EDITORIAL

Biological Prosthetics for Hernia Repair

Muhammad Hanif Shiwani

Nylon was the first polymer synthesized and the first

pure synthetic fiber manufactured as hernia prosthetic in
1935. The initial reports of its use as prosthetic dates
back to 1948 and 1959. In the last two decades numbers
of manufacturers have developed many different kinds
of products, majority of which are made of synthetic
materials. To-date there are about 37 manufacturers and
about 166 various products available in the market.1 It
reflects the fact that surgeons and manufacturers are
still looking for an ideal mesh. At present there is not a
single mesh available in the market which is uniformly
suitable for all varieties of hernia repair in every patient.
Various classifications have been proposed based on
the biomaterial used and the weight of the prosthetic.
The prosthetics are classified on the basis of weights
as ultra light weight (< 35 g/m2), light weight (> 35
< 70 g/m2), standard (> 70 < 140 g/m) and heavy weight
(> 140 g/m2).1
According to a recent classification proposed, there are
four types of prosthetics available based on the basis of
the biomaterial with which they are manufactured. The
mesh could be a simple prosthetic made of one pure
biomaterial with the same texture on sides, mono or
multifilament with or without drugs included. The second
type is composite prosthetics; these are made of two or
more different layers, one of which is simple while
the other are non- absorbable or absorbable. Mesh
could be made of a combination of two materials knitted
or woven together, where either both materials are nonabsorbable or only one filament is absorbable and the
fourth type are biological.1
There are many properties of a prosthetic which are
important to consider repairing an incisional hernia. This
include weight, thickness, tensile strength, burst
strength, tear strength, elasticity, suture retention, pore
size, percentage porosity and yarn diameter.2 The ideal
mesh for the repair of incisional hernia would be strong,
durable, resist infection, be immunologically inert, have
dual surface properties such that the abdominal wall
side will facilitate tissue ingrowth and incorporation into
Department of General Surgery, Barnsley General Hospital
NHS Foundation Trust, University of Sheffield, Barnsley,
UK.
Correspondence: Dr. Muhammad Hanif Shiwani, Barnsley
General Hospital, NHS Foundation Trust, University of
Sheffield, Gawber Road, Barnsley, S75 2EP, UK.
E-mail: mhshiwani@gmail.com
Received August 28, 2012; accepted August 31, 2012.

the fascia, muscle and the peritoneal side will minimize

adherence to the visceral organs and prevent ingrowth
of the tissues.3
When a mesh is used at a position where direct contact
with the bowel is unavoidable like intraperitoneal repair
of ventral and incisional hernia, repair of parastomal
hernia or repair of hiatus hernia and pelvic organ
prolapsed treatment, there is always a risk of causing
erosions to the bowel and development of enterocutaneous fistula. In such a situation, mesh is required
which has got at least on one side a layer of
antiadhesive barrier of some kind. Hence, there is a
rapidly increased use of composite mesh in the last few
years. The absorbable barrier layer in these composite
meshes are made of oxidized regenerated cellulose,
omega-3 fatty acid, or collagen hydrogel. This collagen
could be of animal origin. This protective layer reduces
the formation of intraperitoneal adhesions.
When the mesh is used in a situation where the operative
field is contaminated or potentially contaminated, then
the use of synthetic mesh could result in a disastrous
outcome and very often ultimately the mesh will need to
be removed at some stage.4 Post-operative wound
infection where a mesh has been implanted would result
in higher rate of recurrence of incisional hernia.
Most of the synthetic meshes do contract, some more
than others. It is not surprising for the surgeons when
operating on the recurrent incisional hernia to find that
the size of the mesh is half of the size when implanted at
the index operation. Hence, a reasonable good margin
of overlap is required, usually about 3-5 cm. This results
in need of a bigger size mesh.
Along with the development of laparoscopic repair of
internal and external hernia other recent development in
the field of hernia surgery is the development of
prosthetics which are derived from natural tissues called
the biologics. The collagen based biologics have been
produced since 1980s. The acellular collagen matrix
use in these prosthetic is slowly degraded and replaced
by fibrocollagenous tissue of the host. The source of
these materials could be human dermis, porcine dermis,
porcine small intestinal submucosa or bovine pericardium. After harvesting, these materials are made
functionally acellular to prevent foreign body response,
while still maintaining their extracellular collagenous
structure that allows for the host tissue ingrowth. Some
of these are then further processed using cross linking
technique to minimize the enzymatic degradation of
the graft which allows more time to deposit the fibro-

