURPOSE: The aim of our retrospective analysis was to compare the results of incisional hernia repair by porcine small intestinal submucosa-derived (SIS) meshes with those obtained by alloplastic polypropylene-based (PP) meshes in comparable surgical indications by matched-pair design. We hypothesized that in incisional hernia, SIS mesh repair is associated with fewer recurrences and SSO than PP mesh repair in incisional hernias. METHODS: Twenty-four matched pairs (SIS vs. PP mesh repair between 1 January 2005 and 31 December 2013) were identified by matching criteria: gender, age, comorbidities, body mass index, EHS hernia classification, mesh implantation technique, CDC wound classification, and source of contamination/primary surgery leading to incisional hernia. Minimal follow-up time was 24 months. Means and standard deviations were compared by paired t test; categorial data were compared by McNemar's test. Poisson's distribution and negative binominal distribution were employed to detect significant correlation. RESULTS: There were no statistically significant differences between both groups in the pre- and perioperative factors and the follow-up times. There were significantly more wound complications (19 vs. 12, p = 0.041), longer hospital stay (22.0 ± 6.3 vs. 12.0 ± 3.1 days, p = 0.010), and significantly more recurrent hernias (25 vs. 12.5%, p = 0.004) after SIS mesh repair. Both the Poisson's distribution and the negative binominal distribution unveiled significantly more complication points (3-6 vs. 1-2) per month after SIS mesh repair. CONCLUSION: There is no advantage of SIS meshes compared to PP meshes in incisional hernia repair with different degrees of wound contamination in this matched-pair analysis. Further prospective and randomized trials or at least registry studies such as the EHS register with standardized and defined conditions are warranted.

Reconstruction of an abdominal wall defect with biologic mesh after resection of a desmoid tumor in a patient with a Gardner's syndrome.

INTRODUCTION: Desmoid tumors are rare proliferative and invasive benign lesions. They can be sporadic, but in most instances, desmoid tumors develop in the context of Gardner's syndrome with principal localization in the abdominal cavity and abdominal wall. CASE-REPORT: We report the case of a 24-year-old female presenting Gardner's syndrome with a symptomatic abdominal wall desmoid tumor. Lack of response to medical treatment led to surgical management consisting in a complete resection and parietal reconstruction with a biologic mesh. Postoperative course was uneventful and there was no evidence of recurrence at 12 months of follow-up. DISCUSSION: Conventional treatment of abdominal wall desmoid tumors consists in a wide and radical resection. However, complete resection is not always feasible because of difficulty to differentiate the desmoid tumor from adjacent tissues. The surgical approach may require different techniques to repair the parietal defect including prosthetic material such as synthetic or biologic meshes. Biological mesh is an ideal alternative to synthetic graft, mainly in case of infection. CONCLUSION: We have encountered a case of a symptomatic growing desmoid tumor of the abdominal wall in a young patient with Gardner's syndrome, successfully treated by complete resection and reconstruction with a biologic mesh to correct the parietal defect.

[Economic evaluation of medical devices not included in the French list of products and services qualifying for reimbursement: Example of biologic meshes]. / Impact économique à l'hôpital de dispositifs médicaux non remboursés en sus des GHS : exemple des prothèses de renfort biologiques.

OBJECTIVES: To present a method aimed to evaluate the economic impact associated with the use of medical devices (DM) not reimbursed in addition to diagnosis related groups (DRGs) tariffs using the example of biological meshes for parietal reinforcement. METHODS: In this multicenter retrospective cohort study, we included all patients who received a biological mesh between January 2010-April 2014 (University hospitals of Saint-Étienne, France) or between January 2010-March 2015 (Lyon University hospitals, France). Measured costs associated with biologic meshes were compared to those of the "Étude nationale des coûts à méthodologie commune" (2012) to weigh the economic impact of biologic meshes with the French DRGs costs. We also compared these costs to the fares perceived by the hospital from the French sickness fund (GHS). RESULTS: Thirty-six patients received a biological mesh and were treated by a total of 38 biological meshes. Of these, the implant was Protexa®, Permacol® and Strattice® in 66%, 29% and 5% of cases respectively. The hospitals incomes were 10,496±5562€ per stay. Meshes-related expenditures represented in average 28% of DRGs costs and 38% of GHS tariffs. The mean additional cost for biological meshes was 3793±2292 euros compared to the mean cost on implantable medical devices in the French DRGs. CONCLUSION: Given their currently restricted use, the hospital budget impact of biological meshes remains limited although the incremental cost per patient is substantial. Analytic costs data can be useful within the scope of decision-making related to DM not refunded by the French health system.

