A Systematic Review of Synthetic and Biologic Materials for Abdominal Wall Reinforcement in Contaminated Fields

Lawrence Lee, MD, MSc, Juan Mata, MD, Tara Landry, MLIS, Kosar A Khwaja, MD, MBA, Melina C Vassiliou, MD, MEd, Gerald M Fried, MD, Liane S Feldman, MD. McGill University Health Centre.

INTRODUCTION: Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields.

METHODS AND PROCEDURES: A systematic literature search (Medline, Embase, Biosis Previews, Cochrane, Scopus and Web of Science databases, in addition to grey literature) identified all articles published up to April 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias), and reported outcomes specifically in contaminated fields. Quality assessment was performed using the MINORS instrument. Two authors independently screened all citations, reviewed relevant full-text articles and extracted data. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Secondary outcomes included incidence of prosthetic explantation and enterocutaneous fistula formation. Weighted pooled proportions were calculated using a random effects model.

RESULTS: A total of 2032 unique citations were identified, out of which 32 studies met the inclusion criteria and were included for synthesis (bioprosthetics: 18 studies; synthetic non-absorbable: 12; both 2). Mean sample size was 41.4 (range 10–190), and duration of follow-up was >1year in 72% of studies. Overall quality was low (mean 6.2, range 1-12). Pooled wound infection rates were 31.6% (95% CI 14.5–48.7) with biologic and 6.4% (95% CI 3.4–9.4) with synthetic non-absorbable prosthetics in clean-contaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2% (95% CI 9.5– 44.9) with biologic and 3.2% (95% CI 0.0–11.0) with synthetic non-absorbable prosthetics. Other outcomes were comparable. In subgroup analyses, there were no differences in wound infection or hernia at follow-up for different synthetic non-absorbable (coated polypropylene (PP), heavyweight PP, lightweight PP) or biologic (human dermis, porcine dermis, porcine small intestine submucosa) in clean-contaminated, or contaminated and/or dirty fields.

CONCLUSIONS: The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.

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