Advancements in Fully Absorbable Mesh for Hernia Repair Key Insights from WALS 2025

Naveen Pandey

https://www.laparoscopyhospital.com/SERV01.HTM   At the 8th World Congress of Laparoscopic Surgeons (WALS) 2025, Dr. Neeraj Goel presented a groundbreaking session on the use of fully absorbable mesh for hernia repair. His talk explored the evolution, benefits, and clinical outcomes associated with this innovative approach to hernia surgery.   Why Fully Absorbable Mesh?   Traditional synthetic meshes, though effective, have been associated with foreign body reactions, chronic pain, and mesh-related complications. Fully absorbable meshes, composed of biodegradable polymers, offer a temporary scaffold for tissue regeneration, ultimately being replaced by native collagen.   Key Advantages of Fully Absorbable Mesh   ✅ Reduced Risk of Chronic Inflammation – Since the mesh dissolves over time, the risk of chronic foreign body reactions is minimized.  ✅ Lower Infection Rates – Unlike permanent meshes, absorbable materials reduce long-term infection risks.  ✅ Enhanced Tissue Integration – Promotes natural collagen deposition and healing.  ✅ Ideal for Contaminated Fields – Suitable for cases where traditional synthetic meshes may pose infection risks.   Clinical Evidence & Surgical Applications   Dr. Goel presented clinical studies demonstrating favorable results in selected cases, particularly in:  🔹 Inguinal and Incisional Hernia Repair  🔹 Contaminated Surgical Fields  🔹 Young and Active Patients – Avoiding permanent foreign bodies in younger patients with long life expectancy.   He also discussed the limitations of absorbable mesh, including:  🔸 Cost Considerations – Higher initial costs compared to traditional meshes.  🔸 Risk of Recurrence – Requires meticulous patient selection to ensure long-term success.   Future of Hernia Repair with Absorbable Mesh   With advancements in biomaterials and tissue engineering, fully absorbable mesh is paving the way for a more physiological and complication-free hernia repair approach. However, ongoing studies are needed to establish long-term durability and cost-effectiveness.   Dr. Neeraj Goel’s insights at WALS 2025 emphasized that while fully absorbable meshes are not yet a universal replacement for synthetic meshes, they represent a valuable option in select cases where minimizing foreign body presence is a priority.

Transcript

00:00everyone welcome back now I would like to invite dr. Neeraj Goyal and he's going to

00:08speak on fully reabsorbable mass for hernia repair combining the best of the for the world

00:14good morning everybody thank you so much for giving me this opportunity to share my experience on this

00:31one of the most recent advances in the world of hernia surgery the fully resorbable mesh not the

00:37biologic I am talking about the fully resorbable mesh I bring compliments from my ng360 Academy

00:44and max super specialty hospital but present where I regularly work so this very old statement that

00:52this search for the ideal scaffold ideal mesh ideal tissue for bridging for reinforcing the hernia

00:59defect has always been there even till now we have seen the shift in available options as mesh

01:08from polyethylene to polypropylene they were game changers even till date they are being in use

01:14they are in use everywhere so before we talk about this particular mesh that I am going to talk how

01:21does the mesh work why a mesh was required so dr. B. B. Agarwal from our own country he published this

01:27very interesting concept that it is mesh aponeurosis scar tissue all these meshes they are porous they

01:37induce foreign body reaction some aponeurotic tissue collagen is laid down and over a period of few

01:42weeks to months this plate this kind of mass tissue mesh complex prevents the further herniation so we

01:52need a mesh to introduce the foreign body reaction some macrophage reaction the m1 or m2 type of reaction

01:59we will talk so in principle if we can visualize once this kind of tissue is laid down collagen is laid

02:08down a foreign body is not required in the form of that mesh before we go further we should also remember

02:15that recurrence of hernia or complications of hernia are multifactorial it is not only mesh dependent we

02:23very well know there are patient related factors there are surgeon or surgery related factors so when a

