Assessing the GRIP of Ventral Hernia Repair: How to Securely Fasten DIS Classified Meshes

Abstract

Recurrences are frequently observed after ventral hernia repair. Based on clinical data, the mesh–defect area ratio (MDAR) can lead to lower recurrence rates. Using dynamic intermittent strain (DIS) in a pig tissue model, MDAR can be modified to give a measure called grip to better assess the mechanical stability of ventral hernia repair. The focus of this experimental study is to assess the different aspects of mesh overlap (OL) and fixation only in bridging repair of ventral hernias. DIS mimics coughing actions in an ex vivo model with the repetition of submaximal impacts delivered via a hydraulically driven plastic containment. Tissue derived from pig bellies simulates a ventral hernia with varying defect sizes. MDAR is calculated from the hernia orifice and the mesh OL. Commercially available meshes were strengthened with glue, tacks, and sutures to bridge the defects. The reconstructions are strained with up to 425 dynamic impacts. The grip of each repair is assessed using MDAR modified by the strength of the fixation. The DIS classification is based on bridging of a 5 cm ventral hernia orifice with an OL of 5 cm in a sublay position. The classification discriminates meshes properties upon DIS strain. MDAR is calculated to be 9 under these conditions. Decreasing the OL or increasing the hernia orifice reduces MDAR to numbers below 9. MDAR is modified to reach GRIP. Closure of the peritoneum adds about 4 to the grip given by MDAR. The multiplying factor of a transmural suture or one tack of Securestrap® or Protack® is 0.5 times the number of tacks applied. The multiplier given by a bonding spot of Glubran® is similar to that of an Absorbatack® being 0.33. Plotting the likelihood of a bridging repair to survive more than 400 DIS impacts versus the grip estimated from the factors given above, the grip to be passed for a durable repair is 10 for Parietex Progrip®, and Dynamesh Cicat® and 25 for Dynamesh IPOM®. Clinical data previously published can be reculculated to assess MDAR and permit an estimation of the grip of the reconstruction. In these recalculations, a correlation between MDAR and long-term recurrence rates is found. A dimensionless number called grip can be calculated. The grip can be modified by fixation in a reproducible way. A higher grip can improve the durability of ventral hernia repair. We believe that a higher grip leads to lower recurrence rates in the clinical setting.

Increasing hernia size requires higher GRIP values for a biomechanically stable ventral hernia repair

“…The DIS test has been described previously [ [5] , [6] , [7] , [8] ]. In brief, the test bench consists of a water-filled aluminium cylinder coated with a thin polyethylene foil and covered with tissues derived from pig bellies.…”

“…1 ). Since the mesh was previously classified as primarily stable (DIS class A) no fixation was necessary when used according to the instructions given by the manufacturer in proper sizes [ 8 ]. With reduced overlap and low mesh: defect area ratios, fixation was needed and applied with 16 points placed as a single crown.…”

“…With reduced overlap and low mesh: defect area ratios, fixation was needed and applied with 16 points placed as a single crown. Novafil ® 2-0 sutures (Medtronic, Meerbusch, Germany), Securestraps ® (Ethicon, Norderstedt, Germany) and Absorbatacks ® (Medtronic, Meerbusch, Germany) were used for comparison to include strong and weak fixation methods [ 8 ].…”

“…In this study, DIS was applied mimicking coughs lasting for up to 2 s with peak pressures between 180 and 220 mmHg and a plateau phase of 0.1 s. Ventral hernia repair was simulated with hernia meshes in the sublay position secured by tacks, glue or sutures as needed to achieve certain grip values. Grip of the reconstructions was calculated taking into account the mesh: defect area ratio (MDAR) and the fixation strength as described earlier [ 8 ]. Data were assessed using non-parametric statistics as described earlier [ [6] , [7] , [8] ].…”

“…A dimensionless measure called “grip” can be derived which defines the durability of the reconstruction [ 7 ]. The grip of a repair takes into account the mesh: defect area ratio, the position of the mesh within the abdominal wall and the influence of a fixation technique [ 8 ]. In this manuscript, changes of the grip related to increasing hernia sizes are investigated.…”