HerniaEpisode6Mesh

Hello and welcome to another episode from Behind the Knife with the hernia team at Cleveland Clinic. I'm Sarah Maskell here with Ryan Ellis, Michael Rosen, Ben Miller, and today we're going to do a deep dive into the clinical challenge of mesh materials for hernia repair. Even though general surgeons are using mesh and hernia repairs on a daily basis and there's a multitude of options, there's very little education during training on this topic and if you want to learn more about a specific material it can be hard to find through manufacturer websites.

Now, Dr. Miller, we're going to have a reference as part of the podcast is your chapter in surgical clinics on mesh selection and mesh types. Now I helped you put together, you know, a lot of the data for this and information. And what we realized I think was every company out there, there's a multitude of options over the last few years.

Everybody has some sort of proprietary name or device or function of each type of mesh. Do you have any recommendations for if a surgeon or a resident is trying to learn something that they should be looking for specifically for each type of mesh? So if I

can back up just a little bit, before I did a fellowship in abdominal wall reconstruction and MIS surgery, I knew almost nothing about mesh and I think this is true for most general surgeons.

We go through residency and learn to do operations from certain staff, certain faculty, and we feel comfortable doing the operation with the mesh that they use, and when you leave residency, all you really know is the mesh that this surgeon who trained you used, and that's what you just tend to keep using.

I think a big problem, there's a huge gap in resident training and education, and for even surgeons out of training, is that there's no education in mesh, even though this is a. Often a permanent object, we're putting in somebody that we think may last for the rest of their life, we know honestly relatively little about it for the most part.

So I think that there could be a lot done there in residency and surgical societies to educate residents and surgeons about the

basics of mesh. I'll also say that this information, to answer your question, Kind of is really difficult to find. I think one thing we learned in writing this paper is that often when we go to reps to industry reps to ask them about certain characteristics of their mesh, they didn't even know.

And so they would have to go back to their industry sponsor and ask them about these details of the mesh. And sometimes we were able to get. Straight answers, and sometimes they were very vague and sometimes we still didn't get the answers we were looking for. So just to be totally upfront, these things can still be difficult to find.

And one thing that would be nice if is, if like a cereal box or any kind of food we eat has the nutritional information on it. If the mesh manufacturers put the mesh characteristics on the box, it would be easy to see how big the pores are and what the density of the mesh is and what, even what it's made of sometimes is difficult to find.

So. So, I think that if you, I think that for most people, there are a few mesh, meshes available in their hospital.

And just to be familiar with the, if you're putting in permanent mesh, it was some basic characteristics that I think we'll cover. And if you can't find that information, some of it's available in this article that we wrote, the tables you made, I think can answer some of those questions, but perhaps not all of them.

And so I, if there are other questions and things you don't know, I would have to go to the industry. And ask your reps at your hospitals for help getting your answers. So, a couple things to add to that. So, I'll take kind of an opposite position, just for the fun of debate. And so, I think that we are so far from labeling, because unlike nutritional labels where we know what is good for you and what is not good for you, that's one of the fundamental challenges with labeling.

All mesh is they have many, many properties, but sorting out marketing claims from preclinical basic science or small animals up to large animals. And then one of the things that's grossly lacking is comparative data in human trials. And so I

think as a society, as a group of surgeons, that's one of the things that we really need to focus on.

Is understanding what the differences of all of these properties are with head to head trials because otherwise we're very susceptible. And I always like to say when opinions are at their highest and passionate and. people just believe that they know the truth is almost always when data is at its lowest.

And so when there's not a lot of data, we got a lot of opinions. And in the world of mesh, there is a ton of opinions and there's very little data, particularly comparative data of different properties. And the majority of the data between different properties probably shows not much difference with obviously some exceptions.

So, so I think as a group of clinicians focusing on trials to look at the differences and then for our industry partners to understand what

the advantages are, design meshes that perhaps will show some mechanical, poor size material, all the different characteristics that could fulfill the needs that we identify in clinical trials, and then hone in on that.

But in the absence of that, it is kind of the wild west and it's obviously, I mean I often get Mess reps that bring me the new mesh and what is sent to me is a cartoon of why this mesh is better or a video of some hypothetical situation that the mess is going to work in. And to me, I just, you know, we've been all burned so many times that we need to see this stuff.