02:29recurrence or a complication in a postoperative period in any hernia happens dr. Tarun Mitchell was showing

02:35the mesh is always important whether it is high test or any hernia as of date we have more than 300

02:43options as a mesh broadly we divide them we can classify them into permanent synthetic mesh which

02:52are completely non-absorbable then the biologics came with a lot of promise but we know that these

02:59biologic meshes have also lost their relevance because of the limitations the flaws coming with

03:07them and then always there has been a search for absorbable material in the absorbable material there

03:15has been polygalactin or kind of vicle mesh but their absorption time is so short that they could not be

03:22used as a sole molecule for manufacturing these meshes now we have this molecule called as poly 4

03:30hydroxybutyrate P4HB the absorption time of this molecule is between 12 to 18 months from the time of its

03:39deployment when we encounter a patient of a hernia what is the job of a surgeon we surgeons are required

03:49to diagnose and decide which surgery we want will be best for we need to individualize and of course

03:56the discussion of mesh comes so for me today after deploying more than hundred such fully

04:02resorbable mesh in last almost five years almost 56 57 months I divide them into two that is

04:09conventional non-absorbable mesh we eat a single layer mesh or a composite mesh depending on in which

04:15plane we have to put this and a fully resorbable poly 4 hydroxybutyrate mesh so today I'm going to

04:22talk about what is this molecule poly 4 hydroxybutyrate what we surgeons across world have started seeing

04:29this in India this is something new but in UK US in so many countries surgeons individually have deployed

04:36more than 400 500 mesh in their case series because cost is a little little less limiting factor there they

04:43have got it approved from their government hospital agencies India is still not so well organized on

04:50this side so cost comes into the deployment why this is the most potent mesh today in our opinion and my

04:59journey of hundred plus meshes how did this start and today where we I am and what are the indications

05:05as on date so this molecule is available since 2009 in the form of a suture monomax is the branding by

05:14B Braun and since 2010 it is available as a mesh by the name of phasics or a composite mesh called as

05:22phasics st from BD that is bar more than 70 very well large volume studies have been published on this mesh

05:33so there are some vital very peculiar scientific properties of this molecule when I heard when I read

05:43them when I have experienced in last so many months I have become a fan of this molecule as a surgeon why so

05:51poly for hydroxybutyrate the monomer of this is hydroxybutyrate this is produced by aciditya

05:58coli the ecoli bacteria fermentation so it's a naturally derived molecule it does not contain any

06:06residue from the metal catalyst when the mesh is manufactured unlike these synthetic meshes where

06:12these metal catalyst produce acidic reaction in the area where that they are deployed now what happens this

06:19hydroxybutyrate is a normal component of our human cells of brain kidney muscle and heart can you believe

06:28a molecule which is inherent which is natural to our human body is the molecule which is produced by

06:35ecoli and you is used for manufacturing this mesh so this molecule is not foreign to human body the

06:42whole game changes here because it is not foreign so the synthetic scaffold all those meshes they use to

06:50produce m1 type of macrophage response which will result in that fiber optic thick plate wherever we do operate

06:57we find that scar the imbalance in the abdominal wall wherever the foreign body this mesh is placed

07:06conventionally when we place a poly for hydroxybutyrate mesh there is m2 type of macrophage response which

07:14leads to change in collagen type from type 3 to type 1 and over a period of 6 to 8 months around 12 months

07:23the patient starts feeling as if there is nothing in the abdominal wall this is what is the testimony of

07:28my patients when they come in the follow-up how does this get disintegrated or degraded it gets degraded

07:36and vivo through hydrolysis into water and carbon dioxide so it is fully dissolved in 365 to 545 days that

07:45is a very good absorption time for covering the requirement of a mesh to reinforce the abdominal

07:50wall resulting byproducts are easily metabolized from the site of their hydrolysis by krebs cycle and beta

07:56oxidation so unlike these absorbable scaffolds of dexon or vicryl whose byproducts they decrease the ph at

