Hernia (2000) 4:2o6-211

Hernia
9 Springer-Verlag2000

In vivo tissue reaction to different prosthetic materials in abdominal wall hernia repair

A. Coda ~, F. Botto-Micca 2, F. Quag'lino ~ and G. Ramellini ~

' PresidioSanitario "Gradenigo",EnteAutonomo,Divisionedi Chirurgia, ~Serviziodi AnatomiaPatologica,8, C. so ReginaMargherita,I-~o~53Torino,Italy

Summary: Several well tolerated materials are currently available for the
treatment of hernias. Polyester (Dacron) and polypropylene (PPL) are currently the most frequently used materials. Experimental work has highlighted ~;;i~i
the biological response of laboratory animals treated with a range of prostheses. Authors agree that an inflammatory response rarely occurs, although !~!~
materials generate a range of responses. In the years 1996-2ooo, hystological
tests were performed to assess the in vivo response to the range of materials. ~;~
Thirty-five prostheses were examined in 34 patients. Twenty-six were men
and 8 were women with an average age of 59.3 years (range 35 to 89). Samples
were fixed in formalin, de-hydrated and placed in paraffin. Four micron sections were dyed with hematoxylin and eosin and then underwent microscopy. ~
The type and the amount of prosthesis-englobin connective tissue was eva- ~:~
luated, as was the number of giant cells, of inflammatory elements and of y e s - ~ i~
sels. Evaluation scores ranged from - to ++. The microscope highlighted a !~i!
range of patterns according to the implant: a) Dacron prostheses were sur- ~;.
rounded by a large amount of thick connective tissue, with scarce fibroblastic ;~
elements, engendering a lively response with polynucleate giant cells in relati- i l
rely large quantities, b) PPL plug prostheses were englobed in a looser ii~
connective tissue, rich in fibroblasts and with a scarce amount ofinflammato- ~:i
ry elements and giant cells, c) PPL patches were s u r r o u n d e d by thicker
connective tissue, appear to be more inert, and were often surrounded by adi- ~,
pose tissue. The type of prostheses, as well as its form, may engender diffe- ~;!i
rent tissue responses.
~!~

Correspondence to: A. Coda

e-mail: coda.an@tiscalinet.it

Key words: Biomaterials - Hernia repair - Polypropylene - Polyester - Histolo- ~

gical examination
~i{~
Received lune 15, 2000
Accepted in final form October lo, 2ooo

Several well-tolerated biomaterials are

currently available for the treatment of
abdominal wall hernias. Last century,

when Bassini was suggesting his wellknown method of cure, Billroth had an
idea: if only the right material could be

f o u n d , then the p r o b l e m of h e r n i a
repairs would have been solved. Materials displayed tolerance problems until

A. Coda, et al.: In vivo tissue reaction to different prosthetic materials in abdominal wall hernia repair
the late 195o's b u t t h e n in 1959 F r a n c i s
Usher p u b l i s h e d the results of research
d o n e o n reticulate prostheses m a d e with
a p o l y m e r derived f r o m ethylene glycol
a n d terephthalyc acid, called D a c r o n (a
polyester). C h e m i s t r y m a d e e n o r m o u s
p r o g r e s s i n t h o s e years; t h u s e n a b l i n g
Usher to test a n o t h e r p o l y m e r soon after
[Usher 1961 ]. This one derived from propylene condensation and was called
p o l y p r o p y l e n e (PPL). The material becam e widely used in the U.S., while Europe
c o n t i n u e d to f a v o u r D a c r o n , especially
the F r e n c h surgeons. Usher h a d fulfilled
Billroth's d r e a m !
Experimental work [Petit 1974,
A r n a u d 1977, R a t h 1 9 9 6 , D a s d i a 1 9 9 8 ,
Klosterhalfen 1998, Bellon 1998] has lead
to evidence of b i o - r e s p o n s e in laborato1T a n i m a l s u n d e r g o i n g a n u m b e r of operations with a range of prostheses.
A u t h o r s ' results were c o n s i s t e n t in staring that an i n f l a m m a t o r y response was
low, although materials generated specific a n d therefore diverse responses. The
reaction was s e l d o m assessed in v i v o in
h u m a n s [Trabucchi 1998, Klosterhalfen
2000].
To evaluate the response to materials
evoked in v i v o , we p e r f o r m e d a histological a n a l y s i s o n r e m o v e d or s a m p l e d
prostheses.

