Biologic versus Synthetic Mesh Reinforcement: What are the Pros and Cons?

Abstract

Preserving patients' native tissues has posed many challenges for surgeons. Increased life expectancy is leading to a proportionately older surgical population with weaker tissues. The growing population of morbidly obese patients in addition to those with multiple comorbidities which influence the native strength and perfusion of tissues compounds the surgeon's challenge. Certainly, there is a rising demand for materials to replace or augment a patient's native tissue when it has been compromised. Over time, the number of products available has increased substantially. The ideal substitute, however, is debatable. The manufacturing and processing of these materials has become more complex and this has resulted in a significant increase in cost. The composition of the mesh, clinical scenario, and operative technique all interact to impact the long-term results. Surgeons require a thorough understanding of these products to guide proper selection and use, to ensure optimal outcomes for patients, and to properly steward financial resources. This review will outline the properties of commonly used materials, highlighting the strength and weakness of each. It will then discuss recommendations regarding mesh selection, coding, and reimbursement. While general principles and trends can be highlighted, further studies of biologic versus synthetic meshes are clearly necessary.

Keywords: biological mesh; coding; synthetic mesh.

Figures

Fig. 1

Biologic mesh comes directly in contact with the colon without impunity in this parastomal hernia repair reinforcement. Photo credit: Dr. Jennifer Ayscue.

Fig. 2

Image of Zenapro (Cook Medical, Inc., Bloomington, IN), a hybrid made up of porcine small intestinal submucosa encasing a lightweight macroporous polypropylene mesh.

Fig. 3

Repair of infected synthetic mesh with biologic mesh. (A) Synthetic mesh seen eroding though skin. Outline shows mesh extension. (B) Specimen photo of excised mesh and mesh-fascial scar. (C) Facial defect prepared for biologic mesh underlay. (D) Biologic mesh measured and cut to size over defect allowing >3 cm overlap with fascia. (E) Mesh underlay with suture fixation. Fascial edges were then approximated over mesh (not pictured). Photo credit: Dr. Praful Ramineni.

Fig. 4

Exposed biologic mesh in a patient with Crohn disease who has an ileostomy with a leaking appliance in close proximity to the wound resulting in likely contamination with enteric flora. Photo credit: Dr. Neil Mauskar.

Fig. 5

Component separation with biologic mesh reinforcement (onlay). Photo credit: Dr. Tung Tran.

Fig. 6

Preservation of perforators in a sublay biologic mesh procedure. Photo credit: Dr. Praful Ramineni.