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Impact of mesh positioning on foreign body reaction and collagenous ingrowth in a rabbit model of open incisional hernia repair

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Abstract

Background

Incisional hernia remains as one of the most common surgical complications. Different mesh techniques are used in 75–80% of hernia repair. The aim of this study was to evaluate the dependence of mesh positioning and the type of mesh implanted on foreign body reaction and collagenous ingrowth.

Materials and methods

In 24 male Chinchilla rabbits, an incisional hernia repair was performed with mesh reinforcement either by sublay (n = 12) or by onlay technique (n = 12). In each group, two different types of mesh prosthesis were investigated: polypropylene (PP, Prolene®) and polypropylene-polyglecaprone 25 composite (PP-PG, UltraPro®). On postoperative day 60, the inflammatory and connective tissue formation was characterised by measuring the diameter of inner cellular infiltrate and outer fibrous capsule of the foreign body granuloma, and by verifying the collagen type I/III ratio. Furthermore, the expression of matrix metalloproteinase-2 (MMP-2) was analysed.

Results

Microscopic investigation of the mesh/host-tissue interface showed typical formation of foreign body granuloma. The diameters of the inner part of the foreign body granuloma representing the amount of inflammatory cell infiltrate were significantly increased in the PP mesh compared to the PP-PG mesh, both in the sublay group (PP 13.1 ± 1.21 μm vs. PP-PG 11.7 ± 0.34 μm; P = 0.026) and in the onlay group (PP 13.1 ± 1.24 μm vs. PP-PG 11.2 ± 0.55 μm; P = 0.009). The diameter of the fibrous capsule as the outer ring of the granuloma was significantly increased when investigating the PP mesh in sublay position (29.5 ± 1.12 μm) compared to the PP mesh in onlay position (27.9 ± 0.73 μm) (P = 0.026). Investigating the quality of perifilamentary collagen deposition expressed as collagen type I/III ratio, the sublay group showed significantly elevated values compared to the onlay group (PP sublay 3.1 ± 0.18 vs. PP onlay 2.4 ± 0.41; P = 0.004) (PP-PG sublay 3.5 ± 0.34 vs. PP-PG onlay 2.6 ± 0.13; P = 0.002). The analysis of MMP-2 expression revealed no significant differences.

Conclusion

The beneficial results of mesh reinforcement in the sublay technique might be due to a superior quality of postoperative connective tissue formation. Mesh incorporation, irrespective of positioning, is favourable in low-weight, large, porous mesh material represented by a reduced inflammatory part of the foreign body granuloma.

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References

  1. Conze J, Klinge U, Schumpelick V (2005) Incisional hernia. Chirurg 76(9):897–909

    Article  CAS  PubMed  Google Scholar 

  2. Amid PK, Lichtenstein IL (1996) Retromuscular alloplasty of large scar hernias: a simple staple attachment technique. Chirurg 67(6):648–652

    CAS  PubMed  Google Scholar 

  3. Schumpelick V, Klinge U, Welty G, Klosterhalfen B (1999) Meshes within the abdominal wall. Chirurg 70(8):876–887

    Article  CAS  PubMed  Google Scholar 

  4. Trupka AW, Hallfeldt KK, Schmidbauer S, Schweiberer L (1998) Management of complicated incisional hernias with underlay-technique implanted polypropylene mesh. An effective technique in French hernia surgery. Chirurg 69(7):766–772

    Article  CAS  PubMed  Google Scholar 

  5. Conze J, Kingsnorth AN, Flament JB, Simmermacher R, Arlt G, Langer C et al (2005) Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 92(12):1488–1493

    Article  CAS  PubMed  Google Scholar 

  6. Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege RV et al (2000) Factors affecting recurrence following incisional herniorrhaphy. World J Surg 24(1):95–100

    Article  CAS  PubMed  Google Scholar 

  7. Girotto JA, Malaisrie SC, Bulkely G, Manson PN (2000) Recurrent ventral herniation in Ehlers–Danlos syndrome. Plast Reconstr Surg 106(7):1520–1526

    Article  CAS  PubMed  Google Scholar 

  8. Thomas GP, Purkayastha S, Athanasiou T, Darzi A (2008) General surgical manifestations of Marfan’s syndrome. Br J Hosp Med (Lond) 69(5):270–274

    CAS  Google Scholar 

  9. Klinge U, Zheng H, Si ZY, Schumpelick V, Bhardwaj R, Klosterhalfen B (1999) Synthesis of type I and III collagen, expression of fibronectin and matrix metalloproteinases-1 and -13 in hernial sac of patients with inguinal hernia. Int J Surg Investig 1(3):219–227

