Journal of Visceral Surgery (2013) 150, 5259

Available online at

www.sciencedirect.com

ORIGINAL ARTICLE

A review of available prosthetic material for

abdominal wall repair
M. Poussier , E. Denve , P. Blanc , E. Boulay ,
M. Bertrand , M. Nedelcu , A. Herrero , J.-M. Fabre ,
D. Nocca
Service de chirurgie digestive A, Hpital Saint-Eloi, CHU de Montpellier, 80, avenue
Augustin-Fliche, 34295 Montpellier cedex 5, France

KEYWORDS
Prosthetic material;
Abdominal wall
repair;
Hernia

Summary Abdominal wall incisional and inguinal hernia repair can call for utilization of
implants or prostheses as an alternative to simple suture techniques. The various implants
can be synthetic, biologic or mixed: their physicochemical properties condition the mechanical
results and the long-term outcome of the repair. The increasing number of available materials allows the surgeon to choose between a wide variety depending on the indication, the
site of implantation, the surgical approach and whether the operative eld is contaminated
or not. With regard to evidence-based medicine, while several synthetic implants have been
shown to be superior in efcacy to simple suture, other studies are underway to develop the
indications for bioprostheses, in particular in contaminated elds. This review of the literature summarizes the current knowledge on synthetic and biologic implants (physicochemical
characteristics, forms, indications).
2012 Published by Elsevier Masson SAS.

Introduction
Reinforcing the abdominal wall with an implant during hernia or incisional hernia repair is
accepted by all. The French Health Authority (Haute Autorit de sant or HAS) published
a study in 2008 showing that reinforcement with implant decreased the recurrence rate
(< 1.5%) in comparison to repair without implant [1] (which can be as high as 50% according
to the size of the defect) [2]. More than one million implants are inserted worldwide every
year. Use of prosthetic material for abdominal wall surgery dates back more than one
century. Around 1900, the rst prosthesis used for the treatment of inguinal hernia was
an inoxidable steel metallic mesh, later abandoned because of its rigidity, responsible
for sequellar pain. The modern era started in 1958 with the introduction of polypropylene
implants [3]. At the present time, several new implants are available on the market. These
are made of textile mono- or multilaments, woven, knitted or glued in the form of a mesh.
Ideally, these implants should be chemically inert, not elicit any inammatory reaction,
not be carcinogenetic, not provoke any allergy, be resistant, easily sterilisable, easy to
handle, and inexpensive [2].

Corresponding author.
E-mail address: d-nocca@chu-montpellier.fr (D. Nocca).

1878-7886/$ see front matter 2012 Published by Elsevier Masson SAS.

http://dx.doi.org/10.1016/j.jviscsurg.2012.10.002

A review of available prosthetic material for abdominal wall repair

Synthetic implants
Classication and properties
The HAS has classed the abdominal wall implants in three
categories: at, 3-D preformed, and biface implants [1].
However, the distinction between the different implants
is greater when their physical properties are taken into
account:
long-term physical behavior: elective hernia repair
(non contaminated or non-infected eld) where nonabsorbable prostheses can be used [1]. Absorbable
prostheses (example: Vicryl ) can be used for emergency
repair, in a contaminated or infected eld, to reduce
the risk of evisceration, but with poor long-term results
with regard to hernia recurrence because of the weakness of the connective tissues generated by the insertion
of the Vicryl mesh. More recently, a new generation of
absorbable synthetic implants (Gore BioA ), composed of
polymers, is under evaluation. Moreover, some implants
associate non-absorbable and absorbable material, in
general to obtain a softer or lighter prosthesis or an antiadhesion effect: these are biological products of vegetal
(Beta D glucane, cellulose), or animal (collagen, omega3)
origin [2];
grid: the implant can be knitted, woven, thermoformed
or present as a lm (example: ePTFE or expanded polytetrauorethylene). The implant is characterized by its
thickness, its density (g/m2 ), its porosity and the diameter
of the grid;
porosity: porosity determines the tissular reaction of
implants. The grid is said to be macroporous when pores
are greater than 75 m, and microporous when the pores
are less than 10 m. The pores must be at least 75 m
to allow penetration of macrophages, ingrowth of broblasts, collagen deposition and neovascularization within
the pores. Implants with large pores create less tissue
reaction and preclude granuloma formation bridging the
interstices. Effectively, an isolated inammatory reaction
is generated by each individual ber; if the implant is
microporous, the granulomas blend together, enveloping
the implant and providing the implant with rigidity;
resistance: the mechanical resistance of implants must
be at least 180 mmHg, that is superior to the maximal
abdominal pressure (which can reach 150 mmHg during
efforts of coughing);
weight: this parameter depends on the type of polymer and the size of the grid. Heavy-weight prostheses
(> 90 g/m2 ) are made by tight braiding with thick,
microporous laments. Light wieght prostheses are composed of thin laments and/or large macroporous grids
(> 1 mm), leading to less inammatory reaction and more
elasticity;
elasticity: this characteristic varies according to whether
the implant is light-weight (2035% at a pressure of
16 N/cm2 ) or heavy-weight (416% at a pressure of
16 N/cm2 ). Elastic implants are characterized by a certain
degree of freedom on mobile parts of the abdominal wall
(example: the groin) while rigid, non-elastic, implants
reduce abdominal distension. As an example, a rigid,
nearly non-distortable implant might be preferred to
repair a recurrent linea alba hernia in a patient with
chronic bronchitis, because what is needed is abdominal containment; conversely, inguinal hernia repair would
benet from a light-weight, large grid implant where elasticity would increase patient comfort during movements

