complex ventral hernia repair using biologic or synthetic mesh

Conditions: Hernia, Ventral

Summary: hernias are often treated using a prosthetic mesh to add support to the healing wound. prosthetic meshes have been used for decades to repair ventral hernias, level 1 data regarding which type of mesh to use is limited. the purpose of this study is to compare the effects, good and/or bad, of two types of prosthetic meshes: one that is made from pig skin (called a "biologic prosthetic"), and one that is made in a laboratory (called a "synthetic prosthetic"). this study will include some patients who have an infection in/near the hernia, and other patients who do not have an infection. we expect the synthetic mesh to be associated with a higher rate of early post-operative surgical site infection and fluid collections (seromas), while we expect the biologic mesh to be associated with a higher rate of recurrence.

this is a prospective, single-blind, randomized study comparing the clinical efficacy and overall costs of two prosthetic meshes in the repair of complex ventral hernias. the two prosthetic meshes to be studied are ventralight (bard, murray hill, nj), a synthetic mesh chiefly made of polypropylene and strattice (lifecell, branchburg, nj), a biologic mesh derived from porcine dermis. the study population will consist of patients who are in need of a repair of a complex ventral hernia. patients will be enrolled in the study for 24 months following their operation or until they experience a recurrence of their hernia, whichever occurs first. the primary outcome variable is recurrence and the secondary outcome variables are post-operative surgical site infections and overall costs. there is no universally agreed upon definition of what constitutes a "complex" ventral hernia. for our purposes, a "complex" ventral hernia is one that involves a compromised surgical field, in which gastrointestinal, biliary, or genitourinary procedures are performed, one in which the wound class is considered clean-contaminated, contaminated, or dirty due to other causes, such as infected meshes and enterocutaneous fistulas, or surgical procedures conducted in patients with large ventral hernia defects (\>10 cm in any single dimension).

Eligibility criteria:
inclusion criteria: * clinical evidence of a midline, ventral hernia, regardless of degree of wound contamination, with the exception of class iv wounds due to the presence/discovery of fecal peritonitis. specifically, the repair will or will not involve a compromised surgical field in which gastrointestinal, biliary and/or genitourinary procedures will be performed. the surgical wound class may be classified as clean, or it may be classified as clean-contaminated, contaminated, or dirty-infected, due to the repair of an enterocutaneous fistula, takedown of an intestinal stoma and/or removal of infected mesh * age \>21 * negative pregnancy test * no allergic, religious or ethical objections to either polypropylene or porcine prosthetics * signed, witnessed informed consent to take part in the study exclusion criteria: * lactating women * patients who are unable to commit to the follow evaluations over 24 months * severe malnutrition (serum albumin \<2.0 in the setting of a normal crp) * use of an investigational agent within 1 month prior to study enrollment and/or planned during this study * presence of pre-existing parenchymal liver disease characterized by the presence of child's class c liver dysfunction (including all of the following: bilirubin ≥ 3.0 mg/dl; albumin ≤ 3.0 mg/dl; refractory ascites; encephalopathy or coma; and poor nutritional status) * immunocompromised patients, as evidenced by: administration of high doses of corticosteroids (i.e. doses ≥ 1.5 mg/kg/day of prednisone or equivalent) within 72 hours before study enrollment; status post solid organ transplant or bone marrow transplant and experiencing acute organ rejection or bone marrow failure or rejection; evidence of neutropenia (absolute neutrophil count ≤ 500 cells/mm3 (≤ 500 x 106 cells/l); chemotherapy or radiation therapy within 90 days before study enrollment; known aids; any disease sufficiently advanced to suppress resistance to infection (including, but not limited to leukemia, lymphoma or hypogammaglobulinemia); administration of immunoglobulin of g-csf within 90 days before study enrollment * ascites refractory to medical management * presence of an underlying disease/injury with life expectancy less than two years and/or severe underlying disease that would preclude study entry (e.g. known malignancy) * wound classification iv due to the presence/discovery of fecal peritonitis. other cases of wound class iv including presence of purulent inflammation, soft tissue/mesh infection, or visceral perforation resulting in a contained fistula (e.g. enterocutaneous fistula) are still considered eligible for enrollment.

Keywords: hernia ventral incisional abdominal herniorrhaphy recurrence infection mesh biologic synthetic