What type of mesh should I use if I cannot close the abdominal fascia?

Mesh Selection for Abdominal Fascial Closure Failure

When primary fascial closure is not achievable, biologic meshes are the preferred option for definitive abdominal wall reconstruction in contaminated fields, with cross-linked biologic meshes being optimal for fascial-bridge positions where the linea alba cannot be closed. 1

Decision Algorithm for Mesh Selection

Assessment of Defect and Field Contamination

1. Determine if primary fascial closure is possible
2. Assess the size of the defect (< 3 cm or > 3 cm)
3. Evaluate the degree of contamination (CDC wound class)

Mesh Selection Based on Defect Size and Contamination

Small Defects (< 3 cm)

• First choice: Attempt primary repair with non-absorbable sutures 1
• If primary repair not feasible due to tension, proceed to biological mesh options

Large Defects (> 3 cm) in Contaminated/Dirty Fields

• First choice: Cross-linked biologic mesh in fascial-bridge position (when linea alba cannot be closed) 1
• Second choice: Non-cross-linked biologic mesh in sublay position (when linea alba can be reconstructed) 1
• Third choice: If biological mesh unavailable, consider polyglactin mesh or open wound management with delayed repair 1

Contraindications

• Synthetic non-absorbable meshes (polypropylene, PTFE, polyester) should NOT be used as a fascial bridge in contaminated fields 1
• Direct application of synthetic prosthesis over bowel loops should be avoided 1

Rationale and Evidence

Biological meshes are specifically designed to perform in contaminated fields while minimizing mesh-related complications. The 2018 WSES guidelines strongly support their use in these scenarios 1. Cross-linked biologic meshes demonstrate lower ventral hernia recurrence rates when used in a fascial-bridge position, while non-cross-linked meshes integrate more easily with reduced fibrotic reaction and lower infection rates when used in a sublay position with linea alba closure 1.

Synthetic meshes in contaminated fields are associated with significant complications including adhesions, erosions, and fistula formation 1. Guidelines explicitly recommend against using synthetic mesh (polypropylene, PTFE, polyester) as a fascial bridge in definitive closure after open abdomen management 1.

Special Considerations

Temporary Closure Options

• For unstable patients requiring damage control surgery, consider temporary abdominal closure with negative pressure wound therapy (NPWT) 1
• NPWT can be used in combination with biologic mesh to facilitate granulation and skin closure 1

Alternative Approaches

• Component separation technique may be considered for definitive closure of large midline defects (Grade 1B recommendation) 1
• If definitive fascial closure cannot be achieved, consider skin-only closure with delayed abdominal reconstruction using synthetic mesh after the contamination has resolved 1

Pitfalls to Avoid

• Do not use synthetic mesh directly over bowel loops as this increases risk of fistula formation 1
• Avoid excessive tension during closure as this can lead to fascial necrosis and wound sepsis 2
• Multiple reoperations (>4) significantly reduce the likelihood of achieving primary fascial closure (93% success with ≤4 operations vs. 32% with ≥5 operations) 3

Recent evidence suggests that immediate closure with non-crosslinked biologic mesh during emergency laparotomy may prevent open abdomen complications and reduce ICU stays compared to temporary abdominal closure techniques 4, though this approach requires further validation.