Materials and methods

I n the y e a r s 1996-2ooo, the Service o f
Pathology of the Presidio Sanitario
" G r a d e n i g o " , T u r i n , Italy, p e r f o r m e d
35 histological e x a m i n a t i o n s o n 34 alloplasties (groin or incisional hernia)
requiring re-operation. There were
34 patients: 26 males a n d 8 females. The
average age was 59.3 years, with a range
of 35-89 years (Table 1). Mesh was removed following chronic infection in
4 cases; biopsies were p e r f o r m e d d u r i n g
operation for hernia recurrence in
27 cases, while in 3 cases m e s h was sampled d u r i n g pelvic surgery.
PPL prostheses h a d b e e n p o s i t i o n e d
as a cone or dart plug in 8 cases a n d as a
cigarette plug in o n e case. A n o t h e r cigarette p l u g was d o n e with D a c r o n m e s h
(case # 15). The latter was used to treat a
direct recurrent hernia [Dieudonn4
1992] b u t re-recurrence occurred becau-

207

Table 1. Personal series of hystological tests on explanted mesh (1996-2o00)

n. cases

Sex - Age (years)

Implant

Material

Type of mesh

1
2
3
4
5
6
7
8
9
lO
11
12
13
14
15
16

M - 62
M - 47
F-58
M - 73
M - 54
M - 48
M - 58
M-55
M - 56
F - 54
F - 65
M - 67
F - 61
M - 62
M - 59
M-5o

Cone Plug
"
"
~c

PPL

Trelex|

17

M - 77

18
19
20
21
22
23
24

25
26
27
28
29
30
31
32
33
34 A
34 B

M - 79
M - 43
M - 69
M 69
M-78
M - 73
-

F - 35

F - 47
M - 70
M - 89
M - 45
F - 44
M - 53
F - 61
M - 59
M
M - 37
Same patient
-

58

c~

c~

,,

Marlex|

"
"
,,

Hermesh3 |
Prolene|
Trelex|

Between
Onlay
Between
"
?
Cigarette Plug
Between

"
,,
,,
"
Dacron
,,

Marl|174
Trelex|
Marlex|
Tramex|
Prolene|
Ligalene|
Mersilene |

"

"

"
"
"
Sublay
"

"

Sublay
Onlay
5ublay
"
Between
Onlay

Cigarette plug
Between
"

"
Sublay
Sublay
Onlay
Between
"

Cone Plug

se o f p l u g s h r i n k a g e . T h e p l u g w a s
removed using a posterior approach.
T h e PPL c i g a r e t t e p l u g was r e m o v e d
because of recurrence of the femoral
h e r n i a (# 25). O n e PPL c o n e p l u g in a
female patient (# 3) - who h a d an anterior a p p r o a c h - was r e m o v e d because of
displacement. In six cases of recurrence,
the PPL plug was correctly applied a n d
cured the previous indirect hernia. In all
cases, plugs were r e m o v e d b y a posterior
approach. There was o n e case of pelvic
s u r g e r y for rectal c a n c e r n i n e m o n t h s
a f t e r h e r n i o p l a s t y (# 6). P l u g s w e r e
r e m o v e d to carry out histological tests.
Their r e m o v a l did n o t w e a k e n the inguinal wall.
A 62 y e a r s o l d m a l e p a t i e n t (# 14)
h a d u n d e r g o n e anterior groin alloplasty
in 1996 a n d h a d s u b s e q u e n t l y received
radical cystectomy for b l a d d e r cancer in
1997. A repeat l a p a r o t o m y for recurring

"

"
"

,,
PPL
PPL
PPL
PPL
PPL
PPL
PPL
Dacron
PPL
Dacron
PPL
PPL
PPL
PPL

?
?

Ligalene|
?

