Currently, more than 200 different textile constructions, so-called 'meshes', are available for use world-wide in the more than 20 million operations performed annually for the reinforcement of tissues. As any reintervention at the mesh-tissue compound is a surgical challenge, sometimes resulting in almost untreatable defects, huge efforts are being made to improve the biological and functional performance of the meshes. Based on numerous experimental and clinical studies in the past 20 years, our understanding of them has improved markedly. This includes the biomechanical aspects and the histopathological evaluation of the recipient tissue. Sufficiently large pores as well as structural stability in case of mechanical strain have been identified to be crucial to reduce excessive inflammation and fibrosis. Furthermore, large pores prevent bridging of the foreign body reaction through the pore and thereby help to reduce clinical adverse events as erosion, shrinkage or pain. However, with regard to the many different indications for meshes, there will never be one single ideal mesh for all purposes. To achieve an optimal performance, every construction should be designed according to the specific functional requirements, charging the surgeon to identify the best mesh for his purpose.

The Ideal Mesh

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

/pdf/european-hernia-society-guidelines-on-the-treatment-of-3gpmvq0mxo.pdf

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Reduced anticoagulation after mechanical aortic valve replacement: Interim results from the Prospective Randomized On-X Valve Anticoagulation Clinical Trial randomized Food and Drug Administration investigational device exemption trial

With more than 1 million implantations per year worldwide, mesh repair has become a standard procedure for the treatment of hernias. Apart from various technical problems, the type of material has been proven to be of considerable importance for the functional and histological outcome, particularly for long-term implantation. Whereas the advantageous application of low-weight, large-pore meshes based on multifilaments can be stated without doubt, it is still open whether similar results can be achieved on the basis of pure monofilaments.In the present study, a low-weight polypropylene mesh (LW) made purely of monofilaments was compared to a common heavy-weight polypropylene mesh (HW) in regard to the functional consequences and the tissue response. After implantation in rats as an inlay for 3–90 days, the abdominal-wall mobility of the implant region was recorded by 3D stereography, and the tensile strength of both the suture zone and the mesh was measured. The morphometry of the histological reaction in regard to the inflammatory infiltrate, the connective tissue, the number of granulocytes, macrophages, and fibroblasts served to reflect the tissue response. As parameters for the remodeling process at the interface the cellular activation was evaluated by TUNEL (DNA-strand breaks or apoptosis, respectively), Ki 67 (cell proliferation), and HSP 70 (cell stress). The measured tensile strength of the LW mesh confirmed a sufficient strength of the material-reduced mesh modification. After implantation the consecutive impairment of the abdominal-wall mobility was reduced compared to the HW mesh, concomitant to the reduced fibrotic level at the interface. At the end of the observation period the foreign-body reaction was significantly lowered for the LW mesh, almost reaching physiological values. In conclusion, these data confirm the improved biocompatibility of material-reduced mesh implants. © 2002 Wiley Periodicals, Inc. J Biomed Mater Res (Appl Biomater) 63: 129–136, 2002; DOI 10.1002/jbm.10119

Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair

The phenomenon of infection with abdominal wall reconstruction.

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices.

Background: The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of late rejection or infectious complications related to the mesh. The aim of this study was to describe the extent of these complications. Methods: We performed a retrospective study of 500 consecutive patients with TAPP for inguinal hernia. Results: Late mesh rejection was observed in three patients at 5–19 months after surgery. The mesh was removed via a suprapubic midline incision. At 3–4 month's follow-up, none of the patients had recurrence of the hernia, even though no hernia repair had been done. Conclusion: Late mesh rejection is a potential complication of TAPP and has to be considered when choosing the surgical method of hernia repair.

Late mesh rejection as a complication to transabdominal preperitoneal laparoscopic hernia repair

All patients who received a Carbomedics heart valve prosthesis were assessed retrospectively by interview regarding thromboembolic, hemorrhagic, or other valve-related events. In cases of such even...

Low-Dose Warfarin in Patients with Carbomedics Heart Valve Prostheses

Robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: A case report and review of the literature.

BACKGROUND AND AIM OF THE STUDY: Homografts and the Ross procedure are recommended by many surgeons for aortic valve replacement (AVR) in young adults. The study aim was to monitor patient outcome over a 14-year period after implanting mechanical CarboMedics prosthetic heart valves in young adults with aortic valve disease. METHODS: Between November 1987 and December 2000, 55 patients (42 males, 13 females; median age 33 years; range 15-40 years) each received a CarboMedics valve in the aortic position. All patients were included on a consecutive and non-selected basis. Concomitant surgery was performed in five patients. Anticoagulation was commenced on postoperative day 1. After discharge, patients were followed up by their cardiologist or general practitioner using questionnaires and telephone calls. Actuarial estimates of survival and freedom from morbid events were calculated using the Kaplan-Meier method. RESULTS: No patient died during surgery. Complete follow up data were available for all patients; total follow up was 404 patient-years (pt-yr). The 30-day mortality rate was zero. Actuarial survival at 14 years was 90 +/- 4.9%, and actuarial freedom from all valve-related events 92 +/- 3.7%. No valve thrombosis or major bleeding events were identified. Linearized rates per 100 pt-yr were: embolism 0.25; paravalvular leakage 0.25; prosthetic endocarditis 0.25; and reoperation 0.50. There was no hemolysis, prosthetic valve dysfunction, or structural deterioration. CONCLUSION: Over a 14-year period, implantation of the CarboMedics prosthetic heart valve has proven to be an excellent solution for AVR in young adults with aortic valve disease.

Fourteen years' experience with the CarboMedics valve in young adults with aortic valve disease.

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