53

(exion of the thigh) and decrease inammation in an

abundantly innervated region;
size: the size of the prosthesis should be adapted to the
size of the orice to be covered. In the treatment of
incisional hernia, the overlap should be at least 5 cm in
all dimensions [2]. One must not forget the shrinkage
effect, which translates as in vivo shortening of the
implant due to tissular reaction.

Classical implants
At the present time, there are three different nonabsorbable implants available that differ by their chemical
composition as well as by their plaiting: polypropylene,
polyester and expanded polytetrauoroethylene (nylon
meshes have been abandoned because they degrade in the
long-term):
polypropylene: hydrophobic, inert, rigid, highly resistant,
this basic material is used in most woven prostheses
(example: Prolene , Marlex );
polyethylene terephtalate polyester (Dacron): elastic,
hydrophilic, woven. These meshes are supple, easy to
use, and exist also as large grid, highly porous woven
material (example: Mersutures );
expanded polytetrauoroethylene (ePTFE) (example:
Dual Mesh ). This material is rigid, hydrophobic and its
absence of integration by the organism decreases the risk
of adherence, but this material is rarely indicated for
parietal repair.

Light-weight and extra light-weight implants

The concept of light-weight material appeared in 1998 with
the commercialization of Vypro by Ethicon. The basic material was reduced by 30% compared with classical implants
while the size of the pores increased (3 to 5 mm vs. < 1 mm
for the classical implants). Large grids were therefore used
to obtain light-weight prostheses.
Later, partially absorbable (50%) implants were obtained
either by adding absorbable lament meshes to polypropylene meshes, or coating the polypropylene laments
with absorbable polymers. With this type of implant,
the inammatory reaction is decreased by 70% and healing takes place around each monolament, not globally.
The initial partially absorbable light-weight prostheses
were composed of polypropylene + polygalactine 910 (example: Vipro and Viproll ) or polypropylene + polyglycapone
(example: Ultrapro ). Polygalactine (Vicryl ) is absorbed
within 6 weeks and polyglycapone (Monocryl ) within 12 to
20 weeks. These composite implants are supple, easy to use
because of their form memory and provoke less inammation [4].
The other materials used in association with polypropylene include -D glucan (Glucamesh ), or poly-L-lactic acid
(PLLA) (example: 4DDome ), the goal of which is to accelerate tissue integration.
Hernia repair with light-weight prostheses have been
noted to decrease the risk of chronic pain [5,6] when the
anterior approach is used, and are associated with better
tolerance when the laparoscopic approach is used [7].

Biface implants
When implants are placed intraperitoneally, as for example, during laparoscopic incisional hernia repair, the face
in contact with the abdominal wall should have good

54

M. Poussier et al.

Table 1 Cost of implant: implants for abdominal wall reconstruction, suspension, or wrapping. Non-absorbable without
tissues or derivatives of biologic origin.
Nomenclature

Non-absorbable implant
knitted or woven, coated
or non-coated

Non-absorbable
implant not knitted nor
woven

Implant for endoscopic

or mini-invasive
surgery, anatomic,
pre-formed, pre-cut,
with positioning
system, plugs