Ligalene|
Trelex|
Hertra2 |
Prolene|
?
Prolene |
Hertra2 |
Prolene |
Ligalene|
Trelex|
Mersilene |
Trelex|
Hertra2 |
Hertra2|
Hermesh3 |

partial small bowel obstruction was perf o r m e d in 1999. Following lysis of adhesions a r o u n d the ileal b l a d d e r c o n d u i t ,
a n o b s t r u c t i o n was r e m o v e d f r o m the
pelvis o n the deep side of the i n g u i n a l
c a n a l . A PPL m e s h was h i s t o l o g i c a l l y
identified in the mass, b u t we could n o t
c o n c l u d e w h e t h e r it was a p l u g or the
patch. The m e s h was k n i t t e d with two
PPL yarns, b o t h identified as Protene|
In one patient with recurrence (# 34), we
r e m o v e d the p l u g (b) a n d s a m p l e d the
patch (a) with a n o p e n posterior approach.
T w e n t y two o t h e r p a t i e n t s h a d the
p r o s t h e t i c p a t c h r e m o v e d or biopsied.
In 6 cases, the m e s h had b e e n posit i o n e d u s i n g a posterior approach in the
p r e p e r i t o n e a l s p a c e for g r o i n h e r n i a
repair. Two PPL m e s h repairs followed a
l a p a r o s c o p i c TAPP repair, o n e a G i a n t
Prosthetic R e i n f o r c e m e n t of the Visceral

A. Coda, et al.: In vivo tissue r e a c t i o n to d i f f e r e n t p r o s t h e t i c m a t e r i a l s in a b d o m i n a l wall h e r n i a r e p a i r

208

Table 2. H i s t o l o g i c a l tests on PPL m e s h

Cases

Recurrence

ThickC.F.T.

Loose C,F.T.

G i a n t cells

Lymphocytes

Vessels

t
2

yes
yes

++
++

+
+

+
-

++
++

3
4
5
6

yes
yes
yes
no

++
++
++
++

+
-

+
+
+
+

+
++
+
+

yes

+b

++

++

yes

++b

yes

+b

++

++

lO

yes

+b

++

11

yes

+b

++

12

no a

++

++

++

13

yes

14
22

no
yes

+b

++

++

23

yes

++

24

no a

+b

++b

++

25

yes

+b

26

yes

++

27

yes

+b

++

28

yes

++b

3O

yes

++b

32

yes

+b

++

++

++

33

no a

++

++

++

++

34 A

yes

+b

++

++

++

34 B

no

++b

++

+
+
+

A b b r e v i a t i o n s : C.F.T.: C o n n e c t i v e F i b r o u s T i s s u e
a. P a t i e n t o p e r a t e d for c h r o n i c s i n u s tract
b. P r e s e n c e o f a d i p o s e tissue

Table 3. H i s t o l o g i c a l tests o n PPL m e s h H i s t o l o g i c a l tests on D a c r o n m e s h

Cases

Recurrence

T h i c k C.F.T.

15.

yes

16.

no b

17.

Loose C.F.T.

Giant cells

Lymphocytes

Vessels

++

++

++

++

++

++

++

++

yes

++

++

~8.

yes

++

++

++

19.
2o.

yes
yes

++
++

++
++

++
+

+
+

21.

yes

_[.+a

++

29

yes

++

31

yes

++

++

++

N.B.a. P r e s e n c e o f a d i p o s e tissue
b p a t i e n t o p e r a t e d for c h r o n i c sinus tract
A b b r e v i a t i o n s : C.F.T.: C o n n e c t i v e F i b r o u s T i s s u e

Sac (GPRVS) [Stoppa 1984] for a bilateral primary inguinal hernia (# z2) and
two a Unilateral GPRVS [Wantz 1989]
for r e c u r r e n t h e r n i a (# 9, 19). One
patient (# za) had been previously operated upon with a Dacron GPRVS and

the mesh was sampled during radical

c y s t e c t o m y for bladder cancer. The
other 5 patients were re-operated using
an anterior route. In the latter group,
there were 4 PPL and 1 Dacron mesh.
Another prosthesis was removed from

