Absorbable meshes

[Good intentions]

Hello Alephy. It is a confusing area to talk about, I think. The word “absorbable” is a vague word that means different things to different surgeons. It seems to be used interchangeably with resorbable. The nomenclature used in the hernia repair field is a big problem in understanding what people are saying. I linked an article describing the problem in a different area of the field, below.

I think that the same problem exists in describing these absorbable, resorbable, and synthetic materials. Even worse, “synthesis” is used to make all of them. “Synthetic” is another vague word.

Here is some literature that uses a variety of words. “Incorporate” is also there, used in the past to describe synthetic (petroleum-based, plastic) meshes.

https://www.bd.com/assets/documents/pdh/initial/Phasix-Brochure-with-LX.pdf

https://link.springer.com/article/10.1007/s00268-017-4037-0

[Alephy]

@good-intentions thanks for the link…if I understood correctly there is an ongoing effort to reduce the risk of infection, both for absorbable as well as non absorbable meshes, which is a good thing.

I had the impression though that the main criticism against absorbable meshes was that the recurrence rate was too high, and/or it caused too much inflammation (see Dr. Towfigh’s comment on the video above):
I still don’t see the evidence for this…

[Good intentions]

Here is a recent paper with a pretty good short review of absorbable meshes, with references. It’s in the second section.

Antimicrobial Meshes for Hernia Repair: Current Progress and Perspectives
by Simona Mirel 1ORCID, Alexandra Pusta 1,*ORCID, Mihaela Moldovan 2 and Septimiu Moldovan 3

https://www.mdpi.com/2077-0383/11/3/883/htm

[Alephy]

Quite frankly, the long term performance of the various meshes in the market is not well assessed either…

Again, I have not seen any study that reports high rates of recurrence for the synthetic absorbable meshes after e.g. 3 years….I have heard Dr. Towfigh mention that in her opinion after few years they may start failing, but I could not find the paper this was based on…

There seems to be a diffused belief/assumption that people with a hernia cannot regenerate healthy tissue, and that whatever tissue is generated will fail without the support of the mesh: as in many other examples where the doctors got it wrong, it would be good to have this supported by data….

The absorbable meshes have entered the market since many years by now, I honestly do not understand why they are not offered more broadly….also considering the severity of mesh complications, a mesh that disappears seems something to consider, there might still be chronic pain but it would improve with time also in the most severe cases without the mesh being there….

[MarkT]

I thought the critique of bio/absorbable was significantly higher risk of recurrence…that they either did not last long enough and/or there was not enough scar tissue to be sufficient to hold a repair once it was gone.

I don’t recall if it was that video with Dr. Heniford, but I’m almost positive that one HerniaTalk guest briefly mentioned a newer absorbable that lasted longer (12+ months?), but I can’t remember what they said about it…either/both that it was not yet widely available and/or was so new that there was not enough time yet to see if it improved outcomes…?

[Good intentions]

Much of Dr. Heniford’s work is in the area of ventral hernias. Which are different than inguinal hernias, the dynamics of the body movement are not the same. Something to be aware of.

I think that one reason that more absorbable or resorbable materials are not offered is because all of the mesh makers are using the 510(k) program to introduce new products. Because it’s cheaper. New products are just small variations, supposed improvements, on old products. That’s how the 510(k) program works.

I did not watch the video so am not sure what “absorbable” means here. Ovitex is called “resorbable” as opposed to absorbable.

https://www.telabio.com/assets/download/OviTex-PRS-Resorbable-IFU.pdf

Here is a recent publication with Heniford as a co-author. They are still studying polypropylene. It’s not really clear what they will do with the new knowledge.

https://link.springer.com/article/10.1007/s00464-021-08882-4

[Alephy]

@good-intentions

Yes, with Dr. Heniford.

Here is the link to the video

https://www.youtube.com/watch?v=_wdB-QfJDKc

and the relevant bit is after 43:30 more or less….it seems as though Dr. Heniford is in favour of absorbable meshes, whereas Dr. Towfigh has reservations…

It is mentioned in the video above that synthetic absorbable meshes are highly inflammatory: but then again so are the non absorbable ones, with the caveat that the absorbable ones go away, and so in case of problems one would have an easier life I guess?

