What type of mesh is recommended for IntraPeritoneal Onlay Mesh (IPOM) hernia repairs?

Mesh Selection for IPOM Hernia Repairs

For IntraPeritoneal Onlay Mesh (IPOM) hernia repairs, composite meshes with an anti-adhesive barrier on the visceral side should be used to minimize intraperitoneal adhesions and associated complications.

Types of Mesh for IPOM Repair

Clean Surgical Fields (CDC Wound Class I)

• Synthetic composite mesh is the preferred option for IPOM repairs in clean surgical fields 1
• These meshes feature:
  • A macroporous component facing the abdominal wall to promote tissue integration
  • An anti-adhesive barrier on the visceral side to prevent adhesion formation
  • Examples include PTFE (Gore-Tex™) which is recommended for its strength and impermeability 1
  • Lightweight, large-porous mesh designs show better outcomes with fewer long-term complications and improved quality of life 2

Contaminated Surgical Fields (CDC Wound Class III/IV)

• Biological mesh is recommended for contaminated or dirty surgical fields 1
• Two main types:
  • Cross-linked biological mesh: More resistant to mechanical stress, better for larger defects
  • Non-cross-linked biological mesh: Can be used in contaminated settings without requiring mesh explantation 1
• If biological mesh is unavailable, alternatives include:
  • Polyglactin mesh (absorbable)
  • Open wound management with delayed repair 1

Evidence-Based Considerations

Mesh Characteristics

• Composite meshes with anti-adhesive coatings significantly reduce intraperitoneal adhesions:
  • Recent research shows zwitterionic-functionalized elastomer coatings can reduce adhesion extent by 94% and tenacity by 90% compared to uncoated polypropylene mesh 3
  • PTFE (Gore-Tex™) is particularly recommended for diaphragmatic reconstruction due to reduced risk of bowel fistulation 1

Surgical Outcomes

• Long-term follow-up (up to 6 years) shows extremely low rates (0.62%) of mesh-related complications requiring reoperation with modern IPOM techniques 4
• Compared to laparoscopic IPOM, open IPOM technique has higher postoperative complication rates and recurrence rates 5
• For optimal outcomes with open IPOM:
  • Use wide mesh overlap
  • Avoid excessive dissection in the abdominal wall
  • Close the defect when possible 5

Mesh Placement Considerations

• In clean-contaminated hernias (CDC wound class 2), synthetic and biological meshes show comparable surgical site complication rates (9% recurrence for both) 1
• In contaminated hernias (CDC wound class 3 and 4):
  • Biological mesh shows 30% hernia recurrence rate
  • Recurrence rates are lower when primary fascial closure is achieved versus bridging repairs 1
  • Non-cross-linked biological mesh can be used without subsequent need for mesh explantation 1

Pitfalls to Avoid

• Avoid using standard polypropylene mesh without anti-adhesive barriers in IPOM repairs due to high risk of adhesions and fistula formation
• Avoid absorbable prosthetic materials alone as they lead to inevitable hernia recurrence due to complete dissolution of the prosthetic support 1
• Avoid bridging repairs when possible as they are associated with higher recurrence rates compared to repairs with primary fascial closure 1
• Consider defect size when choosing between cross-linked and non-cross-linked biological mesh in contaminated settings 1

Algorithmic Approach to IPOM Mesh Selection

1. Assess wound classification:

   • Clean (CDC Class I): Use synthetic composite mesh with anti-adhesive barrier
   • Clean-contaminated (CDC Class II): Either synthetic composite or biological mesh
   • Contaminated/Dirty (CDC Class III/IV): Biological mesh preferred

2. Consider defect size:

   • Small defect (<3 cm): Primary repair if possible
   • Medium/large defect: Mesh repair with appropriate overlap
   • For large defects in contaminated fields: Cross-linked biological mesh

3. Evaluate risk of adhesions:

   • High-risk patients: Use mesh with enhanced anti-adhesive properties (e.g., zwitterionic coatings)
   • Standard risk: Regular composite mesh with anti-adhesive barrier

4. Consider repair technique:

   • Always aim for primary fascial closure with mesh reinforcement
   • Avoid bridging repairs when possible, especially with biological mesh