the p r e p e r i t o n e a l space because of

recurrence of incisional hernia treated
with retromuscolar implant of Dacron
mash (# 2 9 ) . All 7 patients had a sublay
mesh patch.
Three female patients had onlay
inplants for incisional hernia repair (i.e.
over the anterior sheath of the muscoli
recti abdominis). A biopsy was performed on a 65-year-old female suffering
from recurrence of incisional hernia
treated with PPL mesh onlay implantation (# 11). The other case (# z4) displayed a chronically secreting umbilical
sinus tract.
The remaining 13 inguinal hernia
cases were repaired with a tension-free
repair. Two patients requiring surgery
following chronic infection of their
groin alloplasty (case # 12, 16) did not
show recurrence. More recently, another
man was re-operated because of a sinus
tract (# 33). Three male patients had had
Dacron mesh implantation as buttress
reinforcement of a sutured hernioplasty
(case # 17, 18, 20). Eight patients had
recurrent hernia after a PPL anterior
tension-free repair. Two were female
(# lO, 13): one had an anterior Marlex
repair for recurrent hernia using a prosthesis that was too small; the second had
a tension-free sutureless repair that needed fixation. Six were males in which
Prolene | mesh (# 26, 28), Trelex | or
Marlex| mesh (# 32), and Hertra2|
(# 23, 27, 34) had been fixed with nonabsorbable stitches.
Time elapsed between the implant
and the re-operation was longer than
6months
in 33 cases (average
25,4 months; range 2-178 months). It is
believed that the process of integration
was c o m p l e t e d in a l m o s t all cases
Although inflammation seemed to persist. At least 2 months elapsed between
the first surgery and the re-operation in
case # 27. Only two Dacron cases had
been operated 15 and 7 years previously.
Samples were fixed in formalin, dehydrated and placed in paraffin. Four
micron sections were dyed with hematoxylin-eosyn and then underwent light
microscopy. The type and amount of
prosthesis connective tissue incorporation was evaluated, as was the number of
giant cells of inflammatory elements and

A. Coda, et al.: In vivo tissue reaction to different prosthetic materials in abdominal wall hernia repair

209

Fig. 1

Fig. 2

Dacron mesh patch: the Dacronfibres are multifilaments surrounded by fibrous tissue
including inflammatory elements and giant polynucleate cells (10x)

Dacron mesh plug: Dacron multifilaments surrounded by compact fibrous tissue where giant
polynucleate ceils can be observed (10x)

Fig. 3

Fig. 4

PPL mesh plug fibres (Hermesh3| surrounded by loose tissue with some inflammatory
elements (lOx)

PPLmesh patch (Prolene| PPLfibres surrounded by compact fibrous tissue that passes
throughout and around them (lOx)

vessels. Score values of "-", "+", " + + "

were used. The type of prosthesis was
determined from the patient's chart in
16 cases.

Results

Results are summarised in Tables 2. and

Table 3.
Light m i c r o s c o p i c e x a m i n a t i o n s
highlight different behaviour patterns
according to the type of material as well
as to the type of implant. Whatever the
implant and the reason for the biopsy
(be it infection, recurrence or other sur-

gery), Dacron mesh was always surrounded by compact connective tissue with a
small n u m b e r of fibroblasts (Fig. 1 and
2). Large numbers of inflammatory and
giant cells were observed.
PPL p l u g p r o s t h e s i s # 1-6 cases
(Fig. 3) were in a looser connective tissue, rich in fibroblasts with a scarce
a m o u n t of inflammatory elements and
g i a n t cells. Case # 7 r e v e a l e d t h i c k
c o n n e c t i v e tissue (+) and case # 34b
even thicker (++), both with adipose tissue. PPL patch prosthesis removed from
the pre-peritoneal space - via open or
laparoscopic route, or from onlay pre-

muscolar site (Fig. 4) - were often surr o u n d e d b y adipose tissue as well as

i n t e r m e d i a t e c o n n e c t i v e tissue. The
Dacron mesh showed presence of adipose tissue a r o u n d it o n l y in one case

(# 21).
In two cases (# 20, 21) the Dacron
m e s h (after 15 a n d 7 years), did n o t
demonstrate degradation of the mesh
macroscopically at excision or microscopically. The appearance of degradation of the material was detected only in
the case of chronic infection (case # 16):
the Dacron mesh had been implanted
for 20 months.