08:04the wound site so these are the microscopic or tissue level advantages of this molecule

08:11the most one of the most important requisite of a mesh is that it should support the abdominal wall

08:19on the parameter of strength now look at this graph this is very interesting that in the prosaic model

08:26this was done when the mesh has been placed this is the mesh strength the lower gray area and this pinkish

08:33area is the tissue which is growing the fibrotic tissue or the collagen

08:39what happens on the principles of physics like we put an implant in the bone a fractured bone

08:46till the bone has united the load is born by the implant once the bone heals then the bone is able

08:55to take the load and the patients are allowed to bear weight and walk and do all the activities similarly

09:01when a mesh is placed unlike a fully non-absorbable mesh where this foreign body remains the fibrotic tissue

09:09which grows especially at the edges of the mesh there is a complete change transition just sudden transition

09:17from this fibrotic plate to normal abdominal wall where usually the recurrences happen and there are complications

09:23of meshes after the surgery unlike those full non-absorbable meshes here what happens because this mesh starts

09:31getting disintegrated after 7.5 months gradually this collagen which is being for which is being laid down there

09:40it starts taking over the function of the mesh therefore it's a gradual transition from disintegration

09:47degradation of the mesh and the tissue simultaneously being laid down so patients don't feel this foreign

09:54body fibrotic reaction later on and secondly there is not sudden change in the abdominal wall where the

10:02mesh is placed including its peripheries in the studies it has been found that it maintains it is able to

10:10provide almost three times the requirement of normal abdominal wall strength so the strength of this mesh

10:16is no challenge at all now since it is coming from e coli so it has inherent antibacterial properties

10:25preclinical studies were done a group of animals were deployed with this polyphorohydroxybutyrate mesh

10:33and some comparable non-absorbable synthetic scaffolds bacteria were inoculated after 10 days of

10:39surgery in the site of surgery where the mesh was placed and in the follow-up following weeks these

10:46patients who were having physics mesh of polyphorohydroxybutyrate mesh they did not have any

10:53complication whatsoever they did not need any they did not have any separation or in mesh infection

11:00inflammatory changes requiring mesh explantation which was the case in those comparable group

11:06so it has got even in the presence of mrsa the performance is that it completely maintains

11:15its strength when mrsa was there so this was initiated this mesh was initially used for contaminated

11:22cases contaminated settings where you could not push put the other mesh but over a period of years when

11:27you can put a mesh in a contaminated case or an emergency surgery where strangulation is there

11:33obstruction is there why not in clean cases as well now two variants of this mesh are available one is

11:40called as the single layer mesh polyphorohydroxy mesh or the phasics mesh and the other is the composite

11:47variant which is polyphorohydroxybutyrate sg mesh so to summarize again this is a natural polymer

11:55hydroxybutyrate the monomer form normally occurs in human brain muscle liver and kidney

12:00produced by ecoli maintains 100 percent of its strength in at 56 days even in presence of mrsa

12:09degradation only into carbon dioxide and water 52 percent distance reduction by seven and a half

12:16months so gradually it is reducing but still it is able to maintain the required strength completely

12:21absorbed in 12 to 18 months time not to mention but still very important whenever we are using such a

12:28mesh it needs to be fixed with all absorbable things whether it is suture or the tacker

12:36how did my journey start with this in may 2020 i deployed this mesh for the first time in open only

12:44ventral mesh hernioplasty why because the male 49 years presented with mesh infection abscess after one

12:51month of a surgery elsewhere he was operated for bilateral inguinal hernia tep with a proline mesh he

12:59had suppuration presented to us go morbidities were there when we operated sorry for the poor quality

13:07of the pictures this is what we found the mesh was there frank bus was there we needed to explant the mesh

13:15and put do the peritoneal lavage put the drain to our surprise during this procedure we found a defect in the

13:23peritoneum in the left right lower quadrant a ventral hernia defect right lower quadrant which was not