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (11): 681-682

681

Muhammad Hanif Shiwani

collagenous tissue and remodel the prosthetic into a

strong native tissue. These prosthetics are sterilized in
various ways including gamma radiation and with the
use of ethylene oxide gas or hydrogen peroxide. The
processing of these meshes for production is by and
large a proprietory procedure, making it difficult for
surgeons to access all the information about the final
products.
The biocompatibility of these biologics help in rapid
vascularisation and migration of host immune cell.
Hence, these prosthetics are less prone to get infection
and even if infection sets in the neo tissue it can
potentially be treated with antibiotics. These meshes are
usually soft and pliable, which potentially decreases the
risk of erosion and fistula formation if they are in contact
with bowel and less painful if used at the anterior
abdominal wall.
Low risk of infection, graft rejection and complications
seem to be an additional advantage of this new
innovation. These products are expensive. They are
relatively new in the market compared to the synthetic
mesh; hence, the available data with long-term results
and level-I evidence is limited. In general, the use of
biologics is very selective and will remain selective for
quite some time.5 Further studies with large number of
patients and a longer follow-up are required to make an
informed decision to use the appropriate prosthetic
according to individual patient's requirement.6,7 The FDA
reported complications of these materials warrant further
caution and sound surgical judgment.8,9
Dietary consumption of porcine and bovine material is
not permissible for the people of certain faiths. The
non-dietary consumption of porcine is controversial
according to some Muslims. In the presence of alternatives to porcine prosthetics i.e. the availability of the
human dermis and bovine products, the acceptability of
the porcine dermis will be poor in Pakistan due to
biomedical and ethical reasons. Knowledge of religious
and cultural preferences regarding biologic mesh assists
the surgeons in obtaining a culturally sensitive informed
consent for procedures involving acellular allogeneic or
xenogeneic grafts. Patient's religious or other belief may
be fundamental to their sense of well-being and they
have all the rights to know what type of mesh is used for
their treatment. At the same time, as a part of informed

682

consent, they should be informed about the options of

alternative treatment. A doctor should not assume on the
basis of his or her belief and preference that patient
would accept or not accept an implant that contains
product of animal origin.10
In order to meet the local requirements, the surgeons
from United Kingdom have used the mosquito nets for
the repair of hernia in Africa.11 There is a need to promote
research at local level to develop biologics which are
cost effective and acceptable to the community.

REFERENCES
1.

Coda A, Lamberti R, Martorana S. Classification of prosthesis

used in hernia repair based on weight and biomaterial. Hernia
2012; 16:9-20.

2.

Malanoni MA, Rosen MJ. Sabiston textbook of surgery: the

biological basis of modern surgical practice. 19th edn. Philadelphia.
WB Saunders 2012.

3.

Scott RP, Bruce JR. Laparoscopic ventral and incisional hernia

repair. 10th edn. Cameron. Curr Surg Ther 2010.

4.

Szczerba SR, Dumanian GA. Definitive surgical treatment of

infected or exposed ventral hernia mesh. Ann Surg 2003; 237:
437-41.

5.

Hiles M, Ritchie RD, Altizer AM. Are biological grafts effective for
hernia repair? A systemic review of the literature. Surg Innov
2009; 16:26-37.

6.

Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J,

et al. Use of acellular dermal matrix for complicated ventral
hernia repair: does technique affect outcomes? J Am Coll Surg
2007; 205:654-60.

7.

Lo Menzo E, Martinez JM, Spector SA, Iglesias A, Degennaro V,

Cappellani A. Use of biologic mesh for a complicated
paracolostomy hernia. Am J Surg 2008; 196:715-9.

8.

Rosen MJ. Biologic mesh for abdominal wall reconstruction: a

critical appraisal. Am Surg 2010; 76:1-6.

9.

Harth KC, Rosen MJ. Major complications associated with

xenograft biologic mesh implantation in abdominal wall
reconstruction. Surg Innov 2009; 16:324-9.

10. Jenkins ED, Yip M, Melman L, Frisella MM, Matthews BD.

Informed consent: cultural and religious issues associated with
the use of allogeneic and xenogeneic mesh products. J Am Coll
Surg 2010; 210:402-10.
11. Stephenson BM, Kingsnorth AN. Inguinal hernioplasty using
mosquito net mesh in low income countries: an alternative and
cost effective prosthesis. BMJ 2011; 343:d7448.

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (11): 681-682