Engineered Regeneration 1 (2020) 19–33

Contents lists available at ScienceDirect

Engineered Regeneration
journal homepage: www.elsevier.com/locate/engreg

Hernia Mesh and Hernia Repair: A Review

Carmine Wang See, Tiffany Kim, Donghui Zhu∗
Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York 11794

a r t i c l e i n f o a b s t r a c t

Keywords: Hernia repair for primary and incisional hernia is the most commonly performed abdominal surgery done with
Hernia extremely high costs. Treatment for hernia requires surgery to close the defect; however, there are post-operative
hernia repair complications like chronic pain, adhesion, and infection that are common. Hernia repair involves two types of
abdominal wall
biomaterials: a fixation biomaterial and a mesh biomaterial to close the defect. Synthetic meshes, mostly made
hernia mesh
from different polymers, provide adequate mechanical support but are associated with postoperative complica-
mesh materials
biomaterials tions like infection. Biological meshes are derived from allografts and xenografts that are prone to less infection;
however, their mechanical strength may be too weak depending the characteristics of the hernia defect. Novel
meshes being developed try to combat the post-operative complications of current surgical meshes. Composite
meshes that have two different surfaces have shown to have less adhesion effects but still produce varying inflam-
matory responses. Drug-loaded meshes are also a novel mesh that is designed to reduce infection with antibiotics.
This review will highlight the different fixation methods as well as the pros and cons of different mesh options.
Possible future improvements will be highlighted as well.

1. Introduction produce poor recovery and a multitude of postoperative complications

Hernia repair is the most prominent type of abdominal wall surgery
done because of various reasons. Hernia is caused by a wide range of
medical problems from trauma and underlying conditions that cause
the abdominal wall to weaken. There are multiple types of hernias
that are categorized by their location on the body. The World Society
of Emergency Surgery (WSES) broadly categorizes abdominal wall
hernias into groin hernias and ventral hernias based on anatomical
location [1]. Groin hernias are located at the bottom half of the body
and includes these types of hernias: indirect inguinal, direct inguinal,
and femoral hernias [1,2] (Fig. 1). Ventral hernias encompass the
other types of hernias which include umbilical, epigastric, Spigelian,
lumbar, and incisional hernias [1] (Fig. 1).The risk factors associated
with ventral hernias are obesity, genetic conditions, pregnancy, trauma
to the bowel area, or constant heavy lifting [3]. In general, internal
organs push through a hole in the abdominal wall, causing discomfort
or pain in that area. Hernia recurrence is common among patients
that undergo surgical treatment and is most likely due to weakening
tension of sutures over time and disorder of collagen metabolism [4].
Therefore, a lot of research goes towards developing better scaffolds
and biomaterials to prevent this problem.
It was reported that over one million repair procedures were per-
formed for both types of hernia in 2003 [5]. In addition, with each year,
more cases of hernia reoccurrences happen because current treatments
[1]. The estimated costs for both types of hernia repair costs around
$10 billion/year and will only increase as the population ages with new
cases of reoccurrence [6]. Furthermore, the surgery for hernia repair is
demanding because it requires many considerations like the appropriate
timing for surgery and right placement of the optimal prosthesis [7].
When a hernia is diagnosed, patients are either kept under close
observation to prevent worsening of the hernia or repair the hernia
via surgery. The most common type of surgical repair uses a mesh to
close the defect in a patient. There are three types of meshes currently
on the market for hernia repair. The first mesh developed were syn-
thetic meshes, which are easily manufactured with great mechanical
properties [7,8]. The second type of mesh developed was a biological
mesh which has been shown to be too mechanically weak [8]. The pros
and cons for both types of meshes are broadly summarized in Table 1.
The most recently developed type of mesh is a composite that has two
different surfaces in which one side is usually a synthetic polymer and
the other side is made of natural/synthetic materials. This review will
be dedicated to giving an overview on hernia treatments and discuss
current advancements in mesh development.
2. Treatment Overview
Treatments vary based on size and severity of the hernia. When
the hernia is not severe then the hernia is observed and monitored

∗
Correspondence to: Dr. Donghui Zhu. Stony Brook University, Department of Biomedical Engineering, Stony Brook, New York, United States.
E-mail address: donghui.zhu@stonybrook.edu (D. Zhu).

https://doi.org/10.1016/j.engreg.2020.05.002
Received 17 April 2020; Received in revised form 26 May 2020; Accepted 28 May 2020
Available online 21 June 2020
2666-1381/© 2020 The Authors. Publishing Services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an open access article under the CC
BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Fig. 1. Location of different types of hernia.

