What Is Life Expectancy Of Hernia Mfesh Repair

Long term effect and quality of life after open up incisional hernia repair - low-cal versus heavy weight meshes

Roland Ladurner

ⁱDepartment of Surgery Innenstadt, Ludwig-Maximilian-University of Munich, Nussbaumstr. 20. 80336 Munich, Federal republic of germany

Costanza Chiapponi

¹Section of Surgery Innenstadt, Ludwig-Maximilian-University of Munich, Nussbaumstr. 20. 80336 Munich, Germany

Quirin Linhuber

ⁱDepartment of Surgery Innenstadt, Ludwig-Maximilian-University of Munich, Nussbaumstr. 20. 80336 Munich, Deutschland

Thomas Mussack

ⁱSection of Surgery Innenstadt, Ludwig-Maximilian-University of Munich, Nussbaumstr. xx. 80336 Munich, Germany

Received 2022 Jan five; Accepted 2022 Sep xiv.

Abstract

Background

Mesh repair of incisional hernia is superior to the conventional technique. From all available materials for open surgery polypropylene (PP) is the about widely used. Development resulted in meshes with larger pore size, decreased mesh surface and lower weight. The aim of this retrospective not randomized written report was to compare the quality of life in the long term follow up (> 72 calendar month) afterward incisional hernia repair with "light weight"(LW) and "heavy weight"(HW) PP meshes.

Methods

12 patients who underwent midline open incisional hernia repair with a HW-PP mesh (Prolene^® 109 g/m² pore size 1.six mm) betwixt January 1996 and Dec 1997 were compared with 12 sequent patients who underwent the same procedure with a LW-PP mesh (Vypro^® 54 g/m², pore size four-v mm) from January 1998. The standard technique was the sublay mesh-plasty with the retromuscular positioning of the mesh. The two groups were equal in BMI, historic period, gender and hernia size. Patients were routinely seen back in the clinic.

Results

In the long term run (mean follow upward 112 ± 22 months) patients of the HW mesh group revealed no meaning difference in the SF-36 Health Survey domains compared to the LW group (mean follow up 75 ± 16 months).

Conclusions

In this study the health related quality of life based on the SF 36 survey later open up incisional hernia repair with light or heavy weight meshes is not related to the mesh type in the long term follow upwards.

Keywords: incisional hernia repair, heavy weight, low weight polypropylene mesh, quality of life

Background

Hernia repair is i of the most common surgical operations with more 50.000 incisional hernia repaired every twelvemonth in Deutschland. Patient seek surgical repair considering of concrete discomfort and artful reasons. Both impair their quality of life. Unfortunately some patients complain of abdominal discomfort too after the functioning. Despite the surgical technique one possible factor is the type of mesh used. Polypropylene (PP) is the most widely used mesh material for hernia repair. PP meshes show a high stretch and tensile strength, 5 times college than the maximal physiologic stress. The extent of the scar tissue induced past the mesh depends on the amount and structure of the incorporated material and is responsible for the abdominal wall compliance [1,2]. In 20% of the cases heavy weight (HW) and small pore size PP meshes caused a reduction of the intestinal wall mobility ("stiff abdomen")[3,iv]. This complication was associated with chronic abdominal pain. Equally a consequence macropore low-cal weight (LW) PP meshes potent plenty to resist maximal physiologic stress of the intestinal wall were developed [5]. This development resulted in a reduction of the chronic hurting [1,6,7]. Whether macropore LW-PP meshes accept also a beneficial effect on the life quality of patients in the long term effect after open incisional hernia repair is still unclear. The objective of this written report was therefore to assess the health related quality of life (HrQoL) and the long term outcome of patients with open incisional hernia repair using HW- versus LW-PP meshes.

Methods

Characteristics of the report group

33 patients with midline open up incisional hernias were operated with a heavy weight mesh (Prolene^® 108.5 g/k² pore size 1.6 mm, Ethicon, Nordersted; Germany) between Jan 1996 and December 1997 and were eligible for this study. Unfortunately only 12 of them could be followed up over the years. For the comparison the next 12 consecutive patients operated with a lite weight mesh (Vypro^® 54 thousand/m², pore size 4-5 mm, Ethicon, Nordersted, Federal republic of germany) after January 1998 were enrolled in the study. Nosotros excluded incarcerated, lateral or parastomal hernias, hernia repair non using mesh replacement and hernia repair performed with another procedure (laparoscopic hernia repair, onlay and inlay mesh-plasty).

