How To Tell If You Have Adhesions From Hernia Mesh Repair
Ann Surg. 2003 Jan; 237(one): 123–128.
Prevention of Adhesion to Prosthetic Mesh
Comparison of Different Barriers Using an Incisional Hernia Model
Martijne van 't Riet
Departments of *General Surgery and
†Public Health, Erasmus Academy Medical Centre, Rotterdam-Dijkzigt, Rotterdam, Holland
Peggy J. de Vos van Steenwijk
Departments of *General Surgery and
†Public Health, Erasmus University Medical Heart, Rotterdam-Dijkzigt, Rotterdam, The Netherlands
Fred Bonthuis
Departments of *General Surgery and
†Public Wellness, Erasmus University Medical Centre, Rotterdam-Dijkzigt, Rotterdam, The Netherlands
Richard 50. Marquet
Departments of *Full general Surgery and
†Public Health, Erasmus Academy Medical Centre, Rotterdam-Dijkzigt, Rotterdam, The Netherlands
Ewout W. Steyerberg
Departments of *General Surgery and
†Public Wellness, Erasmus Academy Medical Center, Rotterdam-Dijkzigt, Rotterdam, The Netherlands
Johannes Jeekel
Departments of *General Surgery and
†Public Health, Erasmus University Medical Centre, Rotterdam-Dijkzigt, Rotterdam, The Netherlands
H. Jaap Bonjer
Departments of *General Surgery and
†Public Health, Erasmus University Medical Eye, Rotterdam-Dijkzigt, Rotterdam, Kingdom of the netherlands
Abstract
Objective
To appraise whether utilize of antiadhesive liquids or coatings could foreclose adhesion formation to prosthetic mesh.
Summary Background Data
Incisional hernia repair frequently involves the use of prosthetic mesh. Nevertheless, business organization exists almost development of adhesions between viscera and the mesh, predisposing to abdominal obstruction or enterocutaneous fistulas.
Methods
In 91 rats, a defect in the muscular intestinal wall was created, and mesh was fixed intraperitoneally to cover the defect. Rats were divided in five groups: polypropylene mesh but (control group), addition of Sepracoat or Icodextrin solution to polypropylene mesh, Sepramesh (polypropylene mesh with Seprafilm blanket), and Parietex blended mesh (polyester mesh with collagen coating). Seven and 30 days postoperatively, adhesions were assessed and wound healing was studied past microscopy.
Results
Intraperitoneal placement of polypropylene mesh was followed past bowel adhesions to the mesh in 50% of the cases. A mean of 74% of the mesh surface was covered by adhesions after vii days, and 48% after thirty days. Administration of Sepracoat or Icodextrin solution had no influence on adhesion formation. Coated meshes (Sepramesh and Parietex composite mesh) had no bowel adhesions. Sepramesh was associated with a pregnant reduction of the mesh surface covered by adhesions subsequently 7 and 30 days. Infection was more than prevalent with Parietex composite mesh, with concurrent increased mesh surface covered by adhesions after thirty days (78%).
Conclusions
Sepramesh significantly reduced mesh surface covered by adhesions and prevented bowel adhesion to the mesh. Parietex composite mesh prevented bowel adhesions also but increased infection rates in the current model.
Incisional hernias occur in five% to 20% of patients after abdominal surgery. ane–4 In incisional hernia repair, the introduction of tension-gratis techniques by using prosthetic cloth has reduced recurrence rates from up to 50% to less than 24%. 5–ix Notwithstanding, foreign materials, such as prosthetic mesh, represent a strong stimulus for the evolution of permanent adhesions. 10 Particularly if the mesh is placed intraperitoneally, business exists about development of adhesions between bowel and mesh. These adhesions tin cause serious complications, such every bit abdominal obstruction and enterocutaneous fistulas. 11–xiv
The aim of the present report was to assess whether adhesions due to intraperitoneal mesh tin can be prevented by the apply of physical barriers that tin can exist practical laparoscopically. For this purpose, we assessed if intraperitoneal assistants of liquid physical barriers composed of hyaluronic acid (Sepracoat, HAL-C; Genzyme Corp., Cambridge, MA) or Icodextrin solution (Extraneal, Baxter Healthcare Inc.) could prevent adhesions to a polypropylene mesh without interfering with wound healing and tissue incorporation of the mesh. In add-on, we studied the ability of specifically coated meshes, Sepramesh (Genzyme) and Parietex composite mesh (Sofradim, France), to prevent adhesions.