    CAS  PubMed  Google Scholar 

  10. Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS, Klosterhalfen B (2001) Collagen I/III and matrix metalloproteinases (MMP) 1 and 13 in the fascia of patients with incisional hernias. J Invest Surg 14(1):47–54

    Article  CAS  PubMed  Google Scholar 

  11. Zheng H, Si Z, Kasperk R, Bhardwaj RS, Schumpelick V, Klinge U et al (2002) Recurrent inguinal hernia: disease of the collagen matrix? World J Surg 26(4):401–408

    Article  PubMed  Google Scholar 

  12. Conze J, Krones CJ, Schumpelick V, Klinge U (2007) Incisional hernia: challenge of re-operations after mesh repair. Langenbecks Arch Surg 392(4):453–457

    Article  PubMed  Google Scholar 

  13. Langer C, Kley C, Neufang T, Liersch T, Becker H (2001) Problem of recurrent incisional hernia after mesh repair of the abdominal wall. Chirurg 72(8):927–933

    Article  CAS  PubMed  Google Scholar 

  14. Junge K, Klinge U, Rosch R, Mertens PR, Kirch J, Klosterhalfen B et al (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prostheses. Langenbecks Arch Surg 389(1):17–22

    Article  PubMed  Google Scholar 

  15. Klosterhalfen B, Klinge U, Schumpelick V (1998) Functional and morphological evaluation of different polypropylene-mesh modifications for abdominal wall repair. Biomaterials 19(24):2235–2246

    Article  CAS  PubMed  Google Scholar 

  16. Junge K, Klinge U, Rosch R, Klosterhalfen B, Schumpelick V (2002) Functional and morphologic properties of a modified mesh for inguinal hernia repair. World J Surg 26(12):1472–1480

    Article  PubMed  Google Scholar 

  17. Klinge U, Zheng H, Si Z, Schumpelick V, Bhardwaj RS, Muys L et al (1999) Expression of the extracellular matrix proteins collagen I, collagen III and fibronectin and matrix metalloproteinase-1 and -13 in the skin of patients with inguinal hernia. Eur Surg Res 31(6):480–490

    Article  CAS  PubMed  Google Scholar 

  18. Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS, Klosterhalfen B (2000) Abnormal collagen I to III distribution in the skin of patients with incisional hernia. Eur Surg Res 32(1):43–48

    Article  CAS  PubMed  Google Scholar 

  19. Junge K, Klinge U, Rosch R, Lynen P, Binnebösel M, Conze J et al (2007) Improved collagen type I/III ratio at the interface of gentamicin-supplemented polyvinylidenfluoride mesh materials. Langenbecks Arch Surg 392(4):465–471

    Article  PubMed  Google Scholar 

  20. Chevrel JP (1979) The treatment of large midline incisional hernias by “overcoat” plasty and prothesis (author’s transl). Nouv Presse Med 8(9):695–696

    CAS  PubMed  Google Scholar 

  21. Rives J, Lardennois B, Pire JC, Hibon J (1973) Large incisional hernias. The importance of flail abdomen and of subsequent respiratory disorders. Chirurgie 99(8):547–563

    CAS  PubMed  Google Scholar 

  22. Remmele W, Stegner HE (1987) Recommendation for uniform definition of an immunoreactive score (IRS) for immunohistochemical estrogen receptor detection (ER-ICA) in breast cancer tissue. Pathologe 8(3):138–140

    CAS  PubMed  Google Scholar 

  23. Junqueira LC, Cossermelli W, Brentani R (1978) Differential staining of collagens type I, II and III by Sirius Red and polarization microscopy. Arch Histol Jpn 41(3):267–274

    CAS  PubMed  Google Scholar 

  24. Rosch R, Lynen-Jansen P, Junge K, Knops M, Klosterhalfen B, Klinge U et al (2006) Biomaterial-dependent MMP-2 expression in fibroblasts from patients with recurrent incisional hernias. Hernia 10(2):125–130

    Article  CAS  PubMed  Google Scholar 

  25. Rosch R, Junge K, Knops M, Lynen P, Klinge U, Schumpelick V (2003) Analysis of collagen-interacting proteins in patients with incisional hernias. Langenbecks Arch Surg 387(11–12):427–432

    CAS  PubMed  Google Scholar 

  26. Israelsson LA, Smedberg S, Montgomery A, Nordin P, Spangen L (2006) Incisional hernia repair in Sweden 2002. Hernia 10(3):258–261

    Article  CAS  PubMed  Google Scholar 

  27. Vestweber KH, Lepique F, Haaf F, Horatz M, Rink A (1997) Mesh-plasty for recurrent abdominal wall hernias—results. Zentralbl Chir 122(10):885–888

    CAS  PubMed  Google Scholar 

  28. Langer C, Liersch T, Kley C, Flosman M, Süss M, Siemer A et al (2003) Twenty-five years of experience in incisional hernia surgery. A comparative retrospective study of 432 incisional hernia repairs. Chirurg 74(7):638–645