Price TIPSa

Surface 100 cm2

100 cm2 < Surface
250 cm2
Surface > 250 cm2

Surface 100 cm2

100 cm2 <Surface
250 cm2
250 cm2 < Surface
450 cm2
Surface > 450 cm2

102.45 D

49.7 D
61.44 D
80.49 D

182.94 D
365.88 D
518.33 D
1067.14 D

All prices are net with tax; TIPS: tarif interministriel des prestations sanitaires (Interministerial tariff for health-related acts).

integration characteristics; conversely, the face in contact

with the viscera should resist adhesion formation and
enhance neoperitoneal formation. The non-absorbable parietal face is usually composed of classical material, often
polypropylene; the visceral face can be made of absorbable
or non-absorbable material. Absorbable materials include
oxidized regenerated cellulose (example: Proceed ), carboxymethylcellulose, or a porcin cellulose-based lm,
polyethylene glycol and glycerol (example: Composite
Parietex ) or a bio-absorbable reticulated gel composed of
omega-3 fatty acids (C-QURTM ).
Non-absorbable materials include ePTFE (example: Composix L/P ; Dual Mesh ), silicone, polyurethane (example:
Intra-Swing Composite ), or titan. All are inert materials,
hydrophobic, non-adhesiogenic, intended to avoid cellular
penetration.

Other technical improvements

Table 2 Implant cost: implants for abdominal wall

reconstruction, suspension, or wrapping. Resorbable
without tissues or derivatives of biologic origin.
Nomenclature

Absorbable implant
Knitted or woven,
coated or non-coated

Price TIPS

Surface 250 cm2

Surface > 250 cm2

32.17 Da
83.39 Da

All prices are net with tax; TIPS: tarif interministriel des
prestations sanitaires (Interministerial tariff for health-related
acts).

Bioprotheses
Nature and physicochemical characteristics of
bioprotheses

Regular improvements have been made to facilitate the use

of implants. These include:
preformed or precut implants adapted to different techniques. Examples comprise dome-shaped implants (4D
Dome ; Ultrapro Plug , Perx plug ) for the plug techniques; different pre-cut prostheses to allow the passage
of the spermatic cord (Lichtenstein technique); meshes
that assume the anatomical contours of the inguinal
region for the pre-peritoneal technique (example: Swing
Mesh 4A , 3D Max );
implants facilitating their xation: implants furnished
with either an auto-adhesive cover (example: Swing
Contact , Adhesix , Progrip ) or with thermo-inducted
staples (example: Endorollx );
three-dimensional implants theoretically limiting the possibility of migration (example: UHS , Ultrapro , 3D
patch , PHS );
implants adapted to laparoscopic maneuvering, for example, pre-rolled to facilitate the passage in the trocar
(example: Endoroll ), or with pre-inserted cardinal point
sutures (example: Parietex ).

Collagen is a hemostatic, biodegradable biomaterial that is

easy to handle and indispensable for cellular ingrowth. It
serves as a scaffold for integration of host tissular regeneration via its architectural organization. The rationale is to
guide the healing process and restore the initial host status
so that cellular penetration, neovascularization and broconnective tissue production can form around the implant
[8].

Costs of parietal reinforcement prostheses

Synthesis procedures

The costs of the various prostheses are dened according to

a classication based on their constitution and their properties (Tables 13).

Several procedures exist for the synthesis of bioprostheses

(Tutopatch , SIS , Tissue Science process, etc.); these rely
on the same basic steps irrespective of the origin of the
tissues. In Europe, the Conformit europenne (CE) marking

Origin of bioprotheses
The bioprostheses used in abdominal wall surgery derive
from animal (xenogenic) or human (allogenic) tissues. They
are constituted by type I, III or IV collagen matrixes as well
as sterile acellular elastin produced by decellularization,
sterilization and viral inactivation, in order to enhance integration and cellular colonization of the prosthesis by the host
tissues.

Concept of bioactivity

A review of available prosthetic material for abdominal wall repair

55

Table 3 Cost of implant: implants for abdominal wall reconstruction, suspension, or wrapping. Non-absorbable or
absorbable containing derivatives of animal origin.
Nomenclature

Implant
Knitted or woven,
coated or non-coated

Price TIPS

Surface 100 cm2

100 cm2 < Surface 250 cm2
Surface > 250 cm2

248.80 Da
292.70 Da
380.51 Da

All prices are net with tax; TIPS: tarif interministriel des prestations sanitaires (Interministerial tariff for health-related acts).

is delivered for implantable medical devices. Products are

divided into four classes (I, IIa, IIb and III) according to their
potential health risks; for each of them, precise modalities
have been established for conformity evaluation.

