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Visceral Adhesions to Hernia Prostheses

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Visceral Adhesions to Hernia Prostheses Hernia (2010) 14:375–381 DOI 10.1007/s10029-010-0659-y ORIGINAL ARTICLE Visceral adhesions to hernia prostheses W. B. Gaertner · M. E. Bonsack · J. P. Delaney Received: 25 May 2009 / Accepted: 28 March 2010 / Published online: 18 April 2010 © Springer-Verlag 2010 Abstract Keywords Postoperative adhesions · Prosthesis · Purpose To report our experience with abdominal adhe- Surgical mesh · Ventral hernia sion formation to various synthetic and biologic prosthetic materials in a rat ventral hernia model. Methods A total of 14 prostheses, nine synthetic, four Introduction biologic, and one bioresorbable, were evaluated in the rat. Two synthetic prostheses had bioresorbable coatings and The reported incidence of postoperative abdominal inci- one consisted of synthetic and bioresorbable materials sional hernia generally ranges between 10 and 15% [1–3]. woven together. The model involved the removal from the Approximately 100,000 such hernias are repaired each year midline of a 2.5 £ 2.5-cm segment of full-thickness ventral in the United States [4]. Recurrence rates after anatomic tis- abdominal wall with the test prosthetic material sewed into sue approximation with sutures range from 31 to 54% [5, the defect, thus, exposing the viscera directly to one surface 6]. The use of prosthetic materials has signiWcantly reduced of the prosthesis. There were four or more rats in each hernia recurrence rates, usually to under 10% [7]. group. Adhesions were assessed at autopsy 7 days after Adhesions to intraperitoneal prosthetic surfaces occur in operation or later. The results were expressed as the per- 80–90% of patients [8]. Such adhesions can result in bowel centage area of prosthesis surface involved. obstruction, but the actual incidence directly caused by vis- Results All 14 of the tested prosthetic materials induced cera to prosthesis attachments is not known. Another major adhesions. Vicryl Mesh® and the four biologic varieties had consideration is that subsequent operations are made more lesser overall adhesion coverage than the bare synthetic diYcult [9–13]. Operative strategies designed to avoid prostheses. Sepramesh® developed the least adhesion cov- exposure of the mesh surface to the abdominal viscera erage (15%). The two synthetic materials with bioresorb- include interposition of the intact hernia sac, peritoneal able coatings had smaller areas involved compared to bare reapproximation, and covering the prosthesis with omen- synthetic prostheses. tum. Conclusions All of the tested prostheses attracted adhe- Various approaches to inhibit the formation of adhesions sions. Biologic prostheses had smaller areas of coverage to mesh have been developed. Some involve a bioresorb- compared to synthetic prostheses. Barrier surfaces on syn- able layer that is attached or fused on the macroporous thetic meshes were associated with a much lesser extent of mesh surface exposed to the abdominal viscera (Sepra- adhesion involvement. mesh®, Proceed®, Parietex®, C-QUR™). A bioresorbable coating on the mesh surface provides mechanical separa- tion of raw or injured peritoneum from the mesh, thereby, reducing adhesion formation. Absorption of the coating W. B. Gaertner (&) · M. E. Bonsack · J. P. Delaney occurs by enzymatic degradation and physiological uptake. Department of Surgery, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 195, Residence time varies according to the agent. Manufac- Minneapolis, MN 55455, USA turer-reported experiments have shown that the physical e-mail: [email protected] integrity of the coating dissipates variably between 2 days 123 376 Hernia (2010) 14:375–381 and 3 months after operation, depending on the coating with the principles in the Guide for Care and Use of Labo- agents [14]. Materials used include polylactic acid, oxi- ratory Animals, NIH publication, revised in 1996. The ani- dized cellulose, polyethylene glycol, omega-3 fatty acids, mals were acclimated for a minimum of 7 days before and sodium hyaluronate with carboxymethylcellulose. initiation of the study. They were fed a commercially avail- An anti-adhesive layer fused on the prosthesis must be able rodent diet (Teklad Rodent Diet) and tap water, non-toxic, well tolerated in the abdomen, and, most impor- ad libitum, throughout the duration of the study. The ani- tantly, it should discourage visceral attachments to the sur- mals were monitored daily by physical examination. This face of the prosthesis from the time of the operation until protocol was approved by the Institutional Animal Care and the injured peritoneum and prosthesis surface are covered Use Committee of the University of Minnesota. with a complete layer of mesothelial cells. This occurs 5– 7 days