Page 337 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

in a contaminated environment: grade 3 and 4 hernia repairs of VHWG(52). Although no high-quality evidence exists to support the use of biological meshes in these situations, this decision can be defended. However, the use of biological meshes in clean or clean/contaminated environments – grade 1 and 2 of VHWG(52) – cannot be justi ed by the evidence. Recent studies on grade 2 hernia repairs showed a lower recurrence rate after implantation of synthetic meshes compared to biological meshes, with similar adverse events(82). Furthermore, several synthetic meshes have been shown to be infection- resistant in these circumstances(58). An important factor when choosing a mesh is the associated cost; biological meshes are substantially more expensive than synthetic meshes(53, 78, 80). The mean price of a biological mesh in 2016 was $19.15 per cm2 ; and the mean price of a non-biological mesh was $5.41 per cm2 – an average of 3,5-fold less cost(53). The 2016 costs of the biological meshes used in the experiments in this thesis were: Strattice® $30.29 per cm2; Permacol® $18.24 per cm2; Surgisis® $13.42 per cm2; and CollaMendFM® $13.25 per cm2(53). However, in VHWG grades 3 and 4(52), costs can be reduced when delayed primary closure with implantation of a biological mesh is possible during one hospital admission. In this way, the number of admissions and in- hospital days can be reduced, compared to staged repair(83). An additional bene t is earlier restoration of abdominal wall function, which may lead to accelerated return to work.
Future perspectives
Prevention of IH is a very important issue, and one that deserves a great deal more attention in the surgical community. As Hans Jeekel wisely stated during the 2016 EHS conference: “Don’t judge a surgeon before you’ve seen him or her close the abdomen”. Proper opening and closing of the abdominal wall should become a mandatory part of surgical training. Anatomical education and detailed instructions on the best evidence-based closing techniques will improve the general skills of surgical residents and reduce incidence rates of IH. Improvements in anatomical knowledge of the abdominal wall will also bene t laparoscopically oriented surgeons. Since laparoscopic abdominal surgery requires placement of trocars, there is a risk of vascular or nerve injury, and the development of an incisional hernia, or so-called trocar site hernia – especially
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General discussion and future perspectives
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