And finally, particularly because a lot of these things have become quite expensive. And they need to be worth it. In the absence of data, how do you approach that when somebody sends you a brand new mesh? Like, what are the properties that you go through and think about to decide if you would be willing to use that mesh?

I mean,

you know, I have my own biases in this and I think about kind of the technique that I'm performing. Am I putting the mesh in the peritoneal cavity? Am I putting the mesh in the retromuscular space? Am I gonna potentially do an onlay with high risk of exposure, with skin breakdown, is there contamination, is the goal of the operation durability, or is the goal just to get the patient off the table and treat their hernia disease kind of almost as a staged approach.

And so, and then finally, and I think to be fair to everybody, I think, you know, this is something that we do at the clinic probably more than many places, if there's no superiority data of one or the other, we base it on price. And if mesh is a commodity for certain applications, then we pick the least expensive that gets the job done.

And until we see, by tracking our data, that it's underperforming, you know, that's ultimately how we will perform. So,

Dr. Miller, with your experience, how do you like to organize mesh materials in your mind? We hear about different types, you know, permanent, synthetic, biologic biosynthetic. Is there a way that you can break it down easily?

So, I think that the first way to break it down is by permanent versus absorbable mesh. And, if you're going to talk about, let's talk about permanent mesh first. I think about what the mesh is sort of, multiple characteristics of the mesh, and I think the first thing that I consider is what is the mesh made of, and I think there are three kind of broad categories here.

It's polypropylene, polyester, or PTFE, and polypropylene and polyester have a similar carbon polymer profile, whereas PTFE is a little bit different. I think it's like a floral polymer, if I remember right. And so I have to think about what the mesh is made of, and then The next thing to consider, a couple of things to consider are the pores, the

mesh is a woven material, right?

For the most part. And what are the pore sizes in the mesh and then what is the density of the mesh? And I'll just say back to frozen's comment that I don't, I agree with you that we need to find, we need to find good data out there of just simply saying that even on the mesh a box, you can't even tell.

With these, finding the answers to these characteristics are not available, easily available, like what it's made out of, what the pore size is, what the density of the mesh is, if it's multifilament or monofilament. So I think just understanding what's in this box is also important, but I mean, I agree with you that comparing these meshes is critical, but.

It would just be nice to know some basic mesh characteristics as well. Well, I'll respond to that. So I totally agree. I totally agree. And I do agree that there, there needs to be basic characteristics. But I also think that we all need to be sensitive to the fact that companies for good reasons and not for bad reasons are leveraging these

differences as promoting advantages that perhaps might not be there.

And particularly when we talk about pore size, mesh density, mesh fracturing, all these type of things are starting to be picked up by companies and they're starting to develop solutions that need to be tested and shown to be better because just making the kind of the mesh part thicker while keeping the pores larger is Might be the magic bullet for this, but that needs to be studied Carefully and head to head trials, and so I just always caution everybody that you know the more we label The more we can market those advantages, and that's not bad but our job is to kind of sift through that stuff and be there.

Do you want to, can I, I'll add on to what Ben said about different characteristics. So the other, this would be a pet peeve of mine too, is you know, talking about absorbable and then synthetic. And I think this is one of the things

that people really get confused on in the biologic mesh realm. Is understanding what happens to biologic mesh after we put it in.

Is important and many people think it is a quote unquote absorbable mesh and whether it absorbs or whether it degrades or whether it regenerates into something different. I think it's really key to understand that we don't know that answer and the truth is that that answer probably varies on the application and the circumstances after that application.

And I particularly bring this up because. As we're now putting more and more mesh at the hiatus, next to the esophagus, or wrapped around stomas, we need to be careful and understand, like, our limited knowledge of what happens long term. And so, for me, you know, biologic mesh, always just remember, that you're taking biologic tissue from various different sources, and you are processing it to

decellularize it and reduce the immune response.

And that processing, if you think of it as a spectrum, can increase cross linking of that mesh. Up to, kind of, in the ideal state, a non cross linked mesh, which is unlikely, to an intentionally heavily cross linked mesh that is more like leather, right? Because that's what happens when, with pigskin. We make leather by terminally cross linking pigskin.

So remember, as you're moving across that spectrum, This might go to Ben's point about labeling. And just to be, like, not get too much in the weeds, but there's five different ways to measure cross linking. So, there's not one easy way to define cross linking. There's different methods to assess it. And so, realizing that not all biologic mesh dissolves.