following operation and prevents further adhesions Surgical technique [15, 16]. Other variables related to adhesion formation, suggested Only healthy-appearing animals with normal appetite were mostly by the manufacturers, include the structure of the used. Anesthesia was induced with an intraperitoneal injec- mesh, woven or knitted, pore size, thickness of the mesh, tion of sodium pentobarbital, 30–40 mg/kg. The abdomen and the diameter of the Wbers. These factors do not pertain was shaved and prepared with povidone–iodine solution. to the grossly smooth, microporous synthetic surface. A 3-cm midline skin incision was made and subcutaneous Biologically derived prostheses have been said to induce Xaps undermined far enough to accommodate a 2.5-cm fewer adhesions, theoretically because of increased “bio- square defect. A 2.5 £ 2.5-cm segment of full-thickness compatibility” and lesser foreign body reaction. An impor- ventral abdominal wall was excised from the midline. tant consideration with these materials is the chemical Three by three-cm prostheses were sewn to the cut edges treatments used to eVect decellularization and other pro- with a continuous 4–0 polypropylene suture, thus, exposing cesses which induce collagen cross-linking. Data associat- the viscera directly to the prosthesis. Care was taken to ing these chemical processes with the extent of adhesion evert the edges of the prostheses toward the subcutaneous formation have been inconclusive. tissue. The overlying skin was closed with running intracu- Our laboratory has investigated adhesion formation for a ticular 5–0 vicryl (polyglactin 910) suture. number of years. We have taken a particular interest in the adhesiogenic properties of various hernia prostheses, syn- Groups (prostheses) thetic and biologic. The purpose of this study was to describe our experience over these years regarding the inci- Rough surfaces dence and extent of abdominal adhesions to a number of commercially available synthetic and biologic hernia pros- Marlex® Heavyweight macroporous poly- theses. In many instances, these were control groups for propylene woven mesh, C. R. Bard, anti-adhesion studies. Because of the retrospective charac- Inc., Murray Hill, NJ; n = 39. ter of the report, the numbers in each group vary and, thus, Surgipro™ Heavyweight macroporous poly- do not allow rigid statistical comparisons. However, the propylene knitted mesh, US Surgi- wide diVerences among the groups were obvious and do cal, Norwalk, CT; n =6. permit the useful conclusion that all prosthetic materials cause adhesions, some much more than others. Smooth surfaces Composix E/X Mesh® Heavyweight macroporous polypro- Materials and methods pylene woven mesh with a unilateral expanded polytetraXuoroethylene Animals coating, C. R. Bard, Inc., Murray Hill, NJ; n =15. Mature, female Sprague–Dawley rats weighing between Dual Mesh® Expanded polytetraXuoroethylene 300 and 425 g were obtained from Charles River Laborato- with two distinct surfaces: a ries, Inc. (River Falls, WI). The rats were individually smooth closed structure surface housed in polycarbonate cages with free access to food and for reduced adhesion attachment water, in a controlled environment with temperatures of and a rough surface for faster tis- ranging from 66 to 76°F and a 12-h light–dark cycle. The sue attachment, W. L. Gore & animals were cared for by the University of Minnesota Associates, Inc., FlagstaV, AZ; Research Animal Resources Department in accordance n =10. 123 Hernia (2010) 14:375–381 377 MycroMesh® Expanded polytetraXuoroethylene with a Adhesion quantitation microporous surface, W. L. Gore & Asso- ciates, Inc., FlagstaV, AZ; n =4. The evaluation of adhesions was carried out at autopsy on Soft Tissue Smooth expanded polytetraXuoroethylene or after postoperative day 7. We and others have previously Patch® microporous mesh, W. L. Gore & Associ- observed in the rat that no additional adhesions develop ates, Inc., FlagstaV, AZ; n =5. beyond 7 days after operation [14, 15, 17]. The surface of the prosthesis was visually divided into four quadrants to Bioresorbable synthetic materials alone or woven help estimate the percentage of the surface area involved. with permanent synthetic materials Specimens were photographed for later review and compar- ison. Vicryl Mesh® Knitted macroporous mesh composed of polyglactin 910 Wbers, Ethicon, Somer- Statistical analysis ville, NJ; n =13. Vypro Mesh® Lightweight knitted macroporous mesh Statistical diVerences were determined using a one-way composed of braided polyglactin 910 analysis of variance (ANOVA) and the Tukey–Kramer interposed with polypropylene Wbers, Ethi- multiple comparison test. P < 0.05 was considered to be con, Somerville, NJ; n =5. signiWcant. All calculations were performed using the GraphPad InStat 3 statistics program (GraphPad
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