METHODS
Animals
Ninety-1 male inbred rats of the Wistar strain (weight 250–300 g) were obtained from Harlan (Zeist, The netherlands). They were bred nether specific pathogen-costless weather condition, kept under standard laboratory conditions (temperature 20–24°C, relative humidity 50–60%, 12 hours calorie-free/12 hours dark), and fed with laboratory diet (Hope Farms, Woerden, Holland) and water advertizement libitum. The experimental protocol adhered to rules set past the Dutch Brute Experimentation Human activity and was approved by the Commission in Animal Inquiry of the Erasmus University Rotterdam. Nonpowdered gloves were used routinely in the experimental process.
Operative Procedure
Following initial sedation with ether, each animal received an intraperitoneal injection of 0.xv mL ketamine (100 mg/mL) and 0.04 mL xylazine (20 mg/mL). The belly was shaved and cleaned with booze lxx%.
The experiments were performed in a validated rat model described by Alponat et al. 15 and Hooker et al. 16 In all animals, laparotomy was performed using a midline incision of 4 cm. Peel flaps were raised and a standardized ane.5 × 2.5-cm longitudinal full-thickness defect consisting of fascia, muscle, and peritoneum was created.
Experiments
Experiment 1
In xx rats, the defect of the abdominal wall was repaired with a polypropylene mesh (Prolene, Ethicon Inc., Somerville, NJ) measuring two.5 × 3.5 cm that was fixed intraperitoneally with eight interrupted Prolene 5-0 sutures. Afterwards, the rats were randomized between no additional treatment (command grouping, n = ten) and addition of 4 mL Sepracoat solution (n = 10) intraperitoneally. In all animals, the pare was airtight with continuous 4-0 polyglactin suture (Vicryl, Ethicon). Seven days postoperatively, adhesions were scored.
Experiment 2
In 20 rats, the defect of the intestinal wall was repaired with a polypropylene mesh (Prolene) measuring 2.5 × iii.five cm that was stock-still intraperitoneally with 8 interrupted Prolene 5-0 sutures. After placement of the mesh, the rats were randomized between no boosted treatment (command group, n = 10) and add-on of 4 mL Icodextrin 7.5% solution (Extraneal) intraperitoneally (north = ten). In all animals, the skin was airtight with continuous 4-0 polyglactin suture (Vicryl, Ethicon). To foreclose leakage of the liquid Icodextrin solution, the skin of the animals was additionally closed with Histoacryl glue. Seven days postoperatively, adhesions were scored.
Experiment 3
30 rats were randomly divided into iii groups. In group i (northward = 10), the defect was repaired with a polypropylene mesh (Prolene) measuring 2.five × 3.5 cm. In group 2 (n = 10) the defect was repaired with a polypropylene mesh, coated with hyaluronic acid and carboxymethylcellulose on the visceral side of the mesh (Sepramesh). In group iii, the defect was repaired with a polyester mesh with a collagen blanket on the visceral side (Parietex composite mesh) Meshes were fixed intraperitoneally with eight interrupted Prolene five-0 sutures and the pare was closed with continuous iv-0 polyglactin suture (Vicryl, Ethicon). Seven days postoperatively, adhesions were scored.
Experiment 4
Experiment 4 was identical to experiment iii, but adhesions were assessed after 30 days instead of 7 days.
Scoring of Adhesions, Infection, and Incorporation
7 or 30 days postoperatively, all rats were killed and underwent autopsy. A median skin incision was created and the intestinal cavity was entered through a U-shaped incision, extending caudal and lateral to the mesh. The presence of adhesions between bowel and the mesh was assessed. For each rat information technology was documented whether bowel adhesions were present. After that, the mesh was excised and both bowel and omental adhesions were sharply cut. The surface of the mesh that was covered by bowel and/or omental adhesions was assessed (Fig. 1). For this purpose, the mesh surface was divided into six sections. Each department was later on subdivided in six fields, and for each field the percentage of the surface covered by adhesions was estimated. Density of adhesions was scored co-ordinate to Zühlke nomenclature. 17 Infection was defined equally pus coming from the mesh and wound. Incorporation of the prosthesis in the intestinal wall was scored by dividing the circumference of the mesh into 10 segments and subsequently determining the number of segments in which the mesh was not incorporated in the intestinal wall. Two independent investigators, who were unaware of the group assignment of the rats, performed scoring of adhesions and incorporation. In case of interobserver variance, the mean was scored.
Figure i. Dense bowel adhesion to the mesh.