Sometimes you go back a couple years later, and it's still there. You see the CT scan. It's still there. So, understanding in the biologic mesh realm that there is a spectrum, it's still there. You do not all, even one mesh doesn't perform the same way. Probably in the

setting of infection, most will dissolve, but not all.

Heavily cross linked that we used to have in the market that we don't anymore, do not dissolve. Now the less cross linked ones will dissolve. But a mesh that was placed that remains clean will often encapsulate. And you'll see it a year or two later. And again, that's not a bad thing. It's just understand that that's what happens around there.

And then there's obviously. Absorbable or biosynthetic mess, what many people call them, which again. are designed to absorb, but just caution everybody to remember that those studies are not based on putting the material in an animal model and following it for 18 months or one year and then going back in and proving that it dissolves.

These are all done in simulated lab experiments in different environments where they are predicting the absorption rate. But for all those of us who've gone back, sometimes these meshes are still there. And so again, just

realizing that there's so much that we don't know clinically to me is one of the most important messages and kind of, I always say like being uncomfortable but remaining comfortable and not knowing what we know or knowing what we don't know.

I think that's a, like a, an amazing point about biologic mesh and when I was writing this paper, one of the things I came across frequently was that biologic mesh was almost universally referred to as absorbable mesh. And so when, Ryan, when you went to these industry or industry partners and asked them about these biologic mesh characteristics, I was shocked that they classified all the biologic meshes we looked at in this paper, FlexHD, Stratus, and there was one other as permanent mesh.

The company referred to it as a permanent mesh. And so, Like Rosen said, we don't actually know what happens to these things long term, but often they can be around forever. So I think that's an important distinction to keep in your mind that biologic mesh doesn't necessarily mean that it's absorbed. And just

remember, this is where, right, marketing, science, and data can be at odds with each other.

And not, not in a bad way, but if biologic mesh company, and you want to say that it regenerates into something permanent, like fascia. You will be very uncomfortable using terms like encapsulation and permanent. And again, these are all kind of marketing words, not always clinically relevant words.

And that goes for, by the way, permanent synthetic mesh, right? Because we have learned through some of you all's work that permanent synthetic mesh can fracture. It's a permanent mesh that can break. So, so being permanent doesn't necessarily afford you some luxury that you're better than a biologic or a biosynthetic.

It just means you will perform differently and you, we need to understand those differences and how they relate to clinical outcomes. Can you guys talk a little bit about mesh weight and how you apply that

clinically? Mesh weight we talk about mesh weights but really it's the density of the mesh.

Of the, so there are three categories or three, There are three densities, there are three groups we typically categorize these densities into. Lightweight, which is less than 40 grams per meter squared. Medium weight, which is 40 to 60 grams per meter squared. 60 to 75, which is intermediate weight. And then over 75, which is a heavy weight mesh.

And they have different applications for different cases, whether the case is clean or incontaminated. But we talked about before, there's not a lot of data around this. And so My preference, based on papers that, that we have written as a group, and the paper that you published, Sarah, is to use, for a clean case, to use a more dense mesh, a heavyweight mesh, because we think it's at lower risk of fracturing.

Medium weight mesh, we know, has a fracture rate of about 4%, which is significant if you do a lot of perineal repairs. So for a clean

case, I prefer to use a more dense or heavyweight mesh. Permanent mesh, and that is almost always polypropylene here. And then for contaminated cases, like a peristomal hernia, say, I'll use a less dense mesh, a medium weight mesh.

And that's because Rosen's paper that compared biologic to permanent synthetic mesh used a medium weight mesh in these contaminated scenarios. We don't have good prospective head to head data comparing heavyweight mesh. to something else in this kind of scenario. So that's what I typically use. Another reason that I use heavyweight mesh as compared to mediumweight mesh in clean cases is because our group, David Karpada wrote this paper that compared head to head mediumweight to heavyweight mesh in clean cases.

Open retromuscular hernia repairs. And earlier there was some concern that that heavyweight mesh led to more chronic pain. But we found in studying these head to head that there was similar quality of life between these two groups, heavyweight and mediumweight mesh.

So, that's why our group tends to favor heavyweight mesh in these scenarios over medium weight, especially given the risk or concern about mesh fractures.

