Are Biologic Grafts Effective for Hernia Repair?

Abstract

Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically cross-linked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.

Complex Incisional Hernias

“…Hiles et al have been among the first who have in 2009 published a comprehensive review on the effectiveness of biological meshes for hernia repairs [28]. They found an overall success rate of more than 90%, however there was a limited evidence level (level III) for the analyzed materials (small intestinal submucosa [SIS], acellular human dermis [AHD] and porcine dermis [PD]).…”

Surgical mesh for ventral incisional hernia repairs:Understanding mesh design

“…Although biological meshes are routinely used in infected fields, their high costs remain a barrier to widespread use (43). In addition, there is insufficient evidence in the literature regarding the advantages of biologic meshes over synthetic meshes in hernia repair (44)(45)(46).…”

Regenerative Medicine: Charting a New Course in Wound Healing

“…23 Matrix composition varies by tissue, but collagen is the most abundant component overall, and collagen-based matrices are used in clinical conditions varying from wound healing to urinary incontinence. [24][25][26][27] Other components of extracellular matrices such as proteoglycans and fibrin are also used in regenerative medicine either with or without collagen. Moreover, a variety of synthetic biomaterials are being developed to capitalize on the spatial and biomechanical cues of endogenous extracellular matrices during development.…”