Table 1 fewer complications after surgery [13]. The most significant benefit
List of pros and cons of each type of commercially available meshes for hernia when compared to open repair is the reduction of surgical site infection
repair. [13,14]. Pain studies are variable with some studies showing that
Synthetic Biologic Composite laparoscopic surgery causes greater chronic pain or less pain in early
postoperative stages [12]. In another study, laparoscopic surgery was
Pros • Good mechanical • Mild inflammation • Low formation of
strength • Low formation of fistulae
associated with lower rates of pain after one year compared to open
• Low cost fistulae repair surgery but a small percentage of patients had severe hernia
• Reduced fibrosis recurrences compared to open repair [15]. Additionally, secondary
Cons • Inflammation prone • Higher cost • Various degree of mesh infections can also occur [16]. Laparoscopic repair was observed
• Stiffness • Supposed lower inflammation to be associated with fewer but more severe complications for incisional
• Pain mechanical
hernia repair [17]. Both surgical methods have mixed results regarding
• High infection rate strength
• Fistulae pain thus, it is generally agreed that laparoscopic surgery is associated
with shorter recovery period compared to open repair surgery.
Open repair surgery and laparoscopic surgery can both be done
on all types of hernias hence, the decision is based on the surgeons’
over time with a wait-and-see approach. This is a reasonable and safe comfort and the patient’s decision [18]. The decision is based on the
strategy if the hernia is not life threatening. If the hernia is severe, then common outcomes and circumstances of the patient. Laparoscopic
surgery is done depending on the location and size of the abdominal surgeries are beneficial because they are associated with less pain
hole. A patient’s history of past hernia surgeries is also considered and shorter hospitalization period [19]. A patient might want to do a
when choosing the procedure. Patients typically undergo open repair laparoscopic surgery to be able to return to work early. A disadvantage
surgery, Lichtenstein procedure, where the surgeon closes the hole with of laparoscopic surgery is that it requires general anesthesia with low
various fixation methods by making an incision above the hernia defect chances of intraoperative problems [18,19]. Open repair surgery has
(Fig. 2). The less invasive method is the laparoscopic technique that is the opposite problem of longer hospitalization times and requires local
usually done on hernias that reoccur but not limited to them and are anesthesia. Open repair surgery is also more readily available because
done less often (Fig. 2) [9]. it is a fairly easy surgery that any general surgeon can perform while
The open repair method is done by using a mesh to aid in closing laparoscopic requires more skill [18].
the abdominal hole. The mesh can be attached via tissue glues, tacks, Although both surgical methods each have their own advantages
staples, or sutures. It is also important to note that these attachment and disadvantages, the introduction of a mesh was also what changed
methods are also used in other types of surgeries. The mesh needs to the field. Mesh usage and proper fixation reduced reoccurrence rates
remain in place until tissue integration is complete. Complete integra- to below 5%. However, more complications have arisen as a result of
tion usually happens around 2-3 weeks after surgery [10]. In addition the introduction of the mesh, including mesh migration, chronic pain,
to tissue integration, chronic pain after the surgery is also important to infection and seroma formation [10]. The greatest concern about the
consider and a larger problem compared to hernia reoccurrence [11]. physiology of mesh implantation is the inflammation, wound healing
Around 30% of patients that undergo hernia repair surgery complain of effects and causes of pain [20]. Although a lot of research focuses
chronic pain and this number is higher for patients that did open repair on alleviating these complications, the causes of chronic pain is still
surgery [12]. During laparoscopic surgery, the mesh is placed in the unknown causing road blocks in the research [11]. The development
preperitoneal space to cover hernia sites through a small incision in the of a prosthetic mesh is also complex because they may need to be
abdomen. Like open repair surgery, tacks, glues, and sutures are used to implanted in different parts or layers of the abdominal tissue which
secure the mesh. Laparoscopic surgery results in a shorter hospital and therefore calls for different mesh properties [21].