And I'll tag on a couple of things, because I think this is why it gets so confusing for people, because and Ben said it right, it's the density of the mesh. But remember, and he mentioned this, but just to kind of hammer this point home, the mesh makers can dial up different knobs to increase that density.

And in essence, it, you can make a heavier weight material with thinner threads but keep everything closer together so then you decrease the pore size. Or you can increase the thickness of the threads and then you can have larger pores but still that density. And so even when we kind of try and say, okay well we're going to use Something over 75 grams per meter squared.

We then have to realize different companies have a microporous version of that, a macroporous

version of that, and all of that plays in, and all of that, even in our studies we, and this to be honest, might be something that's beyond the capability of a randomized controlled trial. It needs to be looked at in registry data and long term data, maybe for like a clinically relevant outcome like re operation or something.

But I, you know, I don't, This is probably too much to get into all these little minutiae details in a randomized controlled trial. But just realize that, you know, even within the Kripada study that you referenced, it wasn't all one heavyweight mess. So there might have been, but we couldn't do subgroups because we didn't have enough people.

But this, it gets really, really messy to try and find out, you know, is it the density? Is it the pore size? Is it the size of the actual thread? What is driving here? And. And I think even more, which you can't talk about math without talking about this, is that the technique probably matters more than anything.

anything we're talking

about. And I think that's why it's really hard to look at randomized control trials and apply them to the general population because the majority of them are done by experts and who have great techniques. So that's taken off the table. So it allows you to look at a mesh head to head with the best technique, but that doesn't mean that when that mess is put in, it's getting the best technique.

And I think that's a, it kind of, Subtle background noise and all of this information that it's hard for us to process and which is my final point of that is why you need to be tracking your own outcomes so that if a randomized control trial comes out with, let's say, microporous heavyweight mass that a lot of people would not like, and if you can then look at your SSI rate versus their SSI rate, look at your You know, major complication rate versus theirs.

Look at their hernia recurrence rate and say, Okay, well this does not apply to me. I do, I'm doing better than that. Or not. But if you don't know your own outcomes, you can't do that

application. That's also how this group recognized that there were issues with first text match too. Right? Was that you were tracking your outcomes and you realized that there was a pattern.

Yeah, well, so this is another great example. And again, this will be a shameless plug of the ACHQC. And to be honest with you, the collaboration of the ACHQC because this allowed us, we had a signal with a monofilament heavyweight polyester mesh that we were seeing a fracture rate that was higher than what we thought we should.

We, the company worked incredibly diligently with us and really wanted to get to the bottom of this. And what you find out when you do that is, it's hard to get to the bottom of this stuff. Because you're talking about a 50 by 50 piece of mesh. These are big, complex hernias. And how do you weigh in the patient factors, the hernia factors, but by having such a large database where we could really match up

people, match up outcomes, we were able to get to the bottom quickly.

Limit the amount of patients who might have been harmed from it and make a change. And so, again, that cannot be done by people's gut feelings because rightfully so, a company is going to say, well, wait a second, how would another mesh do with the 50 by 50? You know, and is it the procedure that perhaps is weakening the abdominal wall?

Is it you're doing this on terrible patients? So this really, It is important when you start talking about making decisions and making changes, you need that data and then it needs to be approached collaboratively with the patient's best interest in mind. Trying to relate this a little bit to patient factors, and you talked about that we preferentially use medium weight mesh because we think it might have a better bacterial clearance.

How do you deal with patients who come in with mesh infections and they have maybe medium weight polypropylene or heavy weight polypropylene? How do you know when you can salvage the mesh and when you can't and you have to re

operate? Fortunately, Sarah, this is not a super common complication to have and so I have some limited anecdotes to go on here but I think that the patient's clinical status drives a lot of this and if they're, most of the time a mesh infection is kind of a smoldering process Rarely, it's like an acute life threatening process.

And if it's a, if the, if there's a wound infection, and there's a fascial disruption, and some mesh is exposed, we try, or I try, to salvage the mesh in that situation and wash the wound out, and do water dry dressings and see if the mesh will granulate in. And with a permanent macroporous mesh, it often does.

And you can salvage the mesh. I just had a case recently where someone had permanent synthetic mesh in the retrovascular space, had done a huge hernia repair, and they were critically ill, in septic shock from a mesh infection. And he had a he

was immunosuppressed, he was a transplant patient, and I ended up operating on him in, essentially in the middle of the night for this mesh infection.

