Elsevier

Biomaterials

Volume 22, Issue 11, 1 June 2001, Pages 1415-1424
Biomaterials

Functional assessment and tissue response of short- and long-term absorbable surgical meshes

https://doi.org/10.1016/S0142-9612(00)00299-4Get rights and content

Abstract

Within the last few years meshes have become essential for the temporary closure of the abdominal cavity to avoid the development of an intra-abdominal compartment syndrome. The interposition of a mesh as an inlay reduces the intra-abdominal pressure and improves markedly the blood circulation, particularly for the intestines and kidneys. Whereas non-absorbable meshes usually tend to produce fistulas in direct contact to the bowels, the interposition of short-term absorbable meshes result in large incisional hernias in almost all cases. In the following study we investigated the functional and histological consequences of a short-term absorbable mesh (polyglactin 910, Vicryl®, loss of 50% of its mechanical stability within 3 weeks) and a long-term absorbable mesh (polylactide, LTS, preserved >50% of its mechanical stability for over 1 year). The mesh-modifications were both tested with the aid of three-dimensional stereography, tensiometry, light- (LM) and transmission electron microscopy (TEM) as well as morphometry after implantation intervals of 3, 7, 14, 21, 45, 90, 135 and 180 days in a standardised rat model. The PG-mesh initially revealed a pronounced inflammatory reaction and a significantly increased formation of connective tissue. The extensive arrangement of connective tissue in the interface mesh/recipient tissues correlated to an increased stiffness of the abdominal wall compared to the sham-group. However, a loss of mechanical stability and an increase of elasticity could be detected after 3 weeks of implantation which may be explained by the rapid absorption of the mesh material. In contrast to PG, the LTS-mesh indicated a decreased but persisting inflammatory reaction in the interface mesh-fibres/recipient tissues and a significantly reduced induction of connective tissue. Although, the formation of scar-tissue was diminished compared to PG the LTS-mesh preserved its mechanical stability after 180 days. The results indicate that the frequent development of incisional hernias with short-term absorbable meshes (PG) might be due to the decreased mechanical stability and dilatation of the newly formed connective tissue after 2–3 weeks. Moreover, extensive scar tissue development may promote adhesion formation. The implantation of the long-term absorbable LTS-mesh seems to be favourable with respect to its long-term mechanical stability and the decreased connective tissue formation.

Introduction

Within the last years meshes have become essential for the temporary closure of the abdominal cavity, in particular, to avoid the development of an intra-abdominal compartment syndrome. The interposition of an absorbable mesh as an inlay reduces the intra-abdominal pressure and improves markedly the blood circulation, particularly for bowels and kidneys [1], [2]. Whereas non-absorbable materials usually tend to produce fistulas in 40–80% in direct contact to the intestines [3], [4], [5], [6], [7], [8], [9], fistula formation is rarely seen after implantation of absorbable meshes, probably due to reduced adhesion formation [10], [11], [12], [13], [14]. Unfortunately, the interposition of short-term absorbable meshes results in large incisional hernias in almost all cases [15], [16], which basically requires revision operations with a definitive abdominal wall closure including the implantation of non-absorbable meshes.

Particularly, in paediatric surgery and in case of infected wounds the use of absorbable meshes seems to be favourable. Non-absorbable meshes can prolong the persistence of bacteria in the wounds and thereby increase the risk for infection [17]. In children non-absorbable meshes should be avoided because of their unknown long-term risks and their hindering of growth. Furthermore, the increasing number of reported complications of non-absorbable meshes after long-term implantation such as fistula formation [3], [18], pain and restriction of physical capabilities [19], [20] would favour the use of an absorbable mesh-modification provided that sufficient mechanical stability of the abdominal wall can be achieved with such materials.

However, attempts to repair abdominal wall hernias or defects of the diaphragm with absorbable meshes were disappointing [21], [22]. In 1998, Pans found no significant decrease of the rate of incisional hernias after abdominal wall closure with polyglactin meshes in sublay position [23]. Overall, it is still doubtful whether short-term absorbable mesh modifications can principally achieve an abdominal closure with adequate long-term mechanical properties [24].

The reason for the lack of persistent mechanical stability after the implantation of short-term absorbable surgical meshes remains to be unclear [14], [25], [26], [27]. The most commonly used short-term absorbable meshes (Vicryl®) consist of polyglactin 910, a combination of glycolide and lactide in a ratio of 9 : 1. Polyglactin loses half of its tensile strength within 2–3 weeks, although, fragments of the polymer are detectable for up to 3 months after implantation [25], [28]. In contrast, the newly developed material LTS, a combination of 95% lactide and 5% glycolide maintains 50% of its tensile strength for at least more than 9 months and tends to be one of the first available long-term absorbable mesh modifications.

The aim of the present study, therefore, was to investigate and to compare functional and histological variables after implantation of the short-term absorbable mesh PG and the long-term absorbable LTS-mesh in a standardised rat model of full-thickness abdominal wall defects. The results indicate that LTS may be favourable for the temporary closure of the abdominal wall compared to PG.

Section snippets

Experimental animals

168 male Wistar rats (250–300 g) were studied. The animals were housed under conditions of constant light and temperature and received a complete diet of rat feed ad libidum throughout the entire study, which was performed according to the rules of the “Deutsche Tierschutzgesetz” (AZ 23.203.2 AC 18, 17/94) and to the NIH guidelines for the use of laboratory animals. The animals were randomly divided into three groups. The two test groups (each n=64) received either the short-term polyglactin

Material properties (Figs. 1 and 2)

Both absorbable meshes are constructed of multifilaments. They both have small pores (PG 0.5 mm, LTS 0.2–1.4 mm) with a considerable high weight of more than 50 g/m2. In the test tearing out the seam the initial strength of PG was less than of LTS with 15.2 vs. 29.4 N vertically and 23.4 vs. 30.1 N horizontally.

The conservation of the meshes in saline solution at 21°C showed a complete loss of stability after 6 months in case of the PG-mesh, whereas, the LTS preserved more than 60% of its original

Discussion

However, after the introduction of non-absorbable meshes in hernia repair in the early 1960s modern hernia surgery is not conceivable without the use of these prosthesis, the absorbable meshes are used mainly for the temporary wound closure to prevent the development of an intra-abdominal compartment in complicated cases in abdominal wall surgery. The most severe disadvantage of short-term absorbable meshes is the induction of mechanical unstable scar structures, although, short-term absorbable

Acknowledgements

This work was supported by a BMBF grant project no. 01KS9503/9 for IZKF-Biomat, RWTH-Aachen. In addition, the authors would like to acknowledge the financial support of the project from the Deutsche Forschungsgemeinschaft (DFG) in Bonn, Germany, and Ethicon® in Norderstedt, Germany.

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