The standard technique consisted of laparotomy, adhaesiolysis, hernia sac resection, closure of the posterior rectus fascia and retromuscular positioning of the PP mesh. Mesh size was chosen and so that the margin extended beyond the margin of the defect throughout the defect's entire circumference. The mesh overlap was at least v cm. Mesh fixation was performed with interrupted PP three/0 sutures in the midline and at the border of the mesh. The lateral mesh fixation occurred along the margin of the rectus muscle. By doing this the intercostal nerve branches were carefully preserved to avoid muscular atrophy. The anterior rectus sheath was closed with a continuous PDS ii/0 running suture loop.

Patients were routinely seen back in the clinic 3, vi and 12 months postoperatively, then yearly thereafter. The standard follow upwardly consisted of anamnesis, physical examination and ultrasound or MRI, when needed (anamnesis and concrete test suggestive of hernia recurrence or intestinal adhesions). The follow up could exist completed in all 24 cases.

Life Quality (SF36)

We used the SF-36, a multidimensional questionnaire composed of 36 items to determine the health related quality of life [8]. The SF36 wellness survey consists of eight different health quality domains: physical role (ten items), function limitations due to physical functions role (4 items), bodily pain (2 items), general health (5 items), vitality (iv items), social role (2 items), role limitations due to emotional part (3 items), mental wellness (v items). The results from each scale vary from 0 to 100 (worst to best possible health status). Additionally, the SF-36 Physical Component Summary (PCS), and the Mental Component Summary (MCS) scales were determined, ranging from cipher (everyman well-existence) to 100 (highest well-existence) [9,x]. The SF 36 Wellness survey scores were compared with the historic period-stratified German population. The questionnaire evaluates the negative wellness aspects (disease or illness) and the positives aspects (well being). The generic SF-36 was chosen instead of more specific scales like the CCS (Carolina Comfort Calibration) [11] considering it is the aureate standard for measuring quality of life and it is validated in German [12].

Statistical analysis

All information are presented as means and standard divergence. Differences between the intervention groups (HW vs LW PP meshes) were tested for significance using the unpaired t exam for quantitative parametric variables and the Isle of mann-Withney rank sum test for quantitative non parametric variables. The comparisons were performed using STATVIEW four.5 software (Abacus Concepts, Berkeley, CA). Significance levels were set equally p < 0.05.

Results

Patient characteristics

12 patients (mean age 57.3 ± 11.viii, range 24-80 years) underwent sublay hernia repair with HW-PP meshes between January 1996 and December1997. The body mass index (BMI) was 29.8 ± three.vii kg/g² and the hernia size was 127.two ± 97.two cm². From January 1998 all patients received sublay hernia repair with a LW PP mesh. 12 consecutive patients (mean age 58.3 ± eleven.1 years, range 28-82 years) were enrolled in the survey. The body mass alphabetize (BMI) was 28.7 ± 3.five kg/m² and the hernia size 226 ± 301.5 cmⁱⁱ. The signal plot graph shows the hernia size of the two groups (Effigy ​ i).

Hernia size of the HW and LW-group.

At that place were no pregnant divergence in age, gender, body mass index, hernia size, patient related risk factors, operation fourth dimension and the length of the hospital stay (Table ​ i). Every bit patient related risk factors were considered obesity (BMI > xxx kg/m²), diabetes mellitus, steroid therapy, nutritional deficiencies, renal damage, chemotherapy, smoking, breast issues and hepatic cirrhosis [thirteen]. Comorbidities were also comparable between the groups (Table ​ 2).

Table one

Demographic data

	LW mesh (Vypro®)	HW mesh (Prolene®)	p
number of patients	12	12
sex ratio (male:female)	nine:three	8:4
historic period (twelvemonth)	58.3 ± eleven.1	57.3 ± 11.eight	0.840
number of risk factors	1.eight ± 0.vii	2.3 ± ane.2	0.318
BMI (kg/m2)	28.seven ± 3.5	29.viii ± 3.7	0.462
hernia size (cm2)	226.0 ± 301.5	127.two ± 97.2	0.292
operation length (min)	105.0 ± 41.eight	110.4 ± 23.5	0.699
infirmary stay (d)	ten.iv ± 3.8	6.8 ± 5.5	0.078

Data for the LW light weight and HW heavy weight group are presented equally mean ± standard difference. Differences were considered significant at p < 0.05.

Table 2

Comorbidities

	LW mesh (Vypro®)	HW mesh (Prolene®)
number of patients	12	12
cancer	iii	4
asthma/COPD	3	three
heart disease	ii	1
diabetes	i	ii
back pain	1	-

Long term follow upward

The follow up could be completed in all 24 cases and was significant longer in the HW grouping (HW 112 ± 22 months; LW 75 ± sixteen months).