And I took out all of the unincorporated mesh in that case, just because I thought he was too sick from it. So, I think that it, that You know, there are, there's a spectrum of how to treat these people, and to be honest, there is very limited data to, to guide us here, and I think that we rely a lot on our clinical judgment and the patient's clinical status.

I'll give a couple, like, I think very kind of, I agree with Ben. Like, very 30, 000 foot high level, like, decision analysis thing. So, first of all, if you ever I would say the most important thing about mesh infections is to suspect. So if you have a patient that has any foreign material in them, including sutures, and six months to a year later they have a spontaneous draining sinus, there's an infection of a foreign body inside of them for sure.

So, so then start to investigate. Second is you must get the old operative

reports to find out what type of mess they had. Because there are going to be some kind of Hard Stop Sons. If it's an absorbable synthetic mesh, perhaps you want to wait it out and see if it will eventually go away. Sometimes they do, sometimes they don't.

If it's a biologic mesh, same thing. You know, how cross linked was it like we talked about before? Maybe you want to wait it out and see if it'll just be broken up by the collagenases of the bacteria. So you wait it out. If it is a permanent synthetic mesh, then, particularly if it's a long term infection, I'm not going to get into like the coding and whatnot because That's more of a short term problem.

But long term infections, I think, just to make life easy, if it's polyester, you're probably in trouble, because the polyester mesh is multi filament, and you get the bacteria within it, and often, you know, you can take out what's unincorporated, but later on, it will require more kind of piecemeal debridements, which is also okay.

If it's PTFE, which is a little trick, you will see that white line on the CT scan. That's a common like a

composites mesh or a PTFE mesh of which they're still available. If you see that, the whole mesh has to come out. PTFE, if you take a part of it, it will never heal. So that, and then if you have it as polypropylene, then you want to know what layer in the abdominal wall it is.

I, I agree with Ben, how sick the patient is, and I might be just a little bit more willing to try and get it to granulate in, and then if it doesn't, in those situations you can almost always take out a bit of the mesh, and let the part that's ingrown grow in. But, I also think that if you're long term going back in to, to breed mesh infections, it really is worthwhile to try and get everything out of there, so that you don't compromise your repair six months to a year later.

with ongoing infections. Those are my kind of high level treatment algorithms. It, you know, anybody who spends much time with this group and gets to operate with you guys knows that it's not really common practice for you know, your surgeons to use biologic mesh in these big ventral hernia repairs.

Are there any indications or any times where you would consider using a biologic

or is it like a never event and you do other options? I have only used biologic mesh a couple times and it was before I came here I'll just say that I think that if I was going to use a biologic mesh, it would probably be in like a staged kind of scenario, but in those cases, we use a, typically use a quickly absorbable, quickly absorbing mesh like a vicryl mesh.

So, but when I wrote this article, I, there, you know, there, there's some concern that in, in these scenarios that vicryl mesh is maybe fistulogenic, however, I couldn't find any data to support that. So I think that in the case where you have a contaminated hernia and the. Or, you know, for whatever reason you want to stage this repair, the patient isn't doing well, it's a contaminated case, you don't feel like you have the resources or expertise to deal with this hernia.

I think that in those cases to do like a bridge repair with VicoMesh or BiologicMesh, I think that those are both reasonable choices. But for, like, doing an abdominal wall reconstruction I don't in my practice use BiologicMesh, but I know Rosen has a lot in the past.

Yeah, I mean, so, just a couple things about it.

So, number one, it's definitely not wrong to use a BiolizingMesh. It's not wrong to use an Absorbable SyntheticMesh. I think everybody has to have their own algorithm, and you need to base that on your own, technique in your own outcome. So, in regards to us though I would say, first of all, if you look at the biologic versus synthetic my trial, Michael Yang's trial, Hobart Harris's trial, the synthetic did better, but the biologic mesh still worked 80 percent of the time, which for large complex hernias, certainly, you know, still pretty good data.

Now that's obviously in our hands and the synthetic did better. So, so for us I think one of the keys to realize and often this is missed, is that many people think that we're spending a lot of time thinking about what mesh we're going to use, but our treatment algorithm, that decision happens way further upstream than when it's time to pick the mesh.