The use of crural relaxing incisions with biologic mesh reinforcement during laparoscopic repair of complex hiatal hernias.

INTRODUCTION: Laparoscopic hiatal hernia repair has a better chance of success if the hiatus is closed without tension. This study attempts to answer the following questions: (1) What is the rate of hiatal hernia recurrence in patients who undergo hiatal closure with diaphragmatic relaxing incisions? (2) Can biologic mesh be safely substituted for synthetic mesh as coverage of the relaxing incisions? METHODS: We identified all patients who underwent laparoscopic hiatal hernia repair at our institution between 2007 and 2013 and reviewed their clinical records. Radiologic recurrence was identified by an experienced radiologist and defined as the presence of any abdominal contents located above the diaphragm on esophagram. Clinical recurrence was defined as little or no improvement in symptoms, the development of a new symptom, or the need for medical, endoscopic, or surgical treatment of postoperative symptoms. RESULTS: A minimum of 6 months of radiologic and clinical follow-up was available for 146 (40 %) patients, including 16 with relaxing incisions. There were 66 (45 %) recurrent hernias detected on esophagram. There was no difference in the rate of recurrent hiatal hernia among the three groups: Primary closure of the hiatus (21/36 [58 %]), primary closure with biologic mesh reinforcement (36/94 [38 %]), and relaxing incision with biologic mesh reinforcement (9/16 [56 %]; p = 0.428). Two reoperations were performed on patients who underwent left relaxing incisions and developed symptomatic diaphragmatic hernias through the left relaxing incisions. There were no complications associated with use of biologic mesh at the hiatus. CONCLUSIONS: Rate of recurrent hiatal hernia is similar between patients who undergo diaphragmatic relaxing incisions and patients who undergo primary hiatal closure. Relaxing incisions can be safely performed on either crus; however, biologic mesh should not be used to patch a left-sided relaxing incision due to the risk of developing a diaphragmatic hernia.

Comparative study between biologic porcine dermal meshes: risk factors of postoperative morbidity and recurrence.

OBJECTIVE: Different types of biologic mesh have been introduced as an alternative to synthetic mesh for use in repairing contaminated ventral hernias because of their biocompatible nature. The aim of this study was to compare the clinical outcomes of patients who underwent complex ventral hernia repairs with either non cross-linked or cross-linked porcine dermal meshes. METHOD: This was retrospective analysis from a prospectively maintained database from January 2010 to May 2013. Patients undergoing open incisional hernia repair with a biologic mesh in the presence of a clean-contaminated, contaminated or dirty wound were reviewed. RESULTS: There were 39 patients who underwent single-staged abdominal wall reconstruction for a contaminated ventral hernia with a biologic mesh. In 15 cases, non cross-linked mesh was used (Strattice, n=8; Protexa, n=1; XenMatrix, n=6); a cross-linked mesh was used in the remaining 24 cases (Permacol n=21; CollaMend n=3). The median follow-up was 11.9 ± 10.6 months. The overall morbidity was 71.8% (n=28), with 15.4% (n=6) for grade I, 23.1% (n=9) for grade II, 23.1% (n=9) for grade III (n=3 grade IIIA, n=6 grade IIIB), 7.7% (n=3) for grade IV and 2.6% (n=1) for grade V. In the cross-linked group, there were six complications directly linked to the biologic mesh, compared with three in the non-cross-linked group. Overall wound morbidity was 41.0% (n=16). There were 13 hernia recurrences (33.3%), and recurrence rate was not significantly different for both groups. CONCLUSION: Despite the high rate of wound morbidity associated with the single-staged reconstruction of contaminated fields, it can be safely performed with biologic mesh reinforcement. Recurrence rate was not significantly different between cross-linked and non cross-linked porcine meshes.

Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias.