Histology
Of each group, three meshes with the adjoining abdominal wall were fixed in 10% neutral buffered formalin for at to the lowest degree ane hour. After routine tissue processing, sections were cut at iv to 6 μm and stained with hematoxylin and eosin. Sections were microscopically studied, and incorporation of the mesh in the surrounding tissue and inflammatory reaction were assessed for each grouping. The course of inflammation was assessed using a semiquantitative scoring system, the inflammation grading scale. 16 Class ane on this scale represents a mild inflammatory reaction with giant cells, occasional scattered lymphocytes, and plasma cells. Grade 2 represents a moderate reaction with giant cells and increased admixed lymphocytes, plasma cells, eosinophils, and neutrophils. Course three represents a severe inflammatory reaction with microabscesses nowadays.
Statistical Analysis
Statistical assay was performed using the Mann-Whitney exam for independent samples. P < .05 was considered statistically significant.
RESULTS
Ii animals died before the cease of the experiment on postoperative days 4 and 5 of unknown causes (experiment 3). In all animals, adhesions of the omentum to the prosthetic mesh were seen to some extent. These adhesions could be lysed only by sharp dissection (Zühlke nomenclature 3). 17 No herniations of viscera between mesh and abdominal wall were seen.
With polypropylene mesh, bowel adhesions to the mesh were seen in l% to 60% of all animals. After seven days, a mean surface of 74% to 88% of the mesh was covered past adhesions (Table ane). Instillation of Sepracoat solution in the peritoneal crenel did not significantly reduce the surface of the polypropylene mesh that was covered by adhesions (68% vs. 82%, P = .07) and did not prevent bowel adhesions to the mesh. Instillation of Icodextrin seven.five% solution did non reduce the surface of the mesh that was covered by adhesions, either (90% vs. 88%). Farther, Icodextrin solution had no influence on the formation of bowel adhesions to the mesh.
Table ane.ADHESION Germination AND MESH INCORPORATION
When Sepramesh was used, a meaning reduction in the mean percentage of mesh surface covered by adhesions was establish afterwards 7 days (55% vs. 74%, P = .01), as well as later 30 days (25% vs. 48%, P = .03), compared to the control group. In addition, none of the animals with Sepramesh developed adhesions between bowel and the mesh, compared to 57% of the animals with polypropylene mesh (P = .04).
With Parietex blended mesh, there were no bowel adhesions to the mesh, either (P = .04). Yet, in the Parietex blended group, the infection rate was 57% at 30 days postoperatively compared to 0% in the control group (P = .02). In addition, the pct of mesh surface covered by adhesions was college in the Parietex blended group (78%) than in the command group (48%, P = .03).
Histologic evaluation in each command group showed strange body reaction with giant cells and increased admixed lymphocytes, plasma cells, eosinophils, and neutrophils (grade 2 on the inflammation grading scale). A comparable reaction was plant in the groups with the addition of Sepracoat or Icodextrin to a polypropylene mesh and in the group with Sepramesh (Fig. 2). Notwithstanding, in the group with Parietex composite mesh, a more than severe inflammatory reaction was institute, with the presence of many admixed inflammatory cells and microabscesses (form 3 on the inflammation grading scale). Incorporation of the mesh was similar in all study groups.
Figure ii. Lite microscopy of histology 7 days postoperatively with polypropylene mesh (A), Sepramesh (B), and Parietex composite mesh (C).
Give-and-take
The reduction of recurrence rates following reinforcement of the abdominal wall by mesh in incisional hernia has promoted the use of mesh. 9 Polypropylene is most commonly used because information technology is piece of cake to handle and relatively low in cost. Because polypropylene causes a pronounced and persistent inflammatory reaction, the mesh is well incorporated in the surrounding tissue of the abdominal wall. However, for the aforementioned reason, polypropylene causes a strong stimulus for the formation of adhesions. 18–20
Adhesion formation is role of the normal healing process and is observed following 90% to 100% of all abdominal surgical procedures. 21,22 Surgical trauma and strange body reaction inhibit plasminogen activator action. This inhibition is followed by reduced fibrinolysis, which results in increased deposition of fibrin matrix. 23,24 The fibrin matrix gradually matures into an organized fibrous adhesion over the course of approximately 5 days. 25 With time, the extent of adhesions decreases past approximately 30%, as was institute in the nowadays written report (experiment four vs. experiments i, 2, and three). 26
In the rat, intra-abdominal adhesions form inside 24 hours after the operation, and after 7 days no new adhesions are formed. 18,27 Therefore, adhesion formation in the present study was evaluated subsequently 7 days. In the experiments with the coated meshes, adhesion formation was also assessed after 30 days to evaluate the antiadhesive issue after resolution of the coating.