210

I Discussion
As far as the materials under study are
concerned, Dacron is a general definition attributed to polyester multifilament mesh. Ligalene | and Mersilene |
are brand names and are Dacron textile
mesh, knitted from muhifflament yarns,
which differ slightly in their physical and
microscopic features. The Mersilene |
filament is c o m p o s e d of 14 yarns of
18 micron each. The Ligalene| filament
is c o m p o s e d of 8 yarns of 14 m i c r o n
each. Dacron multifilament mesh and
PPL monofilament mesh, are different
when compared microscopically and on
gross inspection at excision [Coda 1998,
1999]. Trelex Natural s and Marlex | are
brand names of PPL textile mesh knitted
from monofflament yarns, which do not
differ greatly. Microscopically, after
i m p l a n t a t i o n , one can not tell t h e m
apart. Prolene| is quite different since it
is a PPL mesh that shows two r o u n d
monofilament yarns knitted together.
More recently, thick mesh knitted with a
s l i g h t l y l a r g e r PPL y a r n (18o, zoo,
240 micron) and others with even finer
yarns (127, 140 micron) have been marketed. Large yarn mesh are knitted in a
closer tissue to obtain more stiffness, as
fine yarn is used for a looser knit [Coda
1999]. But weaving may also obtain this
difference with the same yarn, as in Hertra2 | a n d H e r m e s h 3 | (18o m i c r o n
yarn).
The prostheses had not always been
pre-identified with certainty in the specimen. The type was known before surgery in only 16 cases (# s 1, 2, 6, 8, 11, 13,
15, 19, 21, 23, 27, 29, 3~, 32, 33, 34). In the
other 18 cases, it was always possible to
distinguish the material and often (in

A. Coda, et al.: In vivo tissue reaction to different prosthetic materials in abdominalwallhernia repair
14 cases) the type. Previous studies on
bio-materials used in hernia surgery
[Coda 1996, 1998, 1999] made it possible
for us to identify the prosthesis using
microscopic filament measurements of
the number and of the diameter. As you
can see in Fig. 1 and 2, and Fig. 3 and 4,
differences are microscopically evident
(as seen in the differentiation between
multifilament braided Dacron and
monofflament PPL).
In vivo results of histological examinations are consistent with experimental
w o r k [Petit 1974, A r n a u d 1977, Rath
1996, Dasdia 1998, Klosterhalfen 1998,
Bellon 1998] and with work on humans
[Klosterhalfen 2ooo]. Materials evoke a
different tissue response and the type of
p r o s t h e s i s can also have an impact.
Dacron mesh is buried in thick layers of
connective tissue and generates a strong
polynucleated giant cell response. When
Dacron was used, the a p p e a r a n c e of
onlay patch biopsies was the same as
preperitoneal sublay patch or cigarette
plug biopsies.
PPL mesh was surrounded by a looser fibrous tissue, appears more inert
creates a smaller amount of giant cell
reactions. In the case of PPL plug mesh,
looser tissue is present (Fig. 3), but compact connective fibrous tissue was not
observed. Our results indicate PPL mesh
used as a plug has a range of histological
reactions which are not the same as
when the same mesh is used as a patch.
The tissue reaction around the mesh
seemed to be due more to the shape,
plug or patch, than to the implant site.
Moreover, the presence of chronic infection does not hamper good fibrotic reaction from developing fibrous response
was noted to be loose in plugs.

Adipose tissue is known to be present in the early PPL implants, but is

later replaced by fibrous tissue [Bellon
1998]. Dabrowiecki (1991) reported no
appearance of adipose tissue in a study
performed using Marlex | mesh in different layers of rat abdominal wall. In our
experience, adipose tissue is still present
in the majority of PPL samples long after
implant.
An implantation period of several
years has been known to be followed by
a complete degradation of the Dacron
mesh [Klosterhalfen 1999]. Although
this was not observed in relation to
recurrent hernias (due to the solidity of
the scar), in cases of excision due to
chronic infection, the process was also
not observed two Dacron mesh excisions (after 15 and 7 years), in which
there was regular incorporation. However, in case # 16 chronic infection lasted
for 20 m o n t h s and caused complete
degradation of the Dacron mesh.
Some authors [Klosterhalfen 1999]
have reported an increasing number of
cases of sarcomas after implantation of
biomaterials, such as dacron vascular
grafts but no cases of tumor after mesh
i m p l a n t for parietal repair has been
documented to date.
This paper is a preliminary report, of
35 sampled mesh cases. Similar reports
of in vivo human mesh tissue interaction
are rare in literature. Further observations are needed to reach final conclusions and to u n d e r s t a n d what really
happens in tissue when mesh is implanted.