The utility of mesh reinforcement for small hiatal hernia found especially during antireflux surgery is unknown. Initial reports for the use of biological mesh for crural reinforcement during repair for defects greater than 5 cm have been shown to decrease recurrence rates. This study compares patients with small hiatal hernias who underwent onlay biologic mesh buttress repair versus those with suture cruroplasty alone. This is a single-institution retrospective review of all patients undergoing repair of hiatal hernia measuring 1-5 cm between 2002 and 2009. The patients were evaluated based on surgical repair: one group undergoing crural reinforcement with onlay biologic mesh and other group with suture cruroplasty only. Seventy patients with hiatal hernia measuring 1-5 cm were identified. Thirty-eight patients had hernia repair with biologic mesh, and 32 patients had repair with suture cruroplasty only. Recurrence rate at 1 year was 16% (5/32) in patients who had suture cruroplasty only and 0% (0/38) in the group with crural reinforcement with absorbable mesh (statistically significant, P = 0.017). Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1-5 cm with significant recurrence rate and failure of antireflux surgery. Crural reinforcement with absorbable mesh may reduce hiatal hernia recurrence rate in small hiatal hernias.

Biomaterials: so many choices, so little time. What are the differences?

The use of biologic mesh has increased greatly in recent years in response to the need for a solution in managing contaminated hernias. Multiple different meshes are commercially available, and are derived from a variety of sources, including human dermis as well as animal sources. For a mesh to be effective, it must be resistant to infection, have adequate tensile strength for hernia repair, and be well tolerated by the host. To achieve this end, biologic meshes go through an intense processing that varies from one product to the next. In this article, the authors review the types of mesh available, how they are processed, and examine these characteristics in terms of their strengths and weaknesses in application to surgical technique.

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse.

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Parastomal hernia repair and reinforcement: the role of biologic and synthetic materials.

Parastomal hernia is a prevalent problem and treatment can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is to perform parastomal hernia repair with mesh whenever possible. There exist multiple options for mesh reinforcement (biologic and synthetic) as well as surgical techniques, to include type of repair (keyhole and Sugarbaker) and position of mesh placement (onlay, sublay, or intraperitoneal). The sublay and intraperitoneal positions have been shown to be superior with a lower incidence of recurrence. This procedure may be performed open or laparoscopically, both having similar recurrence and morbidity results. Prophylactic mesh placement at the time of stoma formation has been shown to significantly decrease the rates of parastomal hernia formation.

Biomaterials in the treatment of anal fistula: hope or hype?

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

The Use of Biologic Mesh for Repair of Perianal Fistulas.

This is a case series of three patients who presented with complex anorectal fistulas. Each patient underwent repair of complex anorectal fistulas with biologic mesh. We will discuss each case and our institution's experience with this relatively new technique. This case series demonstrates the use of biologic mesh for the repair of complex anorectal fistulas. Three patients are discussed who underwent repair of perianal fistulas using ACell mesh by two separate surgeons. We will discuss the rationale for offering this treatment, as well as the advantages and disadvantages. The use of biologic mesh in perianal fistulas is a relatively new topic that needs further investigation. Perianal fistulas can be difficult to manage for both patients and surgeons. There are many options for repair, ranging from simple to complex. Biologic mesh for complex fistulas may be a useful option to avoid the morbidity of more complex repairs, such as flaps.

Large Penetrating Wounds to the Chest Managed With Immediate Chest Wall Reconstruction Using Biologic Mesh, Titanium Plates, and Rotational Tissue Flaps.

Large open chest wall wounds can be difficult to manage due to full-thickness tissue loss with underlying rib fractures and exposed lung parenchyma. Historically, the use of synthetic material has been discouraged in the traumatic setting with the concern that it may be associated with an increased risk of infection. We present 4 patients with large open injuries to the thorax-one from blunt and three from penetrating trauma. We describe our initial management followed by prompt surgical repair using biologic mesh, titanium rib spanning plates, and rotational tissue flaps with Z-plasty of the skin for definite closure. All patients did well post-operatively without complications or wound infections. With the appropriate management, we suspect there may be an advantage in performing immediate reconstruction and closure in large open thoracic injuries utilizing biologic mesh and titanium rib spanning plates with a lower risk of infection than previously believed.