In no case a hernia recurrence occurred. Two patients of the LW-group complained of low dragging pain during concrete activity but no hurting at rest (follow up 18 and 36 months respectively), whereas two patients of the HW-group reported on intestinal pain at rest besides equally in motion (16.half dozen%). 1 of these patients had a "stiff abdomen" (follow up 31 month), the other had no alteration of the abdominal wall mobility (follow upwardly 89 month).

In these four patients (ii HW and 2 LW) ultrasound and MRI imaging studies were carried out. The polypropylene mesh was non visible in any of these cases. The abdominal wall in the patient with the "stiff abdomen" (HW grouping) showed a reduced mobility in the functional cine MRI study and an asymmetric fat cloudburst of the rectus musculus. In the other iii patients (1 HW and ii LW) no changes of the abdominal wall mobility or morphology could be detected. In all four patients intraabdominal adhesions could be identified, still these did non correlate with the mesh type.

Withal in none of the viii domains of the SF 36 health survey a meaning difference could exist plant. The SF36 Survey therefore showed no significant worse or better outcome for one mesh type in the long term follow up. The postoperative health-quality domains were lower than the scores of the age-stratefied healthy German population. (Tabular array ​ 3 and ​ 4).

Table three

SF 36 health survey

	LW mesh (Vypro®)	HW mesh (Prolene®)	p	German normal population
physical functioning	64.2 ± 26.five	71.iii ± 33.3	0.570	83.seven ± 19.5
concrete role functioning	50.0 ± 46.five	45.viii ± 45.0	0.826	lxxx.6 ± 31.9
bodily pain	62.3 ± 35.0	67.three ± 31.nine	0.718	72.7 ± 27.iii
full general wellness perceptions	50.6 ± 26.5	49.3 ± 21.5	0.894	61.0 ± xix.i
vitality	48.3 ± 13.4	51.3 ± 10.3	0.555	61.two ± 17.iii
social part performance	74.0 ± 22.9	70.8 ± 21.5	0.734	86.8 ± xviii.0
emotional role operation	47.2 ± 48.1	77.8 ± 32.8	0.084	88.ix ± 26.9
mental health	60.three ± 29.3	70.3 ± 12.4	0.288	72.4 ± sixteen.1

Table 4

Concrete and mental component summary

	LW mesh (Vypro®)	HW mesh (Prolene®)	German normal population
PCS	47.8 ± 7.5	49.4 ± 7.iii	47.9 ± 9.seven
MCS	46.6 ± 8.5	48.8.8 ± 10.0	51.sixteen ± viii.1

PCS (concrete component summary) and MCS (mental component summary) in comparison to the age-stratified High german population. (Bullinger M, Kirchberger I. S36 Fragebogen zum Gesundheitszustand Holzgreve 1998)

Discussion

PP is 1 of the most widely used meshes in abdominal wall surgery. It elicits an intense desmoplastic reaction in tissue, accompanied initially past serous exudation and resulting somewhen in the formation of a sheet of scar that uses the mesh as a scaffold for its formation [seven,14]. This mesh integration process in the abdominal wall and extent of scar tissue are regulated by the corporeality and structure of the incorporated material. The heavier the mesh weight and the smaller the size of the mesh pores are, the greater the resulting corporeality of scar tissue. The wound healing process causes a contraction of the mesh nearly 40% [15]. A loftier inflammatory activity as in the wake of a high amount of foreign cloth can increase this rate upward to 90% [one]. Moreover the tissue reaction is not uniform simply an individual patient depending factor [16].

The initial deployment of abdominal wall meshes developed meshes with small pore size and appropriately heavy weight. The clinical consequence was an impairment of the abdominal wall compliance: and so 20-38% of the patients complained of reduced flexibility of the abdominal wall ("potent abdomen") [3,4,17]. Since chronic pain has direct impact on most of the daily activities, it'southward an important aspect in the issue of hernia surgery [18]. So the health related quality of life (HrQoL) has been receiving increasingly significance in the outcome evaluation of surgical treatments in the last years [19-26].

To reduce the incidence of abdominal stiffness and chronic pain, macropore light weight PP meshes strong enough to resist maximal physiologic stress of the intestinal wall were developed [5]. The aim of this study was to investigate whether the mesh type (LW vs HW) has an impact on the "quality of life" in the long term follow upward (> 72 months) later incisional hernia repair. Hypothesis was that the use of LW meshes lead to less chronic pain and therefore to a meliorate physical, psychosocial and social well-being compared to patients with HW-meshes.

