W. R. Lorenz1, A. M. Holland1, D. Ku1, G. T. Scarola1, K. W. Kercher1, B. T. Heniford1 1Carolinas Medical Center, Gastrointestinal And Minimally Invasive Surgery, Charlotte, NC, USA
Introduction:
Mesh choice in VHR is controversial. Mesh is often subcategorized by its g/m2: heavyweight, midweight, and lightweight (LW). LW macroporous mesh was developed to improve quality-of-life outcomes, tissue incorporation, foreign body reaction, and infection rates. However, follow-up studies suggest that LW mesh may increase recurrence rate and have mixed QOL outcomes. The study was performed to evaluate long-term recurrence of LW mesh especially considering our published recurrence rate of approximately 2% for heavier weight mesh.
Methods:
A prospective, tertiary, hernia center database was queried for open VHR with LW mesh. Bard™ Soft Mesh (BS) and Ultrapro® Mesh (UP) were specifically reviewed and compared. Standard descriptive, comparative, and inferential statistics were performed.
Results:
In total, 299 patients were evaluated, 98 patients with BS mesh (44 g/m2) and 201 patients with UP mesh (34 g/m2). Average BMI was 33.4 ± 5.5. The average number of comorbidities was 2.8 ± 2.2, 21.6% with diabetes, and 3.9% on steroids. The average defect was 127.4 ± 144.8 cm2. Wound cellulitis occurred in 11%, hematoma in 2.4%, wound infection in 8.7%, and mesh infection in 1% of patients. Average follow up (f/u) was 5 yr and 6 months (mo) (± 57.9 mo). Hernia recurrence was seen in 40 (13.4%) patients and occurred an average of 4-years post-op. Many of the recurrences were due to extensive mesh fracture which continued years after implantation.
When comparing of BS and UP, f/u was 3 yr and 6 mo ± 40.8 mo vs. 6 yr and 10 mo ± 61.0 mo (P<0.001), respectively. There were no differences in comorbidities. Defect size was similar between BS and UP (125.6±112 vs 128.9±167.5 cm2, respectively). BS patients had significantly more component separations, 29.6% vs. 18.4% (P<0.001). Postoperatively, BS had a lower rate of cellulitis (4.1% vs. 14.4%; P=0.006) but more hematomas (5.2% vs. 0.7% P=0.035); other wound complications did not differ. Hernia recurrence was significantly lower in the BS group at 5.1% versus the UP group at 17.4% (P=0.003). Regression analysis revealed that mesh type (BS vs UP) (OR:4.7, 95%CI: 1.34,16.81; P=0.015) and wound cellulitis (OR:3.2, 95%CI: 1.04, 10.2; P=0.04) significantly predicted recurrence. Importantly, however, when considering the difference in f/u, recurrence on a Kaplan-Meier Curve were statistically equal.
Conclusion:
Wound infection remains an important predictor of recurrence in AWR. LW mesh in AWR has a high rate of long-term recurrence with many of the failures due to long-term mesh fracture. LW mesh use should be cautioned in open AWR. Extended follow-up is needed in AWR surgery to effectively judge biomaterial-related outcomes.