    Article  CAS  PubMed  Google Scholar 

  29. San Pio JR, Damsgaard TE, Momsen O, Villadsen I, Larsen J (2003) Repair of giant incisional hernias with polypropylene mesh: a retrospective study. Scand J Plast Reconstr Surg Hand Surg 37(2):102–106

    Article  PubMed  Google Scholar 

  30. Binnebösel M, Rosch R, Junge K, Flanagan TC, Schwab R, Schumpelick V et al (2007) Biomechanical analyses of overlap and mesh dislocation in an incisional hernia model in vitro. Surgery 142(3):365–371

    Article  PubMed  Google Scholar 

  31. Junge K, Rosch R, Bialasinski L, Klinge U, Klosterhalfen B, Schumpelick V (2003) Persistent extracellular matrix remodelling at the interface to polymers used for hernia repair. Eur Surg Res 35(6):497–504

    Article  CAS  PubMed  Google Scholar 

  32. Junge K, Klinge U, Klosterhalfen B, Mertens PR, Rosch R, Schachtrupp A et al (2002) Influence of mesh materials on collagen deposition in a rat model. J Invest Surg 15(6):319–328

    Article  CAS  PubMed  Google Scholar 

  33. Rosch R, Junge K, Quester R, Klinge U, Klosterhalfen B, Schumpelick V (2003) Vypro II mesh in hernia repair: impact of polyglactin on long-term incorporation in rats. Eur Surg Res 35(5):445–450

    Article  CAS  PubMed  Google Scholar 

  34. Rosch R, Junge K, Schachtrupp A, Klinge U, Klosterhalfen B, Schumpelick V (2003) Mesh implants in hernia repair. Inflammatory cell response in a rat model. Eur Surg Res 35(3):161–166

    Article  CAS  PubMed  Google Scholar 

  35. Junge K, Klinge U, Prescher A, Giboni P, Niewiera M, Schumpelick V (2001) Elasticity of the anterior abdominal wall and impact for reparation of incisional hernias using mesh implants. Hernia 5(3):113–118

    Article  CAS  PubMed  Google Scholar 

  36. Klinge U, Klosterhalfen B, Conze J, Limberg W, Obolenski B, Ottinger AP et al (1998) Modified mesh for hernia repair that is adapted to the physiology of the abdominal wall. Eur J Surg 164(12):951–960

    Article  CAS  PubMed  Google Scholar 

  37. Junge K, Binnebösel M, Rosch R, Ottinger A, Stumpf M, Mühlenbruch G et al (2008) Influence of mesh materials on the integrity of the vas deferens following Lichtenstein hernioplasty: an experimental model. Hernia 12(6):621–626

    Article  CAS  PubMed  Google Scholar 

  38. Jansen M, Otto J, Jansen PL, Anurov M, Titkova S, Willis S et al (2007) Mesh migration into the esophageal wall after mesh hiatoplasty: comparison of two alloplastic materials. Surg Endosc 21(12):2298–2303

    Article  CAS  PubMed  Google Scholar 

  39. Jansen PL, Kever M, Rosch R, Krott E, Jansen M, Alfonso-Jaume A et al (2007) Polymeric meshes induce zonal regulation of matrix metalloproteinase-2 gene expression by macrophages and fibroblasts. FASEB J 21(4):1047–1057

    Article  CAS  PubMed  Google Scholar 

  40. Jansen PL, Rosch R, Jansen M, Binnebösel M, Junge K, Alfonso-Jaume A et al (2007) Regulation of MMP-2 gene transcription in dermal wounds. J Invest Dermatol 127(7):1762–1767

    CAS  PubMed  Google Scholar 

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Acknowledgement

We are grateful to Mrs. Ellen Krott for her most excellent and careful assistance during this investigation.

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Authors and Affiliations

  1. Department of Surgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany

    M. Binnebösel, C. D. Klink, J. Otto, J. Conze, P. L. Jansen, V. Schumpelick & K. Junge

  2. Joint Institute for Surgical Research, Russian State Medical University, Moscow, Russia

    M. Anurov

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  1. M. Binnebösel
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  2. C. D. Klink
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  3. J. Otto
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  4. J. Conze
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  7. V. Schumpelick
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  8. K. Junge
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Correspondence to M. Binnebösel.

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Binnebösel, M., Klink, C.D., Otto, J. et al. Impact of mesh positioning on foreign body reaction and collagenous ingrowth in a rabbit model of open incisional hernia repair. Hernia 14, 71–77 (2010). https://doi.org/10.1007/s10029-009-0580-4

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  • DOI: https://doi.org/10.1007/s10029-009-0580-4

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