As for the substances in the blood stream, I think I misunderstood the point, the inflammation side is related to the mesh being a foreign body, not to the material itself necessarily…

Basically I still do not understand why absorbable meshes are not offered more than the non absorbable ones, other than that they may be more expensive….and I never saw conclusive study that showed problems with them (I even asked here few times)

[Good intentions]

“It was mentioned by Dr. Towfigh during a weekly contribution from a panel guest, that

1. bio absorbable meshes do not work, and
2. that absorbable synthetic ones release possibly dangerous substances into the blood when they decompose (apologies if I misunderstood this point somehow); here the assumption seems to be that they work in preventing a recurrence?”

Was this the interview with Dr. Heniford? It would help to show where you saw this so that we could see it ourselves.

Ovitex would be considered an absorbable biologic mesh. Dr. Towfigh was a proponent of Ovitex just a couple of years ago. so it’s not clear what was being discussed, if she said that. “Bio mesh” is an ambiguous word, even the synthetic meshes are sometimes called bio meshes. Because they are used in the body.

The other absorbable materials can degrade in to toxic components or normal molecules already found in the body. It depends on what the material is.

[Mike M]

@Chuck

If it was me – I would go and get the most advanced detailed imaging (MRI or otherwise) of the region that is causing the pain. Based on your previous posts it sounds like it could be a urology related issue now. I would first have that imaging looked at by the best team of specialists I could find to see what they think. Then I would probably have what I deemed the 2nd best team I could find take a look at it for another guess.

I would go to a urology group at the Cleveland Clinic main campus in Cleveland, OH or maybe the Mayo Clinic in Rochester, Minn location. I am a little biased towards Cleveland because of the location and first hand experience with friends and family having “unknown” and “never before documented” problems resolved. One doctor at the Cleveland Clinic who solved and resolved my father’s liver issue completely is actually writing a book about my father’s case. This was after I took my Dad to countless specialists at other “top” hospitals . It was a gallbladder removal that lead to liver complications and nothing would resolve it. Long story not to digress.

You need to determine conclusively the benefit (if there is any) of mesh removal and that means seeing a specialist that can determine if it is causing your issue.

If it is somehow mesh related at all then I would consider talking to an expert in removing the mesh.

I know you had a bad experience with Dr. Grischkan but he is one of the foremost doctors regarding mesh removals and provided critical testimony in multiple lawsuits against the manufacturer of the Bard mesh.

You also have Dr. Yunis and of course my choice Dr. Kang who also wrote the book on mesh related issues overseas.

#1. Identify the problem or problems. Imagining, consulting the best related to that area of the body.

#2. Get a second or even a third opinion.

#3. Identify the best surgeon or surgeons that can resolve the problem.

I really would stress that if it was *me* I would unequivocally want *conclusive* scientific evidence backed by a medical expert in that field that it was the mesh and not another complication related to something else.

You do not want to make a bad problem worse when the underlying issue could be something else?

Get advanced imaging done and see a specialist asap! They may have to do another procedure (maybe a scope?) to go in and get a closer look too before they can determine the root cause(s) of your issue.

[Mike M]

Sorry I did not mean to detract from absorbable *mesh*.

Here is some additional information / studies I found regarding that topic.

“https://pubmed.ncbi.nlm.nih.gov/28492358/”

tldr; “Results: The meta-analyses showed no difference in recurrence rates (median 18 months follow-up) and chronic pain rates (1 year follow-up) between absorbable- and permanent meshes. Crude chronic pain rates for the RCTs were 2.1% for the absorbable meshes and 7.6% for the permanent meshes. For the absorbable meshes, medial hernias were more susceptible for recurrence compared with lateral hernias ( P < .0005). None of the studies reported allergic reactions or other serious adverse events related to the absorbable mesh.

Conclusions: Patients with an absorbable mesh seem to have less chronic pain following inguinal hernia surgery compared with permanent meshes, without increased risk of recurrence.”

It appears the results are similar in this study to the open tissue absorb or not to absorb debate.

I would consult the leading mesh repair experts and take that into consideration.

If they believe the % increase is small then I would lean towards absorb.

I imagine the “recovery” time after surgery would be impacted since you want to give your body time to heal up completely before the mesh “dissipates”.

[Mike M]

Here is some info I received from Dr. Kang when I inquired early on in this process. Note: This is regarding open tissue repair non-mesh.

