Use of Biologic material for grade 2 ventral hernia repair, is it worth the cost?

Shoshana Hacker, MD, Bradley Putty, Bharti Jasra, Brian Holt. Saint Louis University Hospital

Introduction: Ventral hernias are one of the most common surgical complications general surgeons face today, with more than 1 million abdominal wall hernia repairs performed in the US each year. While mesh reinforcement of ventral hernia repair is accepted as the standard of care to reduce recurrence rates, the choice of mesh type remains a dilemma for many surgeons. In an attempt to assist in better defining preoperative risk, the Ventral Hernia Working Group has stratified cases into a 4-tier grading system based on risk of developing a surgical site complication. Although the group recommends consideration of biologic mesh use in high risk grade 3 and 4 hernias, and synthetic mesh for low risk grade 1 hernias, no clear recommendations are made for the moderate risk grade 2 hernias. We sought to evaluate the outcomes of grade 2 hernia repairs in our institution based on employment of synthetic versus biologic mesh.

Hypothesis: There is no significant reduction in infection or non-infectious surgical site occurrence (SSO) rates between grade 2 ventral hernia repairs using biologic mesh as compared to synthetic mesh.

Methods: A retrospective analysis of ventral hernia repairs performed between 2004 and 2013 at a single academic institution was conducted. Demographic data to include medical comorbidities such as American Society of Anesthesiologists class, smoking, obesity, diabetes, COPD, steroid use, and previous wound infection were gathered, and subjects meeting the Modified Hernia Grading Scale criteria for grade 2 were selected. Subjects were divided based on use of synthetic versus biologic mesh use. Primary endpoints included SSO and infection, and recurrence was analyzed as a secondary endpoint.

Results: A total of 158 subjects underwent repair of a grade 2 ventral hernia (102 with synthetic mesh vs. 56 with biologic mesh). Demographics were similar between synthetic and biologic groups, with no significant differences in age (51.5 vs 51.8), male gender (49% vs 55%), diabetes (23.5% vs 17.9%), obesity (45% vs 34%), immunocompromised (5% vs 9%), or ASA class (2.6 vs 2.6). The synthetic group was more likely to include higher BMI (34.1 vs 30.1, p<.01) and smokers (45.1% vs 21.4%, p<.01), though COPD was not significantly different (12.8% vs 3.6%, p=.09). Mean follow up was 450 days. There were no differences in infection (11.8% vs 7.1%, p=.36), non-infectious SSO (12.7% vs 10.7%, p=.71), or recurrence (18.4% vs 13.5%, p=.44).

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Conclusion: The use of biologic mesh in the repair of grade 2 ventral hernia defects is not associated with a significantly lower incidence of infectious or non-infectious SSO compared with synthetic mesh. No evidence of improved recurrence rates was seen when comparing biologic mesh vs synthetic mesh in grade 2 ventral hernia patients at our institution. With the rising costs of healthcare and the uncertainty of which mesh to use in grade 2 patients, we hope this study can help guide the clinician in the appropriate selection of mesh in grade 2 ventral hernia repair.

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