World Journal of Laparoscopic Surgery
Volume 13 | Issue 1 | Year 2020

Laparoscopic Ventral Hernia Repair with Polypropylene Mesh: A Literature Review

Elmutaz Kanani

General Surgery Department, Khoula Hospital, Muscat, Oman

Corresponding Author: Elmutaz Kanani, General Surgery Department, Khoula Hospital, Muscat, Oman, Phone: +968 99533569, e-mail:

How to cite this article Kanani E. Laparoscopic Ventral Hernia Repair with Polypropylene Mesh: A Literature Review. World J Lap Surg 2020;13(1):31–34.

Source of support: Nil

Conflict of interest: None


Background: Laparoscopic ventral hernia repair (LVHR) is currently considered the gold standard. However, the mesh selection is still controversial. The aim of this review is to look for evidence that supports the use of polypropylene mesh (PPM) in the intraperitoneal position in LVHR.

Materials and methods: The literature was searched systematically using Google Scholar and PubMed for controlled studies, prospective descriptive series, and retrospective case series.

Results: A total of 11 studies were retrieved. All the studies were either retrospective or animal experiments. Their outcomes are heterogeneous and they have multiple weaknesses.

Conclusion: The literature clearly lacks data from controlled randomized trials in humans that can give strong evidence. The use of intraperitoneal PPM in LVHR remains an individual surgeon preference decision until well-designed prospective double-blind randomized controlled clinical trials are available.

Keywords: Complication, Laparoscopy, Mesh, Polypropylene, Prolene, Ventral hernia.


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.


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.


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 1: Summary of relevant studies
AuthorsYear of publicationType of studyDetails of studyNo. of subjectsFollow-up timeConclusions
Zieren et al.22004Experimental in pigsCompared Vypro and prolene mesh3 monthsBoth meshes cannot be recommended for intraperitoneal placement in hernia surgery because of their adhesion potential and risk of bowel obstruction.
Bingener et al.42004Case seriesPolypropylene mesh with interposition of omentum over loops of bowel30 patients14 monthsPPM with interposition of omentum is not associated with visceral adhesions in the majority of patients.
Burger et al.32006Experimental in ratsCompared different types of mesh30 daysRecommended the use of Parietex composite and Sepramesh for hernia repair in which direct contact with the abdominal viscera cannot be avoided.
Doctor52006Literature reviewCompared prostheses with and without barrierProsthesis with a barrier only should be used for intra-abdominal placement to prevent bowel adhesions.
Eriksen et al.12007Literature reviewChoice of mesh depends on surgeon’s preference and cost till further randomized controlled clinical trials are available.
Jitea et al.62008Case seriesPolypropylene mesh with omentum interposition between mesh and bowel21 patients6–12 monthsIntraperitoneal PPM in umbilical hernia repair is a safe, efficient, and rapid method avoiding infection complications in obese cirrhotic patient.
Schreinemacher et al.72009Experimental in ratsCompared six mesh types (PPM, Ultrapro, Proceed, Parietex Composite, and c-Qur)30 daysThe absorbable layers of Parietex and C-Qur reduce adhesion formation to intraperitoneal mesh in the short-term, but the effect diminishes and phagocytosis of absorbable coatings may contribute to adhesion formation.
Qadri et al.82010Case series80 patients28 monthsIntraperitoneal use of PPM was not associated with any significant complication.
Yildirim et al.92010Case series25 patients28 monthsThe tension-free repair of incisional hernia with PPM in the intraperitoneal position is a safe and easy procedure with acceptable morbidity and no recurrence.
Tran et al.102012Experiment in pigsCompared PPM and DualMesh with and without fibrin sealant3 monthsDualMesh caused fewer omental and visceral adhesions than PPM did.
Fibrin sealant eliminated adhesions to DualMesh and prevented adhesions to PPM when applied over the entire surface.
Ramakrishna and Lakshman112013Literature reviewIntraperitoneal PPM and newer meshes in ventral hernia repairComplications of intraperitoneal PPM can occur with the newer meshes also. There is no statistically significant difference in the incidence of these complications between these meshes.
Table 2: Some of the common mesh types
UltraproPolypropylene–polyglecaprone composite
TutomeshBovine pericardium
SeprameshPolypropylene with carboxymethylcellulose–sodium hyaluronate coating
TimeshTitanium–polypropylene composite
ProceedPolypropylene–polydioxanone composite with oxidized cellulose coating
C-QurOmega-3 fatty acid-coated polypropylene
MarlexCrystalline polypropylene and high-density polyethylene (HDPE)
Parietex compositePolyester with collagen–polyethylene glycol–glycerol coating


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.


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.


The author would like to thank Professor R. K. Mishra, Dr Chowhan, and their professional team in World Laparoscopy Hospital in Delhi, India, for their great and valuable support.


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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.

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