Liquid Antiadhesive
Sepracoat is a viscous solution composed of 0.4% hyaluronic acrid in phosphate-buffered saline. Hyaluronic acid is a glycosaminoglycan that is naturally found in the human body in connective tissue, synovial fluid, and vitreous humor. The Sepracoat solution coats tissues with a temporary protective layer and is completely resorbed from the abdomen within five days. 28 After gynecologic surgery without a mesh, Sepracoat was found to lessen intra-intestinal adhesion formation. 28 In the present report, Sepracoat did non significantly decrease the incidence of bowel or omental adhesions to the mesh.
Icodextrin is a biodegradable glucose polymer solution that has been registered for peritoneal dialysis. Although iso-osmolar, Icodextrin induces ultrafiltration through colloid osmosis. Through the allure of fluid into the abdominal cavity, it is supposed to separate damaged surfaces while postsurgical regeneration takes place, thereby preventing formation of adhesions betwixt surgical surfaces. Icodextrin is metabolized past amylase to oligosaccharides and remains in the man abdominal crenel for at least 3 to 4 days. 29 In contrast to the present study, in which nosotros found no outcome of Icodextrin on adhesion formation, Verco et al. reported fewer adhesions after administration of Icodextrin in a uterine horn model in rabbits. 30 In the rat, the intra-abdominal amylase concentration is higher than in the rabbit, which may pb to a shorter intraperitoneal residence time of Icodextrin in the rat.
Coated Meshes
Recently, coated meshes, with a protective layer on the visceral side of the mesh, have been introduced in surgery. The aim of the protective layer is to provide sufficient separation betwixt the mesh and viscera while regeneration takes place without impeding tissue ingrowth of the mesh on the other side.
Sepramesh is composed of a polypropylene mesh that is coated with a bioresorbable membrane of hyaluronate and carboxymethylcellulose, which are bonded by polygalactide/polyglycolide. The antiadhesive membrane remains in place for upwards to vii days 31 and is subsequently absorbed. As was shown in the present study, Sepramesh significantly reduced adhesion formation to the mesh after 7 days every bit well as after 30 days, when the membrane was completely captivated. In addition, adhesion of viscera to the mesh was prevented later 7 days. Later on xxx days, the aforementioned trend was seen, although the difference was not statistically significant due to express sample size.
In a rat and rabbit model, a bioresorbable membrane of hyaluronate and carboxymethylcellulose (Seprafilm) has been reported to diminish adhesion formation significantly. 15,16,18,32 However, this membrane is not applicable in laparoscopic incisional hernia repair because of technical difficulties with the introduction and positioning of the sticky membrane. The soluble course of Seprafilm (Sepracoat) would be easier to apply laparoscopically, but it did not reduce adhesions in the present written report. A possible explanation for this discrepancy between the results of Sepracoat and Seprafilm is the deviation in intra-intestinal lifetime. Sepracoat persists at its site of application for but approximately 24 hours, while Seprafilm remains in place for at to the lowest degree 7 days. 28,31 Thus, intra-intestinal residence time might be an important cistron and may have to exceed at least 7 days.
The Parietex composite mesh is a polyester mesh coated with an absorbable and hydrophilic pic on the visceral side. The film is composed of a solution of oxidized bovine atelocollagen type I, polyethylene glycol, and glycerol. 33 Inside 3 weeks the film is completely resorbed and a new peritoneal covering is formed over the mesh. 33 In the present study, the hydrophilic moving-picture show provided significant protection against bowel adhesions after 7 days. The aforementioned trend was seen after 30 days, although the difference was not statistically significant due to limited sample size. Reduction of adhesions with the use of Parietex composite mesh was also found by Mutter et al. 33 Still, in the current study, Parietex composite mesh was more easily infected than the other meshes and showed a stronger inflammatory response. With infection and increased inflammatory reaction, concurrent increase of the surface of the mesh that was covered by adhesions was seen. A stronger inflammatory reaction with an increased incidence of infection and formation of enterocutaneous fistulas (16%) with the use of polyester mesh was too constitute in a clinical written report past Leber et al. 11
In decision, Sepramesh significantly reduced adhesion formation and prevented bowel adhesion to the mesh in the early postoperative period without interfering with wound healing and tissue incorporation of the mesh. Parietex blended mesh reduced bowel adhesions to the mesh equally well merely provoked a stronger inflammatory reaction in the current model. Addition of liquid concrete barriers such as Sepracoat or Icodextrin did non prevent adhesion of omentum or bowel to a polypropylene mesh. Future clinical studies are indicated to assess the promising results of coated meshes.
Footnotes
Correspondence: Prof. dr. H. J. Bonjer, Bookish Hospital Rotterdam, Dr. Molewaterplein twoscore, 3015 GD Rotterdam, The Netherlands.
E-mail: vantriet@hlkd.azr.nl
Accepted for publication April 2, 2002.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513975/
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