Biomechanical characteristics
The biomechanical characteristics of prosthetic reinforcement implants are essential to the intrinsic efcacy
of ensuring mechanically reliable tissue reinforcement.
Deeken et al. [9] recently studied several parameters (physical, thermic, and degradation) in a series of 12 human,
porcine and bovine bioprotheses. All the tested prostheses supported a tension of greater than 20 N applied to
the attachment sutures; half of them tore when tension
exceeded 20 N. Resistance to rupture varied from 66.2 N/cm
for Permacol to 199.1 N/cm for X-Thick AlloDerm . All the
prostheses except Surgiguard , Strattice and CollaMend
manifested signs of wear after application of 10 to 30%
of a mean stress of 16 N/cm. The reticulated CollaMend
and Permacol implants have shown better resistance to
high temperatures and enzymatic degradation of collagen
(by collagenase and metalloproteinases) than the nonreticulated implants.

Reticulation
Reticulation or cross-linking is an old procedure (tanning) long used in the leather industry to render skins
more resistant to degradation The goal of bioprosthetic
reticulation is double: to reduce collagen degradation
by the host collagenases, and to increase the durability and decrease the immunogenicity of xenogenic
implants [10]. Several types of reticulating agents are
used: glutaraldehyde, hexamethylene diisocyanate and 1ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC). These
biological implants were designed with the goal of
reinforcing tissues while gradually degrading over time.
In vivo, reticulation modies tissue restructuring and cellular inltration and increases the duration of the implant
before reabsorption [11]. Some authors feel that reticulation limits tissue regeneration because the bioprothesis
behaves like non- or very slowly absorbable synthetic prostheses; this may potentially result in a reduced robustness of
repaired tissues in the long term [12]. Moreover, reticulated
implants may be very immunogenic (macro/monophage activation) and increase the inammatory response to host
tissues (pro-inammatory cytokines) [13,14]. Clinically, a
recent retrospective study, from the database of the Food
and Drug Administration (FDA) [15] found that there was a
75% complication rate associated with the use of reticulated
bioprostheses, especially when they were used in infected
elds (79%) and that their innate tendency to bacterial

colonization was elevated [16]. Encapsulation of reticulated

implants, a complication that resembles a graft vs. host
rejection reaction, is due to a combination of host inammatory response, immunogenicity, and to inadequate tissue
restructuration due to insufcient tissue integration [15].
When encapsulation occurs, this may lead to decreased quality of tissue repair and necessitate implant removal [17].

Classication
At the present time, there is no consensual agreement
regarding classication of bioprostheses. Nonetheless, these
implants can be classed according to their tissue origin,
the process of synthesis (reticulation), and their indications.
Although less than exhaustive,Table 4 lists the bioprostheses
in use throughout the world for abdominal and reconstructive surgery.

Rationale for bioprosthesis placement

Insertion of synthetic material for tissue reinforcement in an
infected or contaminated eld is contra-indicated because
there are major risks of chronic infection, rejection or recurrence [18]. Nonetheless, there are indications for the use
of temporary interfaces between infected tissues that are
desirable, if not indispensable, even in the contaminated
eld.
In order to respond to this challenging problem, new
implantable medical devices began to be introduced in the
1980s [19]. The rational for these bioprostheses resided
in their progressive biodegradability and their supposedly
weak immunogenicity, while still ensuring high quality tissue regeneration with mechanical characteristics similar
to synthetic prostheses. Among others, Milburn et al. [20]
showed in the rodent experimental model that the acellular
dermal collagen matrix (AlloDerm ) had better resistance
to Staphylococcus aureus inoculation compared with PTFE
for incisional hernia repair; the bacterial clearance was
19.3% versus 0%. These results were conrmed by Harth
and co-workers [21] who compared the bacterial clearance
of a S. aureus innoculum (104 CFU/ml) injected after parietal repair with prosthetic reinforcement comparing four
bioprotheses (Surgisis , Permacol , XenMatrix , Strattice )
versus a synthetic polyester implant. Bacterial clearance
was 0% for synthetic material, 58% for Surgisis , 67% for
Permacol , 75% for XenMatrix and 92% for Strattice
(P = 0.003). This conrms the value of the use of bioprostheses in infected elds; the ultimate outcome depends on
the type of implant.
The indications for bioprostheses have progressively
increased, even though there have been only a few preclinical and clinical studies with high levels of evidence

56

M. Poussier et al.

Table 4

Summary of the principal studies of interest concerning the placement of bioprostheses.

