Mesh Use in Central Hernia Repair
Indications for Mesh Use
- The American College of Surgeons recommends mesh reinforcement for defects larger than 3 cm, as primary repair alone has shown recurrence rates as high as 42% 3
- For small defects (<3 cm) without contamination, mesh repair is still preferred due to significantly lower recurrence rates compared to tissue repair 2
Mesh Selection Based on Surgical Field Classification
- For clean surgical fields (CDC class I), synthetic mesh is recommended due to lower recurrence rates 2
- For clean-contaminated fields (CDC class II), synthetic mesh can still be used safely without increased 30-day wound-related morbidity 2, 4
- For contaminated or dirty fields (CDC classes III and IV), biological or biosynthetic meshes are suggested when direct suture is not feasible for larger defects 1, 2
Types of Mesh Materials
- Biosynthetic, biologic, or composite meshes are suggested due to their lower rate of hernia recurrence, higher resistance to infections, and lower risk of displacement 1
- Biological meshes have shown lower rates of hernia recurrence and higher resistance to infections compared with synthetic meshes 6
- Polytetrafluoroethylene (PTFE/Gore-Tex) is commonly recommended for diaphragmatic reconstruction due to its strength, impermeability, and reduced risk of bowel adhesions 6
Surgical Approach and Technique
- Laparoscopic approach shows lower wound infection rates and shorter hospital stays compared to open procedures 4
- Mesh placement options include Intraperitoneal Onlay Mesh (IPOM) and Transabdominal Preperitoneal (TAPP) Repair, which are laparoscopic techniques placing mesh in preperitoneal space 4
Clinical Pitfalls and Considerations
- Mesh should not be avoided in clean or clean-contaminated fields due to fear of infection, as evidence shows it's safe and reduces recurrence 2
- Synthetic mesh should be avoided in grossly contaminated fields (CDC class III/IV) as infection rates can be high (up to 21%) 2, 5