“Polybutester and Prolene are non-absorbable materials and PDS (Polydioxanone) is an absorbable material.

I use Prolene in most patients but can use PDS if requested.

However, the possibility of recurrence can be slightly increased by 0.5-1%.

In Pure tissue repair, the length of the true material actually remaining in the body is less than 5cm.

The thickness is also very thin.

Therefore, I don’t think there is a possibility of causing problems even if this level of non-absorbable texture remains. ”

There have been some discussion of a 6 month threshold as the turning point to where your body has formed enough tissue to make up the strength of the repair?

Polybustester is polyester type material that Dr. Grischkan claims is the most inert however other commenters have indicated it could have a higher chance for inflammation since it is polyester. Dr. Grischkan uses the flexible polybutester suture to accommodate athletic movements. Athletes, powerlifters, etc. are a big piece of his clientele. Also Shouldice has a higher tension than other types of open tissue repair (desadara, Dr. Kang) so I can see where this makes sense.

Prolene seems to be the type informed patients on here prefer along with quite a few of the leading open-tissue repair doctors. I would like to see some reference material indicating as to “why”.

PDS – “Polydioxanone (PDS II) is a synthetic, absorbable, monofilament suture made from a polymer of paradioxanone (Figure 2). It has greater initial tensile strength than polyglycolic acid and polyglactin 910 but has the poorest knot security of all the synthetic absorbable sutures.24 The suture retains 74% of its tensile strength after 2 weeks, 50% after 4 weeks, and 25% after 6 weeks. There is minimal absorption by 90 days and absorption is not complete until 6–7 months after implantation.9 This retention of strength after implantation is an advantage over other synthetic absorbable sutures and is useful wherever extended approximation of tissues (up to 6 weeks), under tension, is required.35 PDS II is stiff and more difficult to handle than Dexon or Vicryl, but slides easily through tissue. PDS II was developed to improve the handling characteristics of the original form. It has low reactivity and maintains integrity in infected tissues and in urine and is often used in bladder surgery.36 Its long retention time may act as a nidus for calculus formation in patients with a history of urinary calculi. However, it is suitable for use in a wide variety of tissues.1”

Here are some studies between the absorb and non-absorb –

https://pubmed.ncbi.nlm.nih.gov/10365834/

tldr; “Results: Numbers of early complications were similar in the two groups; there were 2 wound infections in each. A total of 193 patients with 201 repairs had a documented follow-up (86%). There were 6 recurrences in the PDS group and 5 in the Prolene group, giving a total recurrence rate of 5%. This difference was not significant (Fisher’s exact test, p = 1.0).

Conclusion: Recurrence rates in both groups were higher than expected, but there was no difference between the two groups.”

Keep in mind this is from 1999 and the recurrence rates reported by the leading Shouldice facilities and doctors are 1% or lower per their data and “modified” techniques.

Here is an updated one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400914/

“Results
Thirty-one trials were included (11,533 participants). No suture material reached the predetermined 90% probability threshold for determination of ‘best treatment’ for any outcome. Pairwise comparisons largely showed no differences between suture types for all outcomes measured. However, nylon demonstrated a reduction in the occurrence of incisional hernias with respect to two commonly used absorbable sutures: polyglycolic acid (odds ratio, OR 1.91; 95% confidence interval, CI, 1.01–3.63) and polyglyconate (OR 2.18; 95% CI 1.17–4.07).

Conclusions
No suture type can be considered the ‘best treatment’ for the prevention of surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence.”

I am going take three things into account before I make my decision next week on PDS / Prolene.

#1. Surgeon recommendation based on my hernia, lifestyle, and anatomy.

#2. Recurrence chance based on #1. Example: Dr. Kang likes Prolene but will use PDS and tell you that there is a 0.5% – 1% chance increase of recurrence. I am assuming that is cumulative so that means you are closer to 1% – 2% overall when you factor in the procedure itself.

#3. Chance of complications later in life if non-absorb is used. This is sort of “pick your poison” between #2. and #3. Also I have zero concerns on “dangerous substances” being absorbed into the blood with PDS.

At the end of the day I think it is kind of splitting hairs as the listed references indicate.

Psychologically I think the edge goes to non-absorb of either type for me.