And I think this would be Mike Rosen's take home point number one from this thing,

is we make the decision. At the end of the GI surgery part of the case, are we going to reconstruct you or are we not going to reconstruct you? And if we are going to reconstruct you, which for us means taking apart the abdominal wall, retromuscular, posterior component separation, tar, all that stuff.

If we think it's safe to do that, you're going to get synthetic mesh of some variety. If we do not think it's safe to put synthetic mesh. Then we either close primarily or bridge with a rapidly absorbable synthetic mesh. And that is our bailout. What I do think in today's world, I do have concerns on, is taking apart the whole abdominal wall and doing all these advanced TARS with a biologic or an absorbable synthetic.

I would say use those as intraperitoneal meshes. as kind of give it your best shot, but don't

violate things in these hard situations for the definitive repair. So that, that's, my choice is never, am I using biological absorber or synthetic? My choice is reconstruction, yes or no. And if yes, it will always be a synthetic mask, because that's how I made that choice.

I think it might be fair, also noting, if you're planning to go back into something, you guys give a thought to like the cost difference, right? Trying to be a conscientious surgeon and taking care of the patient. Some of these biologics are right upwards of like a car, a small car, right, in terms of price.

Yeah, I mean, listen, they're expensive. The absorbable synthetic meshes, or the, you know, the biosynthetic meshes, they're all expensive too. They're less, but they're still, you know, over 10, 000 for the majority of them. So, I think we should be good stewards of healthcare. I mean, you know, for an individual patient You know, cost effectiveness is hard to measure, so I'm always like, you gotta be careful about cost, because you want people doing what's best.

Because of mesh infection, and a fistula is costly too, so. But, but again, I would just stress

that the different types of mesh material, it's really important to understand this, but it's much, much more important to focus on technique, and becoming a good technical ab wall reconstruction surgeon, and understanding all the options, From minimally invasive, robotic, lap, open, up to very, very complex things, and apply things appropriately, rather than focusing on the end of like, well, what mesh am I going to choose?

Because it is almost never the mesh's fault when things went wrong, and it's almost never the mesh gets credit when things go perfect. So, I think it's kind of an innocent bystander that's there to support your operation, but should not be the focal point.

Tip it a little bit to another clinical scenario. What do you say to patients that don't want to have mesh placed or just against the idea of a prosthetic? Or just the bad mesh is the question I like hearing. First I say that, honestly I say that like a bare polypropylene mesh has been used for a long time.

It was one of the very first meshes

that was ever used. And I think nylon was the first mesh that was used around World War II, and then polypropylene came on the market in the 1950s, and we've been using it ever since. So I stress the fact that it's been around for a long time, and we use it here more than any other mesh, and it's, has a track record of safety.

I often say that most trouble that's encountered with the mesh is when it's a buried polypropylene or older meshes that have been taken off the market, placed in the intraperitoneal space, and that interface between the bowel and the mesh causes problems. And I think that's where. Most mesh gets a bad rap and if I'm doing a retromuscular case, I stress that this mesh is not exposed to the bowel, it's in the retromuscular space, sort of sandwiched in between the layers of the bowel.

So that's kind of my approach when discussing mesh with patients. If they are adamantly opposed to mesh, and this is for patients who have inguinal hernias or ventral hernias, if they have an inguinal hernia and they're a perfect candidate for a tissue based repair, I'll offer them that. For an incisional hernia,

I think we don't really know, we're studying this right now in primary closure, primary closures for patients with kind of small to medium sized incisional hernias.

We don't know what the answer is yet, but I tend not to offer patients a primary tissue repair if they're outside that study. Just because I don't know. really how to, we don't know what the data will show yet, and I don't, the standard of care as of today is a mesh based repair for a ventral incisional hernia.

Yeah, I would just say, so, you know, specifically what I talk to patients about is I say, this is how I present it to them, and say, listen, nothing in life is perfect. Everything is risks and benefits. There's no question, there's great evidence that mesh reduces your recurrence rate. You know, for most of the things we do now, kind of re operative recurrence rates in the two to four percent range for the rest of your life.

If you take

away MeSH, for inguinals, it's going to go up, and for ventrals, it's going to go up even higher. And so you've got to be willing to potentially need another operation if you're not going to have MeSH. Now, MeSH also causes potential problems. And I try and, you know, Divert people away from the kind of the bad mess and the TV stuff and say look the majority of problems around mess that like you need to worry about our infection and the majority of causes of infection of mesh are technical things related to me and Being obese diabetic smoker and things that you need to worry about and I kind of backed that up with Every operation has three things in it A patient, a surgeon, and a mesh.

