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Publication:

Surgical Technology International XVI - Surgical Overview

Article title:

Hyaluronan-Based Antiadhesive Agents in Abdominal Surgery: Applications, Results, and Mechanisms of Action

Contents:

 

 

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1. Article Information, Introduction

2. HYALURONAN-BASED ANTIADHESIVE AGENTS

3. HERNIA REPAIR AND HYALURONAN CONTAINING MESHES

4. THE USE OF HYALURONAN IN INFECTIOUS CONDITIONS

5. MECHANISMS OF ACTION OF HYALURONAN

6. Conclusions, References

 

HERNIA REPAIR AND HYALURONAN CONTAINING MESHES

 

Stimulated by the adhesion-reducing properties of HA in abdominal surgery, other applications have recently been explored, including its use in hernia repair. Adhesion reduction after abdominal wall reconstruction using prosthetic meshes is challenging. Incisional hernia after abdominal surgery is a common complication and tension-free repair is considered a prerequisite for successful treatment. This requires the use of a prosthetic mesh. To allow optimal ingrowth and to prevent reherniation, the mesh should be macroporous and nonsoluble. Polypropylene is the most commonly used biomaterial for this purpose. However, a major drawback is the propensity of adhesion formation at the peritoneal side of this mesh, introducing the risk of bowel obstruction, fistula formation, and inadvertent enterotomy at relaparotomy. Experimental studies have shown a successful reduction of mesh-related adhesions using a combination of polypropylene mesh with a separate HA-CMC membrane.47–49 To improve the handling characteristics, a polypropylene mesh was covered on one side with sodium HA-CMC (Sepramesh®, Genzyme Biosurgery, Inc.). Greenawalt et al. were the first to describe results of this antiadhesive mesh.50

The use of the composite mesh resulted in a reduction of mesh-related adhesions compared with a polypropylene mesh or polypropylene/ePTFE mesh in a rabbit model of incisional hernia. Van ‘t Riet et al. performed experiments in a rat incisional hernia model, comparing several antiadhesive meshes or combinations of mesh with antiadhesive agents.51 The composite HA-CMC mesh was the most effective in adhesion reduction. This superior behavior with regard to adhesion reduction compared with other meshes was confirmed by a recent experimental study by Sikkink et al.52 Adhesion reduction was obtained without compromising reherniation and infection rates.

Felemovicius et al. studied the use of the polypropylene HA-CMC mesh and polypropylene HA-CMC mesh combined with an additional HA-CMC membrane in a rat hernia model.53 Polypropylene HA-CMC mesh reduced adhesions by roughly three-quarters compared to polypropylene mesh. The combination of the polypropylene HA-CMC mesh with the membrane nearly eliminated adhesion formation. Building on these successes, human studies should now further enlighten the clinical value of the polypropylene HA-CMC mesh.
Recently, the polypropylene HA-CMC mesh has been further developed into a polypropylene mesh co-knitted with polyglycolic acid (PGA) fibers (Sepramesh® IP, Genzyme Biosurgery, Inc.) (Fig. 4). The PGA surface is coated with a bioresorbable, chemically modified sodium HA, CMC, and polyethylene glycol-based hydrogel. The co-knitting of polyglycolic acid in this mesh provides for a stronger bond between the permanent polypropylene mesh and the temporary adhesion barrier component as compared to the previous generation. A literature search does not reveal any clinical or preclinical data on this second generation product at this time, although the manufacturers claim the same level of benefit as the first generation product with substantially better handling characteristics and easier use in laparoscopic procedures (Fig. 5).