Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh

Abstract

espite years of surgical research, advancements in biomaterial science, and improvement in techniques, ideal mesh selection for ventral hernia repair in the setting of contamination remains controversial. Mesh reinforcement is an integral component of modern hernia surgery, shown to reduce recurrence rates when compared to primary suture repair alone. [1][2][3] With mesh placement, however, comes an increased risk for mesh-related complications. 2 These risks are augmented in patients undergoing contaminated hernia repair, 4,5 and it is "off label" to use mesh in clean-contaminated, contaminated, and infected wounds. 6,7

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields

“…Our previous study noted an immediate improvement in postoperative AHQ and Hernia-Related Quality-of-Life Survey scores that was maintained over 2 years. 18 On review, our study has found that this trend has continued up to 5 years, with a median follow-up of 4 years. This study's results are consistent with other studies on long-term PROs in hernia repair.…”

“…study reproduces the methods found in our 2-year follow-up article on P4HB mesh use remain consistent with our results. 18 Adult patients older than 18 years who underwent a single-stage contaminated hernia repair performed by a plastic and reconstructive surgeon at the University of Pennsylvania Health between January 1, 2015, and May 1, 2020 were identified. Patients had follow-up periods ranging from 4 months to 5 years.…”

“…Studies have implemented P4HB in complex abdominal repair successfully, even in a contaminated or infected field. 2,15,18 Of the biosynthetic meshes on the market, P4HB has been the most studied in the contaminated field. 15,16 Lima et al 15 noted that the most common indication for their center's use of P4HB was contamination or infection of the field.…”

Fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for soft tissue repair and reconstruction: A scoping review

“…It should be noted that clinical outcomes were evaluated in patients along the entire continuum of Centers for Disease Control (CDC) wound classes ( 33 ) and Ventral Hernia Working Group (VHWG) grades ( 34 , 35 ), ranging from clean cases at low risk of postoperative complications to contaminated/dirty cases at high risk of postoperative complications ( Table 4 ). Systematic reviews ( 59 ), commentaries ( 86 ), and clinical studies of CDC Class I (clean) cases only ( 51 , 65 ) comprised a small number of articles, with the majority of the identified clinical studies describing complex cases with elevated CDC wound class or comorbidities placing patients at high risk of postoperative complications ( n = 13) ( 12 , 30 , 31 , 50 , 52 , 55 , 60 , 62 , 71 , 75 , 76 , 83 , 85 ) or “off-label” use of P4HB mesh to repair ventral/incisional hernias in potentially contaminated or contaminated fields ( n = 15) ( 11 , 53 , 63 , 66 – 70 , 72 – 74 , 77 , 78 , 81 , 82 , 84 ). After a thorough evaluation of the clinical studies identified by this scoping review, several major themes emerged, namely: (1) P4HB mesh provides long-term strength at the repair site, leading to acceptable rates of recurrence as compared to higher-risk cohorts and those repaired with non-synthetic biomaterials ( 30 , 31 , 66 , 70 , 75 , 76 ); (2) P4HB mesh performs favorably in contaminated settings where permanent synthetic mesh use may be higher risk or contraindicated, resulting in low incidence of surgical site infection (SSI) ( 70 , 76 , 90 ); and (3) P4HB mesh represents an alternative for ventral/incisional hernia repair relative to biologic meshes and when permanent synthetic mesh complications are taken into consideration ( 30 , 69 ).…”

“…In another study, P4HB mesh was utilized “off-label” in contaminated hernia repairs, Christopher et al . reported hernia recurrence of 8.3% and SSI of 16.7% at 24 months postimplantation in a patient population with CDC wound class ≥2 and VHWG grade ≥3 hernia repairs ( 72 ). These represent favorable results compared to similar studies involving other types of hernia repair materials.…”