WHICH MESH? Several new mesh options available today address common concerns with hernia repair, including complications and recurrence.

What's the best mesh? "If there were one perfect mesh, we wouldn't be having this conversation," says Kent W. Kercher, MD, FACS, a surgeon with Carolinas Hernia Institute in Charlotte, N.C. "We would be using it." While there's no one-mesh-fits-all solution, the ongoing search for the perfect hernia repair has inspired several new meshes and fixation devices designed to prevent complications and minimize recurrence. Here's a look at 3 trends worth noting.

1. Biologic results at half the price
In most healthy patients, a synthetic polypropylene mesh is suitable, says Hien Tan Nguyen, MD, the director of the Johns Hopkins Comprehensive Hernia Center in Baltimore, Md. However, surgeons often will want to use pricey biologics — made from human or animal tissue — when there's a high risk of infection, since they can encourage growth of healthy tissue and potentially reduce bioburden contamination. But biosynthetic or absorbable synthetic meshes could give your docs the benefits of biologics at a synthetic's price tag. Absorbable synthetic options are around half the cost of true biologic meshes, and the non-absorbable meshes are even less, says Dr. Kercher.

Absorbable synthetic meshes are made from synthetic materials that gradually break down over time. They mimic biologic mesh and usually feature a fully reabsorbable monofilament scaffold design that lets new tissue grow and strengthen the hernia repair. Because they help reinforce the repair without leaving a lasting foreign object in the body, they tend to work best in cases where there is bacterial burden near or within the surgical site, says Dr. Nguyen. "You use absorbable mesh in situations where you're concerned that if the mesh does not break down, it can become a source of infection," he says.

While the mesh may help prevent infection, scientific evidence backing up the claims is limited. There's also a chance of recurrence, since the mesh will eventually disappear. "With an absorbable mesh, we can achieve the goals of hernia repair, which is to put some type of mesh in there to keep the abdominal wall closed," says Dr. Kercher. "The downside is, if you have a mesh that's going to go away over 4 to 18 months, then what you have to rely on is that the patient's body will form scar tissue to minimize the chance of recurrence."

2. Hybrids offer best of both worlds
For surgeons who want to maintain some of the benefits of absorbable mesh, but want permanent reinforcement for the hernia repair, hybrid meshes — made from part biosynthetic/biologic, part synthetic material — can be a great addition.

There are 2 hybrid meshes on the market, says Bruce Ramshaw, MD, FACS, chair of the department of surgery at the University of Tennessee Graduate School of Medicine in Knoxville. One uses a polypropylene base that's then coated with a biologic graft to help promote the growth of patient's tissue. The other, approved earlier this year, uses a similar design but features a biosynthetic material instead of a biologic.

"The general theoretical benefit is that the biologic/biosynthetic material on the outside will protect the sensitive structures and the permanent mesh from bioburden, since the mesh will help the patient heal and encourage new tissue growth, and then dissipate," says Dr. Ramshaw. "When it's gone, you'll have a healed wound with the permanent mesh still in place for reinforcement."

Dr. Kercher notes that this style is still relatively new and doesn't yet have proven results, but it could potentially be helpful in situations where you need a permanent repair near a delicate or contaminated structure. "One area is a parastomal hernia repair where the patient has a colostomy, yet there's a hernia around that colostomy," he explains. "In that situation, the downside of putting in a permanent synthetic mesh is that it can erode into the bowel and cause a significant complication. In theory, a hybrid in that situation would give you a durable repair that also allows the biologic to provide a level of protection against the sensitive structure."

Just like biosynthetic options, the biggest benefit may be hybrid's price compared to biologic mesh, the doctors say. "They're pricing it closer to reabsorbable synthetic meshes: $2,000 to $4,000 compared to $8,000 to $20,000 for biologics," says Dr. Ramshaw.

FIGHT INFECTIONS
Could Drug-Eluting Mesh Prevent SSIs?

SSI PREVENTION Lisa Jennings, PhD, is developing a drug-eluting hernia mesh that helps prevent bacterial growth.

Open ventral hernia repair is one of the most common surgeries in the United States, but it has infection rates as high as 40%, says Lisa Jennings, PhD, professor of medicine at the University of Tennessee Health Science Center and chief scientific officer of Ariste Medical. To combat this common complication, Dr. Jennings and colleagues from the university are developing a drug-eluting mesh designed to fight infection from the inside out.

Ariste Medical's polypropylene mesh features a unique coating of antibiotics that keeps microbes at bay as the patient recovers. While the mesh isn't yet available — they hope to earn FDA approval early next year — studies have shown that it's successful at preventing bacteria from contaminating the surgical site immediately after surgery. In a study presented at the Annual Hernia Repair Meeting of the American Hernia Society, researchers found that the mesh sustained antimicrobial activity against common bacteria for at least 14 days after implantation, as well as protection against a broad spectrum of bacterial pathogens associated with SSIs, such as MRSA and E. coli.

"What's unique is that we are able to show robust antimicrobial activity for at least 14 days," says Dr. Jennings, noting that though there are other drug-eluting meshes on the market, those tend to remain antimicrobial for only 7 days. "We hope that in the long term, this would reduce the incidence of infection and have a positive impact on patient outcomes."

— Kendal Gapinski

3. Self-fixating meshes
Some surgeons worry that fixating hernia mesh to the tissue with sutures, staples or tacks can lead to prolonged post-op pain or surgical site infections. While those concerns aren't backed by science, some manufacturers are trying to help docs avoid the situation altogether with self-fixating meshes.

Self-fixating meshes feature a small, hook-like pattern on one side that lets them attach to the repaired tissue and stay put without traditional forms of mechanical fixation. This Velcro-like quality makes it notoriously difficult to handle, says Dr. Ramshaw. "Generally, it's harder to use, especially in laparoscopic cases, because it sticks to everything, though it has gotten better," he says. For those who prefer mechanical fixation, "it's all about angulation" with the latest tackers and staplers, says Dr. Ramshaw. Laparoscopic devices that articulate at the tip let the surgeon reach difficult areas inside the abdomen and fixate mesh more efficiently and quickly.

Dr. Nguyen says self-fixating mesh can work particularly well near sensitive structures that make tacking or stapling difficult or even impossible, such as laparoscopic inguinal hernia cases. "When you place the mesh in this area, the concern is that it's going to slide around and expose the gap, which would cause recurrence," he says. "The most obvious solution is to fixate the mesh, but the question is, where do you tack it down with so many important structures?"

These devices could reduce hernia repair's costs. While tackers typically come as single-use devices preloaded with a set number of tacks, one innovative design now lets the surgeon also insert additional tacks, if needed, with 5- to 10-tack reloadable cartridges. This could save money, since you don't have to open up a new device in the rare occurrence that you discover you need additional fixation during a procedure, says Dr. Ramshaw.

Is there a solution in sight?
While the search for the perfect hernia repair continues, so, too does the debate among surgeons about the best way to increase long-term results and functionality. "Honestly, no one is doing it 100% right," says Dr. Ramshaw. "Right now, cost and surgeon preference primarily dictate the decision. There are so many choices, and hernia repair is so complex, that there's no way to have a uniform answer. Ultimately, we will all need to measure the value of care we provide and use that data to drive what products we use for different techniques and different patient sub-populations." OSM