13:28mentioned in the documents anywhere in pre-operative or during the discharge of the patient so this might

13:36be that the surgery had some peritoneal rent or whatever whatever may be the cause no imaging also showed pre-operatively

13:42that this hernia existed so in the following follow-up period we found that anti-tubercular

13:48treatment was required because tuberculosis was positive in this case in addition to the other

13:52comorbidities so we continue to dress dress the patient medically managed for two to three months

13:58finally when he had all the wounds healed completely we had to operate upon this patient who had

14:06these kind of clean openings of the discharging fluid serious fluid no active infection here

14:14because of this ventral hernia we had to propose a surgery and with a lot of courage i said we can

14:20use this mesh in your case he agreed we did this open only mesh hernioplasty he healed completely without

14:28any complication till date so almost 56 months have passed in this may it will be 60 months follow

14:35for this max longest follow-up case and then i continued to gain the confidence in subsequent months

14:42and i operated upon all the types of hernia i deployed this mesh whosoever agreed i published the first case

14:52series of this mesh last year where the number till that time was 25 january 20 2023 it was published in

15:01march 23 till that time one of the cases had only recurrence else there was no significant complication

15:11related to mesh that recurrence was also a pseudo recurrence to say because this lady was a case of carcinoma

15:18endometrium already having undergone total hysterectomy radical and he she had incisional hernia where

15:27we did the procedure open and deployed this mesh she had a recurrence of malignancy very obese patient

15:33so she had a pendulous abdomen where a recurrence could be counted otherwise till now even in 100 plus

15:42cases i have not seen a mesh infection or significant complication which has encouraged me to continue

15:49to use this there were cases where recurrent hernia was operated and the entrotomy happened where we

15:59needed to do the closer with trimming of the previous mesh put reposited the repaired intestine inside put

16:05this mesh i have done this with stoma closures prophylactic mesh plasty all these cases have done

16:13without any significant untoward effect so far so my indications for today for this fully

16:19resorbable mesh are ventral inguinal stoma closures and trotmes parastomal hernia recently we did

16:25with sugar beet baker one large parastomal obstructed hernia hiatus hernia across world these large studies

16:33are available in these studies various rates of recurrences are mentioned depending on the factors of

16:40hernia how large the defects are what is the technique that has been used but they have all shown

16:45promising results with this mesh so we may say that perhaps this is the best of both the world between

16:52synthetic and the biologic challenges for this mesh are lack of complete information with the surgeons so

16:58far higher cost it is costing a lack of rupee in india for a single layer mesh about 15 by 15 centimeter

17:05and 1.5 lakh rupees for a 15 centimeter composite mesh but cost is a relative thing we are paying in the name

17:12of robots and whatnot so it's up to the patients to decide and not the surgeons whether they want this or

17:18not to conclude my talk i'll say that there are so many options available this is one of the options

17:24definitely a very promising one my study is still going on the goal of zero recurrence is still to

17:30be achieved in hernias because this is a multifactorial issue and the last word on hernias has not yet

17:35been spoken thank you thank you so much for a very patient listening thank you thank you i request all

17:41the speakers to come on the stage can i request the chairpersons to please felicitate our speakers

17:46uh dr abhilash dr deepak subramanyam dr tarun mittal and dr neeraj goyal

17:57i would also request all the fellows of fmas that we will be having a group photo post this next

18:03session post the fifth session you can have your lunch post the photograph we request you to collect

18:10your convocation outfit your gowns and your caps from the registration counter and be prepared for the

18:16photograph post the fifth session

18:26thank you so much

18:30i would also like to request our international faculty to please fill up the presidential and the

18:36secretary form or the nomination form which has been given to you and submitted to us

18:41i request the organizing team and the audio visual team to stay back before the lunch we are going to

18:52have a group photograph on the stage thank you so much thank you chairpersons and thank you speakers

Category

Transcript

Recommended