And when things go wrong, the one person that can't speak up for themselves is the mesh. So they get blamed. In reality, it's almost never the mesh. It's patient factors, it's surgical factors, and so, so, I try and disarm the mesh, but I'll take this as a moment to talk about one thing because kind of Ben set me up good for this.

So, so it's

funny when we talk about mesh as the gold standard. So MESH is the gold standard because of one trial by Luendijk. It is now fairly old, but it was in the New England Journal of Medicine. It's one of four hernia papers ever to make it, and that's a big deal. But I would just caution everybody that the 10 year recurrence rate for MESH in that study was 32%, I think.

None of us are quoting a 32 percent recurrence rate at 10 years for any of the operations that we do. It might be 32%, but we are not using MeSH. We're doing what I said, 2 to 4%, which is kind of based on our own personal experience and whatnot. So I would just tell everybody that we have completely accepted that MeSH is for everybody.

MeSH is obviously for big, complex hernias, but there is some unknown about some of the smaller things. And with some of the newer techniques that are available to close fascia we should question that. And so, me personally, if I

get somebody that has, you know, a small enough hernia and they just don't want mesh, I'm at the point now where I say, hey look, I probably put more mesh than anybody in the world.

It, I don't think mesh is the problem here. If you really don't want it, I'm happy to give it a shot. And if it comes back, I'm Then we have to agree that you need a piece of mesh. And so I've become much more liberal on trying it. And again, I don't know what my outcomes are yet but, you know, some people do.

Okay. So you guys work with mesh every single day. I'm sure you've developed, you know, kind of ideas and things that you'd like to see on the market. What is one innovation if you could put out there that you would like to see in a mesh tomorrow, if it could be made possible? There aren't many options I would say for big, bare polypropylene macroporous meshes out there.

So I would like to see. More of those types of meshes on the market and like a 40 centimeter by 40 centimeter 50 centimeter by 50 centimeter kind of range Just bigger bigger bigger bear polypropylene mesh Yeah, I have a similar thought in that a couple things. I think is

number one Is we are starting to tackle more and more challenging hernias and bigger and bigger patients and what we know about Mesh fracture rate, which again, it's not something to get hysterical about, it's probably 4%, but if you're doing 800, 900 hernias a year, that's like a real number.

So I think a heavier weight material, and I do, although again, like we mentioned, not with great science, larger pores, heavier weight, and polypropylene uncoated mesh, that I think the ideal size mesh. is 43 by 43 centimeters square. And I'm going to tell you why that is. Because a 30 by 30 turned like a diamond is 43 on its long axis.

And the reason why we like the bigger meshes is because they're square and they fill the top and the bottom better. And a 43 will almost always get you from under the xiphoid to behind the pubis. So 43 by 43 squares

heavyweight polypropylene, large pore. 70 to 90 grams per meter squared. That's what's missing.

That's what we need. Let's start putting some of that stuff in but I think it's great that people are taking the time to think about max because you know, as I think about at wall reconstruction and this new field and all the exciting stuff that's happening in this. I think this is a great time. to be a hernia surgeon and to be involved in this.

And I think it's an equally scary time that as more and more people think that this is kind of exciting and fun to do and there's new minimally invasive ways to do this type of stuff, we cannot neglect the potential patient harm in the decisions that we make. And so, I think that ab wall reconstruction is challenging for people because you need to understand anatomy, You need to understand technique, you need to understand optimization, peri and post operative care, and a lot about prosthetic materials

so that you pick the right kind.

Because one of the things that I commonly see in failed retromuscular surgery is coated type meshes that are put which just kind of insinuates to me that there is confusion on mesh choices that resulted in patients getting surgery. imperfect technical operations, major complications. So I you know, my message is this is so important to understand about the mass properties, but don't stop there.

Focus on the technique, focus on kind of who we should be operating, what operations we should do and constantly question if we or you are doing the right thing for your patient for better longterm outcomes for them. Thank you to Dr. Miller and Dr. Rosen for sitting down with Brian and I today to talk about mesh materials.

I know it can be a really intimidating subject for people. And from all of us at the Cleveland Clinic, and behind the knife, dominate the day.