Ackowledgment. The authors thank Mrs. Vicky

Franzinetti for the translation of the manuscript.

A. Coda, et al.: In vivo tissue reaction to different prosthetic materials in abdominal wall hernia repair

A. Coda, et at.: In vivo tissue

References
Arnaud JP, Eloy R, Adloff M, Grenier JF 0977) Critical evaluation of prosthetic materials in
repair of abdominal wall hernias. Am J Surg
133:338-45
Bellon JM, Contreras La, Bujan J, Palomares D,
Carrera-San Martin A (1998) Tissue response
to polypropylene meshes used in the repair of
abdominal wall defects. Biomaterials 19: 669675
Coda A, Botto-Micca F, Bossotti M, Manfredi S,
Mattio M, Ramellini G, Canavesio N, Bona A
(1998) Re-operations for chronic infections
following prosthetic hernia repair. Hernia a:
163-167
Coda A, Fern F, Filippa C, Mattio R, Bona A, Ramellini G (1999) Open mesh-plug repair for primary inguinal hernia (826 cases). Hernia 3:57-63
Coda A, Benedetto C, Mattio R, Filippa C, Ferri F,
Bona A (1996) Trelex Natural mesh: technical
data and personal experience. Int J Surg Sci 3,
[Suppl 1]: 94-97
Dabrowiecki S, Svanes K, Levken J, Grong K 0991)
Tissue reaction to polypropylene mesh: a study
of oedema, blood flow and inflammation in
the abdominal wall. Eur Surg Res 23:24o-9

Dasdia T, Bazzacco S, Bottero L, Buffa R, Ferrero S,

Campanelli G, Dolfini E (1998) Organ culture
in 3-dimensional matrix: in vitro model for
evaluating biological compliance of synthetic
meshes for abdominal wall repair. J Biomed
Mat Res 43:204-9
Dieudonn4 G (1992) L'oblitdration de trajets herniaires par bouchon de tulle prothdtique. Chirurgie 118:377-381
Klosterhalfen B, Klinge U, Schumpelick V (I998)
Functional and morphological evaluation of
different polypropylene mesh modification
for abdominal wall repair. Biomaterials 19:
2235-2246
Klosterhalfen B, Klinge U, Hermanns B, Schumpelick V (2ooo) Pathology of traditional surgical
nets for hernia repair after long-term implantation in humans. Chirurg 71:43-52
Klosterhalfen B, Klinge U (1999) Biocompatibility
of Biomaterials - Histological aspects, In:
Shumpelick V, Kingsnorth AN (eds) Incisional hernia, Springer-Veflag, Berlin, pp 198-216
Petit J, Stoppa R, Baillet J (1974) Evaluation exp4rimentale des r~actions tissulaires autour des
prothases de la paroi abdominale en tulle de

dacron en fonction de Ia durde d'implantation

et du sibge en profondeur. J Chir lO7:667-672
Rath AM, Zhang J, Amouroux J, Chevrel JP (1996)
Les prothbses pari6tales abdominales. Etude
biomdcanique et histologique. Chirurgie 121:
253-65
Stoppa RE, Rives J, Warlaumont CR, et al. (1984)
The use of dacron in the repair of hernias of
the groin. Surg Clin NAmer 64:269-74
Trabucchi E, Corsi FR, Meinardi C, Cellerino P,
Allevi R, Foschi DA (1998) Tissue response to
polyester mesh for hernia repair: an ultramicroscopic study in man. Hernia z: lO7-112
Usher FC, Fries JG, Ochsner JL, Tutfle LL (2959)
Marlex mesh. A new plastic mesh for replacing tissue defects. Clinical study. Arch Surg
78:138-145
Usher FC (1961) Knitted marlex mesh. An improved Marlex prosthesis for repairing hernias
and others tissue defects. Arch Surg 82:771-3
Wantz G (1989) Giant prosthetic reinforcement of
the visceral sac for the management of hernias
of the groin at high risk of recurrence. Surg
Gynec Obstet 168:4o8-13