As an instrument to investigate this question the SF-36 Health Survey was used. This is a well validated generic health status measure as opposed to one that targets a specific age affliction or treatment grouping [10,27,28]. The questionnaire is fabricated of upward viii-scales. Four of them draw the physical and 4 the mental health status. The SF 36 Health Survey has been translated in more than l languages and adjusted to the cultural variations [24,29]. For hernia patients no specific HRQoL questionnaires are bachelor.

In our study two patients of the LW-group complained about low dragging pain during physical activity. The hurting did non persist at rest. 2 patients of the HW-group reported on intestinal pain at rest as well as in motility (sixteen.half-dozen%). The reported intensity of the hurting was lower in the LW-group. Notwithstanding the SF36 Survey showed no significant divergence in the quality of life of patients operated with a LW -or a HW -mesh in the long term follow up.

This lack of difference in the quality of life of the two groups is an interesting finding. In fact most studies investigating the life quality of patients undergoing inguinal hernia repair showed significant better results for LW meshes [30].

This is probably due to the fact that requirements for inguinal and ventral open up hernia repair are dissimilar. The quality and the causes of hurting following surgery are also different in inguinal and incisional hernia repair [31-33]. As a complexity of inguinal hernia repair patients endure mostly of neuropathic pain [32,34]. This is due to nerve pinch caused by nerve injury during surgery (suture, tacks, mesh) or past perineural fibrosis induced by the incorporated mesh. The fundamental to avert chronic neuropathic pain is the preservation of the nerves during surgery beside the pick of an appropriate mesh fabric [35].

After open incisional hernia repair dominates non neuropathic somatic pain, acquired by mechanic pressure of the folded mesh or scar tissue. This pain condition is influenced by the mesh elastic properties and the amount and structure of the material used for repair [31-33]. The mesh type and construction are therefore the main reason for the intestinal wall compliance and pain in the postoperative flow.

An explanation for the lack of difference in the quality of life of patients operated with a more elastic and lighter material compared to those operated with heavier and stiffer material might be that chronic pain did not have the expected influence on the daily activity of the patients.

Nikkolo et al arrived to a like conclusion in a randomised trial comparing LW and HW meshes for inguinal hernia repair [36]. Also Conze et al found in a prospective randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh no deviation in the SF 36 concrete function scores or daily activeness for the first 24 calendar month after the performance. In this report the SF36 scores between 4 and 24 months showed no further improvement. These findings were also irrespective of the mesh type [37].

The hateful historic period of patients undergoing incisional hernia repair was 57 ± 11 and 58 ± 11 years. The health perception changes with increasing age. So despite poorer role and physical function elderly patients have like global health perception compared with younger individuals [38].

Another important aspect is that this study compares the quality of life following open incisional hernia repair later a longer period of time (112 ± 22 and 75 ± 16 months) in opposition to most studies with a follow up of 6 to 12 months. Probably patients become used to the increased abdominal wall stiffness caused in the long term. Yet ii patients of the heavy weight group complained of chronic hurting as opposed to the low weight grouping where two patients complained of discomfort.

More generally the HrQoL of patients undergoing incisional hernia repair (no matter if with low or heavy weight mesh) is worse than that of the healthy population in the same age. There are several possible explanations for this. The comorbidities (cancer, center illness, diabetes, back hurting) might have influence on the quality of life. Some of those diseases or their treatments (diabetes, COPD, corticosteroid-/chemotherapy) are know to be chance factors for hernia formation. On the other mitt patients with chronic disease tend to downscale their expectations for life and feel satisfied as long as they tin can stabilize their condition and be free from complication and aggravation [39].

The study has several limitations. First the group size is pocket-sized. Starting with January 1998 heavy weight meshes were no longer used in our section. Additionally due to the long term follow up likewise the drop out charge per unit was high. Therefore it was non possible to include more than patients in this report. This reduces the power of the statistic.

Second limit is the unlike length of observation of the groups. Nevertheless the shortest median observation time is 75 months. In our feel patients symptoms do non change significantly more than v years postoperatively.

Another limitation is the method of measuring the quality of life. A hernia specific scale would be preferable. Such a validated instrument though was not bachelor at the time of the study and does not exist upward to now in High german linguistic communication. For this reason the SF-36 was used.

Conclusions

In this study the wellness related quality of life based on the SF 36 survey later on open up incisional hernia repair with light or heavy weight meshes is not related to the mesh type in the long term follow up.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

RL and TM conceived this study, RL, QL and CC acquired and interpreted the data, RL and CC wrote the manuscript, TM revised the manuscript critically; all authors have given final approval of the version to be published.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3180243/

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