Contaminated
or infected
operative eld

Indications

Mean follow-up
(months)

Diaz et al. [38] 240

Yes

Multiple

10

RO

Chavarriaga
et al. [17]

18

No

Incisional
hernia

7.8

Permacol

RC

Cobb et al.
[24]

55

No

Incisional
hernia

Strattice

PO

Shaikh et al.
[26]
Hsu et al. [25]

20

No

18

28

Yes

12

Commercial name of
prosthesis

Study
type

Authors

AlloDerm

RO

CollaMend

Number of
cases

PO

Itani et al.
[30]

85

Yes

Incisional
hernia
Incisional
hernia
Hernia

Surgisis

PR

Ansaloni et al.
[33]

35

No

Hernia

36

Veritas

PO

Franklin et al.
[32]
Helton et al.
[34]
Ueno et al.
[35]
Limpert et al.
[36]

116

Yes

Multiple

52

53

Yes

14

20

Yes

Incisional
hernia
Multiple

22

Yes

Incisional
hernia

22

Pohamac et al. 16
[39]

Yes

Incisional
hernia

16

RO

RO
RO
RO
XenMatrix

RO

Commercial name of prosthesis

AlloDerm
CollaMend
Permacol
Strattice

Surgisis
Veritas

XenMatrix

16

15

Complications
Global (%) Recurrent
hernia (%)

Seroma
(%)

Infection Dehiscence
(%)
(%)

Fistula
(%)

Removal of
prosthesis
(%)

86.7

17.1

31

40

8.8

11.6

38.9

44.4

22.2

22.2

6.6

3.3

1.8

40
21
67

15
10.7
15

10
14.3
22

10
3.5
23

5
3.5
15

2.5

0
0

33

17.1

2.9

50
50
23

7
17
30
19

9.4
11
10
3.8

40
3.8

21

32

36

21

6.2

RO: retrospective observational; RC: retrospective controlled; PO: prospective observational; PR: prospective randomized.

to evaluate their efcacy compared with four times as

many publications about implantation of these prostheses
in uncontaminated elds [22].

bioprostheses is not allowed in France. Nonetheless, they

are widely used in the United States where they recently
obtained the authorization from the FDA in spite of the lack
of reference studies.

Evidence-based medicine and bioprostheses

Allogenic bioprotheses

AlloDerm

Allogenic protheses are produced using the dermis or fascia

lata of cadaver donors (Table 4). Commercialization of these

The bioprosthesis AlloDerm , a non-reticulated sterile acellular collagen matrix derived from human dermis, is the

A review of available prosthetic material for abdominal wall repair

57

most widely studied product (547 references) and has been

implanted in more than one million procedures.

soon (Nocca et al. presented the results in the EHS congress

Ghent 2011).

AlloMaxTM

Veritas
TM

TM

The bioprosthesis AlloMax (formerly Neoform ) is a nonreticulated sterile acellular collagen matrix derived from
human dermis used for post-mastectomy reconstruction.
AlloMaxTM can be indicated for complex inguinal or incisional hernia repair in patients where synthetic prostheses
are contraindicated or inappropriate.

Flex HD Acellular Hydrated Dermis

The bioposthesis Flex HD Acellular Hydrated Dermis is
a non-reticulated sterile acellular collagen matrix derived
from human dermis provided by a donor bank (Musculoskeletal Transplant Foundation); it is used for post-mastectomy
reconstruction or repair of complex hernia or incisional hernia.

Xenogenic bioprostheses
Xenogenic prostheses can be of porcine (dermis or intestinal
mucosa) or bovine (pericardium) origin, reticulated or not.
There are more than 20 commercial products available, but
in France, only six products have received the CE marking
and been studied in clinical trials, albeit with a low level of
evidence (Table 4).

CollaMend
This bioprosthesis is composed of reticulated porcine dermis and has been evaluated in three clinical studies, two of
which were retrospective [17,23].

Permacol
This bioprosthesis, originating from reticulated porcine dermis, was evaluated in 110 references, of which 37 were
clinical studies: two retrospective studies can be considered
of value [24,25] while the level of evidence was low in four
prospective studies [2629].

