Laparoscopic Ventral Hernia Repair with Polypropylene Mesh: A Literature Review

INTRODUCTION

In laparoscopic ventral hernia repair (LVHR), there are different techniques practiced like three ports repair, two ports repair, intraperitoneal, and totally extraperitoneal repair. The intraperitoneal technique (IPOM), although simple and successful, faces the dilemma of mesh selection. A large number of variable mesh types are available in the market and each claimed to be superior to others. Likewise, the cost is not uniform as some are very expensive while others are cheaper. Reliable data on mesh safety and efficacy are not available to the clinician.¹ The polypropylene mesh (PPM) is among the cheapest and had stood the test of time in extraperitoneal hernia repair. Its use in intraperitoneal position still remains doubtful due to the possibility of its adhesion to bowel causing serious complications like intestinal obstruction and fistulization. Newly developed meshes proved to reduce the inflammatory response and therefore reduce the adhesion formation.² Coatings added to newer meshes aim also to prevent bowel adhesion to the mesh surface. In fact, this also had been scrutinized and some newer meshes were found to cause adhesions in animal experiments.³ This conflicting information put the surgeon in a difficult situation especially when expensive types of mesh cannot be provided because of financial restrictions. Patient safety should not be simply jeopardized because of financial aspects and this is a major ethical issue.

In this review, we tried to answer the question of is it safe to use intraperitoneal PPM in ventral hernia repair by retrieving the evidence from the published literature about the topic.

MATERIALS AND METHODS

A systematic literature search using the databases of Google Scholar and PubMed was performed. Eleven articles were retrieved. They were four literature reviews, four case series, and three animal experiments. The articles were then analyzed in terms of year of publication, type of study, details of the study, number of participant subjects, duration of the study and maximum duration of follow-up, method of assessment of complications, and the final recommendations.

RESULTS

A total of eleven articles were retrieved. Three were animal experiments, four are case series, and four are literature reviews. Four studies concluded that PPM is safe however; none of them was a prospective randomized study. On the other hand, four studies gave recommendations against the PPM. The remaining three studies either left the choice of mesh to the surgeon’s preference or recommended a barrier between mesh and intestine. The case series have in common limited number of subjects and they vary in follow-up duration as all had short-term follow-up. The assessment methods were also different between the studies. The results of animal experiments cannot be generalized to humans. The literature review recommendations are heterogeneous and nonconclusive. Table 1 summarizes the findings of all these articles.

Table 2: Some of the common mesh types

Name	Composition	Image
Prolene	Polypropylene
Ultrapro	Polypropylene–polyglecaprone composite
Tutomesh	Bovine pericardium
Sepramesh	Polypropylene with carboxymethylcellulose–sodium hyaluronate coating
Timesh	Titanium–polypropylene composite
Proceed	Polypropylene–polydioxanone composite with oxidized cellulose coating
C-Qur	Omega-3 fatty acid-coated polypropylene
Marlex	Crystalline polypropylene and high-density polyethylene (HDPE)
DualMesh	e-PTFE
Parietex composite	Polyester with collagen–polyethylene glycol–glycerol coating

DISCUSSION

Hernia repair has to be completed by the placement of a mesh except in few situations.^12,13 Which type of mesh is the best for each hernia is a controversial issue. There are different surgeon’s opinions as well as a large pool of mesh types to select from. These mesh types differ in composition, coatings, pore size, strength, shrinkage, and methods of fixation. The commonly used mesh types are illustrated in Table 2.

Complications secondary to the presence of mesh do occur and there is no available mesh type without such a risk. In the literature, there are reports of different complications associated with different mesh types.^2,14,15 Among the common complications are adhesions formation leading to bowel obstruction, fistulization, sinus formation, infection, and hernia recurrence. The development of complications is sometimes related to the position of the mesh rather than to its composition. For example, the PPM triggers the formation of adhesions, which is beneficial in the peri-peritoneal position while may be harmful if placed intraperitoneal.¹⁶

Despite the fact that all the case series analyzed in this review recommended a safe intraperitoneal placement of PPM, none of them qualify as an acceptable level of evidence. They have in common limited number of subjects and they vary in follow-up duration as all had short-term follow-up. The assessment methods were also different between the studies, e.g., Bingener and colleagues used ultrasound scan to examine the presence of intraperitoneal adhesions in their study.⁴

In the animal experiments two studies rejected the use of intraperitoneal PPM while the third one did not give clear recommendation but concluded that even coated meshes reduce the incidence of adhesions only in the short-term. Table 2 illustrates the common types of meshes. The results of animal experiments cannot be generalized directly to humans. Beside that they all lack long-term follow-up and had included small numbers of subjects. Tran and colleagues studied the use of the fibrin sealant to cover the mesh and reported adhesions prevention after its use.¹⁰ However, the fibrin sealant itself is costly, which takes us back to square one of the financial limitations.

The literature reviews failed to come up with a high-level evidence. In their review, Eriksen and his colleagues could not make out a clear recommendation from the published literature.¹ Later on, Doctor HG in his review rejected the use of intraperitoneal PPM.⁵ In the most recent comprehensive literature review by Ramakrishna and Lakshman, no statistically significant difference in the incidence of complications between the PPM and newer meshes was found.¹¹ The data they gathered were heterogeneous and they could not find a prospective controlled randomized double-blind study comparing intraperitoneal placement of PPM with newer meshes.

CONCLUSION

The choice of mesh for intraperitoneal placement remains an unsolved issue. Complications had been reported with most of the mesh types. Well-designed prospective randomized controlled double-blind studies are required to generate high-level evidence that can change practice. Until then the mesh selection is a surgeon’s decision depending on his/her preference and patient’s affordability.

REFERENCES

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2. Zieren J, Neuss H, Ablassmaier B, et al. Adhesions after intraperitoneal mesh repair in pigs: Prolene™ vs. Vypro™. J Laparoendosc Adv Surg Tech A 2002;12(4):249–252. DOI: 10.1089/109264202760268014.

3. Burger JWA, Halm JA, Wijsmuller AR, et al. Evaluation of new prosthetic meshes for ventral hernia repair. Surg Endosc 2006;20(8):1320–1325. DOI: 10.1007/s00464-005-0706-4.

4. Bingener J, Kazantsev GB, Chopra S, et al. Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound. JSLS 2004;8(2):127–131.

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