Biologic mesh use practice patterns in abdominal wall reconstruction: a lack of consensus among surgeons.

BACKGROUND: Despite the prevalence of ventral hernias, there is little agreement as to the most appropriate technique or prosthetic to repair these defects. Our objective was to determine biologic mesh practice patterns of reconstructive surgeons with regard to indications, most appropriate technique, choice of prosthetic, and experience with complications. METHODS: A survey was mailed to 2,000 practicing surgeons. Main outcome measures included surgeon experience with biologic mesh and associated complications. RESULTS: Two hundred and forty (12 %) surgeons responded to the survey. Ten were excluded, as surgeons completing the survey indicated they did not perform ventral hernia repairs or left multiple questions unanswered. Of the 230 included, 93.5 % (n = 215) of responders had experience using biologic mesh. Frequency of biologic graft use in the last year was as follows: low-volume users (<5 times in the last year) 50.7 %; medium-volume users (5-20 times in the last year) 37.3 %; high-volume users (>20 times in the last year) 11.9 %. Indications for biologic mesh use based on wound classifications (clean, clean contaminated, contaminated or dirty) were quite varied and lacked consensus among surgeons (p value < 0.05). The most commonly reported influences for use included personal experience (45 %), literature (28.3 %), and availability (17.2 %). CONCLUSIONS: Despite a lack of level 1 evidence, biologic meshes are being used under various wound classifications. Importantly, use in clean and dirty-infected settings may reflect an inappropriate overuse of these expensive materials. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials under the various surgical wound classifications.

Bacterial clearance of biologic grafts used in hernia repair: an experimental study.

BACKGROUND: Biologic grafts used in ventral hernia repair are derived from various sources and undergo different post-tissue-harvesting processing, handling, and sterilization techniques. It is unclear how these various characteristics impact graft response in the setting of contamination. We evaluated four materials in an infected hernia repair animal model using fluorescence imaging and quantitative culture studies. METHODS: One hundred seven rats underwent creation of a chronic hernia. They were then repaired with one synthetic polyester control material (n = 12) and four different biologic grafts (n = 24 per material). Biologic grafts evaluated included Surgisis (porcine small intestinal submucosa), Permacol (crosslinked porcine dermis), Xenmatrix (noncrosslinked porcine dermis), and Strattice (noncrosslinked porcine dermis). Half of the repairs in each group were inoculated with Staphylococcus aureus at 10(4) CFU/ml and survived for 30 days without systemic antibiotics. Animals then underwent fluorescence imaging and quantitative bacterial studies. RESULTS: All clean repairs remained sterile. Rates of bacterial clearance were as follows: polyester synthetic 0%, Surgisis 58%, Permacol 67%, Xenmatrix 75%, and Strattice 92% (P=0.003). Quantitative bacterial counts had a similar trend in bacterial clearance: polyester synthetic 1×10(6) CFU/g, Surgisis 4.3×10(5) CFU/g, Permacol 1.7×10(3) CFU/g, Xenmatrix 46 CFU/g, and Strattice 31 CFU/g (P=0.001). Fluorescence imaging was unable to detect low bacterial fluorescence counts observed on bacterial studies. CONCLUSION: Biologic grafts, in comparison to synthetic material, are able to clear a Staphylococcus aureus contamination; however, they are able to do so at different rates. Bacterial clearance correlated to the level of residual bacterial burden observed in our study. Post-tissue-harvesting processing, handling, and sterilization techniques may contribute to this observed difference in ability to clear bacteria.