Making Sense of Hernia Mesh

General Surgery

By: Joe Paone

Published: 11/14/2019

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Understanding the evolving science behind the implants will help you decide which option to stock.


Good luck trying to figure out which hernia mesh is best. "There are just so many different options out there," says Jeffrey Blatnik, MD, FACS, an assistant professor of surgery at Washington University School of Medicine in St. Louis (Mo.). "That makes it difficult to keep up with some of the latest trends because every 6 months, a new product emerges."

Mesh has also become very specialized, points out Shirin Towfigh, MD, FACS, a hernia specialist at Beverly Hills (Calif.) Hernia Center. "There are different meshes for laparoscopic surgery versus open surgery, for inguinal hernias versus ventral or abdominal wall hernias, and companies within their own line of items have different styles and types," she says.

To help you make sense of the options, we asked some of the country's leading hernia experts about the different types and features of mesh, and what you should consider when deciding which type to stock in your facility.

  • Mesh type. There are 3 basic types available: permanent synthetic, biologic and hybrid.

Permanent synthetic is the most commonly used. It's been around the longest and is the least costly option, ranging from $40 to $100 depending on your contract with the vendor. Dr. Blatnik says it's especially useful in outpatient facilities, "which are more commonly repairing smaller inguinal and umbilical hernias, in comparison to much more complex procedures done in a hospital setting." As its name implies, permanent synthetic mesh doesn't absorb into the tissue. It's there for life.

At the other cost extreme is biologic mesh, typically made of porcine or bovine materials. This mesh completely absorbs into the body over time. Dr. Blatnik says biologic mesh was once commonly used to repair large incisional hernias, but it can cost thousands of dollars just for a single piece. "It's fallen out of favor to a certain extent due to cost constraints," he adds. "It's not the holy grail of meshes that people initially thought it was going to be."

Hybrid mesh falls in between on the cost spectrum. Dr. Blatnik calls these biosynthetic meshes, or absorbable synthetic meshes. He says that while permanent synthetic is like a window screen, and biologic like a solid sheet, hybrid is typically made from chemical polymers and designed with a more mesh-like characteristic reminiscent of the permanent synthetic surgeons know well.

Like biologic mesh, hybrid absorbs over time. "Biosynthetic is the new, up-and-coming mesh because it alleviates the need for permanent synthetic mesh," says Dr. Blatnik. "There's a lot of interest among surgeons to see how this will fill that void with patients who aren't great candidates for permanent synthetic mesh, either because of their comorbidities or other characteristics that put them at high risk for infection, or for patients who desire not to have permanent mesh implanted."

COMBO PACK The synthetic and biologic materials found in hybrid mesh absorb into the body over time and eliminate some of the risks associated with synthetic meshes.   |  Beverly Hills (Calif.) Hernia Center

Dr. Towfigh has increasingly turned to hybrid mesh. "In my opinion, synthetic mesh seems to have evolved into a lower-quality product than it used to be," she says. "What used to be a higher-quality resin to make mesh may have been switched off to lower-quality resin, so now we're seeing much more inflammation, chronic pain and mesh reaction in patients that undergo synthetic mesh repairs than we used to."

Although rare, patients who do experience mesh reactions suffer from chronic fatigue, joint pain, swelling, hair loss, ringing of the ear, visual changes, brain fog, memory problems and rashes on different parts of their body. "I see the same thing over and over again," says Dr. Towfigh. "They get better after the mesh is removed."

The risks associated with synthetic meshes has led her to use hybrid mesh more frequently. "Hybrid meshes work really well in my practice," she says, "and I think over time you'll see more and more usage of these meshes."

  • Pore size. This refers to the space between the fibers of the mesh.

"Pore size is probably the most important characteristic in my mind," says Dr. Blatnik. "A macroporous design — a pore size in the neighborhood of 2 to 3 millimeters — allows for native tissue ingrowth in between the fibers."

That helps do a couple things, he explains. It reduces the foreign body reaction to the mesh and allows for native vascular ingrowth in between the fibers that may alleviate some infection risks.

"A larger pore size allows the body to heal into the mesh faster," agrees Laura Mazer, MD, MS, an assistant professor at the University of Michigan in Ann Arbor. "It's treated less like a solid foreign body and more like a lattice work that the body scars over. The mesh gets incorporated and won't get infected or cause irritation."

  • Weight (density). Measured in grams per meter squared, "Density ultimately is reliant on the size of the pore — if you have a smaller pore size, you have more fibers woven in, so you have a higher density," says Dr. Blatnik.

"In general, we tend to prefer a larger pore size, but a lower-weight mesh, which tends to have a little more compliance and be a little more comfortable for the patient," says Dr. Mazer. "It's less likely the patient will have any sensation of the mesh. That being said, there have been meshes in the past that have been too lightweight and had a tendency to tear. It's a balancing act. A material like polypropylene has the tensile strength, especially in bigger ventral hernias."

  • Barriers. Different meshes have different barriers or coatings that can be made of biologic or chemical materials. The purpose of the coatings is to reduce adhesions. "The choice for barriers ultimately depends on where you put the mesh," says Dr. Blatnik. "A lot of surgeons now strive to put the mesh in between the layers of the abdominal wall, underneath near the intestine, which we call intraperitoneal style of mesh. That alleviates the need to put in a barrier-coated mesh."

Conversely, he says, barrier-coated mesh should be placed in the peritoneal cavity to repair an umbilical or ventral hernia. "Coated mesh will prevent the bowel from sticking to the mesh, and prevents adhesions or scars from forming to that side of the mesh," says Dr. Mazer.

Finding the right fit
BEST OPTION Surgeons must work with a mesh they're comfortable and confident implanting in individual patients.   |  Beverly Hills (Calif.) Hernia Center

There's no perfect mesh for every patient or for every repair. Surgeons run through a mental checklist when assessing their mesh options. What are the goals for that operation? Where's the hernia located? How big is it? Has it been repaired before? All of those characteristics ultimately play into the determination of what kind of mesh and procedure surgeons use and perform for individual patients.

"It comes down to the experience of the surgeon and their understanding of meshes to tailor what mesh they use for what patient and for what procedure," says Dr. Blatnik. "I commonly use four different styles of meshes, and subsequent sizes within those styles. I have a playbook in my mind for different patients and what meshes we're going to use for their problems, and then tailor the size to the individual patient and the issue they have."

Dr. Mazer typically uses a lightweight polypropylene mesh for most hernias unless there's a reason not to. "I use it in part because of the amount of evidence and the amount of stability it has, how long it's been around and my comfort level with it," she explains.

Patient characteristics — comorbidities, obesity, smoking, future surgical needs, plans to have children — also come into play.

"The key is evaluating each hernia and each patient individually, and hopefully having a large toolbox of repair options and mesh options so you can pick the right repair for the right patient," says Dr. Mazer.

"Most hernias are best treated with standard repairs, but not all. Especially as we start seeing the bigger hernias, hernia recurrences or patients who had reactions to mesh. Having a broader toolbox to offer those patients can be really powerful." OSM

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