What type of mesh is recommended for hernia repair in the setting of bowel resection?

Mesh Selection for Hernia Repair in the Setting of Bowel Resection

For hernia repair in the setting of bowel resection, biological mesh is recommended when the defect size is larger than 3 cm; for smaller defects, primary repair should be performed. 1

Decision Algorithm Based on Contamination Level and Defect Size

Clean-Contaminated Fields (CDC Class II - Bowel resection without gross spillage):

• Synthetic mesh can be safely used in patients with intestinal strangulation and/or concurrent bowel resection without gross enteric spillage 1
• This approach is associated with a significantly lower risk of recurrence compared to primary repair, without increasing 30-day wound-related morbidity 1
• Recent evidence suggests synthetic mesh may have lower surgical site infection rates (OR = 0.46) and recurrence rates (OR = 0.2) compared to non-mesh repair 1

Contaminated/Dirty Fields (CDC Class III/IV - Bowel necrosis or gross spillage):

• For defects <3 cm: Primary repair without mesh is recommended 1
• For defects ≥3 cm: Biological mesh is the preferred option 1
• The choice between cross-linked and non-cross-linked biological mesh should depend on:
  • Defect size (larger defects may benefit from cross-linked mesh for greater durability) 1
  • Degree of contamination (higher contamination may favor non-cross-linked for better incorporation) 1

Alternative Options When Biological Mesh Is Unavailable:

• Polyglactin (absorbable synthetic) mesh repair 1
• Open wound management with delayed repair 1

Specific Biological Mesh Considerations

• Reinforced biological mesh (e.g., ovine rumen with permanent suture reinforcement) may offer advantages with lower complication rates (16.7%) compared to non-cross-linked porcine ADM (47.1%), cross-linked porcine ADM (52.9%), and bovine ADM (43.2%) 2
• Reinforced biological mesh may be particularly beneficial in cases of previous failed hernia repair with weakened fascia 3
• Non-reinforced biological meshes are more commonly used in cases with previous mesh infection, during bowel resection, or at the time of stoma takedown 3

Important Caveats and Pitfalls

• High infection rates (up to 21%) have been reported after emergency hernia repairs with polypropylene mesh in contaminated fields 1
• Absorbable prosthetic materials will eventually dissolve completely, leading to inevitable hernia recurrence 1
• Some recent evidence challenges the traditional preference for biological mesh in contaminated settings, with one study showing synthetic mesh had lower surgical site events (22.8% vs 42.0%) and recurrence rates (8.9% vs 26.3%) compared to biological mesh 4
• Bowel resection is a significant risk factor for overall postoperative complications (P < 0.0001) and major complications (P = 0.003), but not necessarily for surgical site infection (P = 0.42) 1
• The presence of non-viable intestine should not be automatically considered a contraindication for prosthetic repair, as some studies show no significant difference in infection rates between viable and non-viable bowel cases 1

Follow-up Considerations

• Patients with mesh placement in contaminated fields require close monitoring for:
  • Surgical site infections 1
  • Hernia recurrence (more common with biological mesh) 4
  • Mesh-related complications 1
• A history of previous infected mesh is an independent risk factor for hernia recurrence (P = 0.019) 3
• BMI >35 is an independent risk factor for 90-day complications (P = 0.028) across both biological and synthetic mesh groups 3