Strattice
This bioprosthesis, originating from non-reticulated porcine
dermis, has been evaluated in 19 references including four
preclinical studies (one being a retrospective case report
and one, a review of the literature, six clinical cases in all)
and four ongoing clinical studies one of which is a multicenter study for ventral hernia: the RICH study (for use
in infected elds) [30]. A prospective multicenter tripleblinded randomized controlled study comparing the use of
Strattice vs. a synthetic prosthesis for primary inguinal hernia in 170 male patients with an average follow-up of 2 years
is underway and should provide interesting data concerning
the behavior of these bioprostheses [31].

Surgisis or Biodesign
This bioprothesis, composed of non-reticulated porcine
intestinal mucosa, was the object of 800 published articles (all domains) of which 614 were preclinical studies and
211 clinical (case reports, retrospective series); only one
was a long-term (5 years) prospective study [32] concerning laparoscopic hernia repair in contaminated elds while
three retrospective studies were deemed of value [3335].

Tutomesh or Tutopatch
This non-reticulated bovine pericardial bioprosthesis was
studied in more than 90 publications (all domains) including
eight preclinical studies and the rst multicenter prospective randomized trial Protocole Tutomesh comparing the
efcacy of this bioprosthesis in contaminated or infected
elds vs. traditional suture techniques; this will be published

This non-reticulated bovine pericardial bioprosthesis was

studied in 20 publications (all domains) including four preclinical and 14 clinical studies [36].

Protexa
This bioprosthesis, originating from porcine dermis, has
been commercialized in France since 2012. A multicenter
study is underway in Italy.

Comparative studies between prostheses

After initial feasibility and efcacy studies, several bioprostheses have been compared among themselves. In
their retrospective study, Shah et al. [23] compared the
use of ve different bioprostheses (AlloDerm , Permacol ,
CollaMend , Surgisis and Strattice ) for complex abdominal incisional hernia repair in 58 patients. They found an
overall complication rate of 72.4% including 19% infections,
8.6% seromas and 5.2% abscesses. Reticulated bioprostheses (Permacol , CollaMend ) had higher infection and
removal rates but lower recurrence rates compared with
non-reticulated bioprostheses. Hiles et al. [22] found a 6.7%
recurrence rate for Surgisis versus 13.6% for AlloDerm at
16 months in clean environment repair.

Cost/effectiveness
There are practically no cost-effectiveness studies available for these bioprotheses. In 2008, Blatnik et al.
[37] estimated that the average cost for parietal reconstruction in an infected eld with AlloDerm was
5330 dollars per patient (4100 euros) not including hospital costs, with a hernia recurrence rate of 80%. By
comparison, the average costs are 53 euros/patient for synthetic Prolene prostheses (Ethicon), 79 euros/patient for
Vicryl (Ethicon), and 237 euros/patient for the composite
Parietex (Sofadim/Bard) prosthesis.

Safety Informed consent

As is the case for implantable medical devices, bioprostheses respond to the health criteria relative to their utilization
according to the country in which they are commercialized (premarket approval [PMA] and 510k of the FDA, EC
marking in Europe). These requirements are supposed to
guaranty the safety of the product for the patient, in particular viral infectious, prion and cancerogenic risks. Despite
all these precautions, results of preclinical studies with
regard to harm are rare and not clear. Along the same lines,
and according the French law of March 4, 2002, patients
must receive complete information concerning the use of
bioprostheses, especially as concerns the tissue origin of
the product, both for ethical reasons and to respect each
patients personal convictions.

Conclusion
The surgeon has to choose the correct implant according to
its properties and the clinical picture. In any case, the procedure should never be adapted to the product available,
which implies that the surgeon should have a wide range of
products at his or her disposal. The important parameters
to take into account include: the size and site of the defect

58
to cover, the rigidity of the implant, the potential contamination of the operative eld, the need or desire for cellular
ingrowth, and the surgical approach; the cost-efcacy ratio
based on similar services should not be ignored. Synthetic
implants have been widely studied and their efcacy proven
for individual indications. Bioprostheses should have their
place in the therapeutic armamentarium of abdominal and
reconstructive surgery, in particular, in complex situations
where the parietal reinforcement has to be made in potentially contaminated or infected elds. The results of the
rst multicenter prospective randomized study in France
comparing the efcacy of Tutomesh versus simple suture
repair for the treatment of inguinal or incisional hernia in
potentially contaminated or infected eld are awaited.

M. Poussier et al.

[15]

[16]

[17]

[18]

[19]
[20]

Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.

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