20
C. Wang See, T. Kim and D. Zhu
Fig. 2. A) Open repair surgery B) laparoscopic surgery.
The position of the implant is also important because different
stresses and pressure result in different parts of the body. The different
positions and abdominal tissue layers are shown in Fig. 3. Onlay im-
plantation is when the mesh is placed between the subcutaneous tissue
and the anterior rectus sheath. Sublay implantation is when the mesh
is placed below the recuts muscle. This can be between the posterior
rectus sheath and the rectus muscle or between the peritoneum and
posterior rectus sheath/muscle (preperitoneal). Inlay implantation is
when the mesh is placed between the edges of the layer of abdominal
tissue where the defect is. The mesh is secured to the edges of the
defect, creating a bridge to close the hole [22].
3. Fixation methods
Implanting a mesh requires the use of a fixation device/material
in order to secure it on the defect. There are three options for mesh
implantation: tissue glue, tacks, and sutures. Table 2 shows the differ-
ent fixation methods available on the market. Note that these fixation
methods are also used in different types of surgeries.
Tissue glue is used predominately in skin closures, suture reinforce-
ment, and abdominal wall defect repair. It was first introduced by
Katkhouda et al. for inguinal hernias [23]. The two types of adhesive
glues available are fibrin glues and cyanoacrylic glue. The two key
substances of fibrin glue are fibrinogen and thrombin [24]. The fib-
rinogen can be autologous, allografts, or synthetic [24]. The fibrin glue
could be modified with other substances like growth factors, platelets
and antibiotics. The fibrinogen component gives the glue its tensile
strength and adhesive properties. The original function of fibrinogen
has hemostatic properties that stops bleeding by causing blood to
coagulate inside the body [25]. Unlike fibrin glue, cyanoacrylic glue is
made of synthetic materials and are classified as hybrid tissue sealants.
Cyanoacrylic glue have rapid adhesive properties that ensures strong
bonding with biological tissues [26]. Currently there is no evidence
to show which glue performs better in mesh fixation procedures [10].
21
Engineered Regeneration 1 (2020) 19–33
There is no difference in chronic pain and hernia reoccurrence outcomes
when cyanoacrylic glue is used compared to absorbable sutures in long
term outcomes [27]. However, early chronic pain is shown to be less
frequent with glue fixation compared to suture fixation, 3-6 months
after surgery [28]. Glue fixation is also faster and less painful in open
repair surgeries [29]. Glue fixation may be a safer alternative approach
to staple fixation without increasing the postoperative morbidity
[30].
Tack fixation is usually done in laparoscopic hernia repairs and
there are three types that are currently used in practice. Tacks are
categorized into the helical titanium tacks, helical nontitanium tacks
and absorbable tacks [10]. Helical titanium tacks place a helical coil
into the muscle of the anterior side of the abdominal wall. The tack is a
helical coil that is 4 mm × 3 mm and penetrates about 3-4mm of tissue
[31]. Helical nontitanium tacks are made of a polymer-based material
called polyacetal. The tack is hollow with an tip that is 6.7mm long
[32]. Absorbable tacks are made of polymers that degrade in tissue.
Longer tacks provide a better tensile strength thus, it is good for keeping
the mesh in place over time [33].Tacks in general have great overall
tensile strength and are easy to use. However, in recent years, negative
side effects have been seen permanent tacks, like titanium tacks, in
long term implantation. Though they have greater mechanical strength
than absorbable tacks, disadvantages like serious adhesion effects and
an increase chronic pain over time have been observed [32]. Despite
these disadvantages, tack fixation is still used in laparoscopic mesh
fixation.
There are two different types of sutures available: absorbable and
nonabsorbable. Absorbable sutures are known to lose their strength
too fast, therefore causing more hernia reoccurrences. Nonabsorbable
sutures are can retain their strength indefinitely in the body. Higher
chronic pain and longer time for pain disappearance are caused by
nonabsorbable sutures compared to absorbable sutures [34]. Non-
absorbable sutures also are shown to have lower recurrence rates in
laparoscopic surgeries [35]. This is because absorbable sutures lose
C. Wang See, T. Kim and D. Zhu
Fig. 3. A) Anatomical scheme of abdominal wall B) Onlay position of surgical mesh (green) C) Inlay position of surgical mesh (green) D) Sublay position of surgical
mesh (green).
their integrity too fast, causing the mesh to loosen and opening the
abdominal hole again before it is fully healed.
Although there are many different types of materials used to secure
a mesh, there have been no dramatic clinical differences between them.
In a study comparing permanent tacks, absorbable tacks, and synthetic
glue, all fixation methods showed no differences in postoperative pain,
and recurrence [36].
4. Mesh Development Properties
An ideal mesh can be used in any type of hernia, any location, and
any type of surgical procedure. Sanders et al. has divided this criterion
22
Engineered Regeneration 1 (2020) 19–33
into five key points: biocompatibility, risk of infection, handling con-
venience, socioeconomic, and longevity. [37] Table 3 describes these
points in more detail.
The properties of a mesh are important because it affects the degree
of fibrotic reaction, chronic pain, stiffness, and other postoperative out-
comes. The mechanical properties (tensile strength and elasticity), pore
size, weight of mesh, biocompatibility/reactivity of the mesh in the her-
nia microenvironment, constitution, and shrinkage all affect how the
mesh will be reinforced in the tissue during the healing process. The pro-
cess of mesh colonization by the host tissue is a complex process that dif-
fers in the rate of development based on the mesh material. Mesh proper-
ties and tissue colonization will be further discussed in the next sections.
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Table 2
List of fixation devices available on the market (N.A – no information in literature).

Fixation Method Fixation Type Product (Manufacturer) Material

Tissue glue Fibrin glue Tisseel (Baxter) Human fibrinogen, synthetic aprotinin, human albumin, L-histidine,
niacinamide, polysorbate 80, sodium citrate dihydrate, human thrombin,
calcium chloride dihydrate, sodium chloride, water for injection
Fibrin glue Evicel (RxList) Human fibrinogen, arginine hydrochloride, glycine, sodium chloride, sodium
citrate, calcium chloride, human thrombin, human albumin, mannitol,
sodium acetate, water for injection
Cyanoacrylic glue Histoacryl (B. Braun) monomeric n-butyl-2-cyanoacrylate
Cyanoacrylic glue Glubran-2 (GEM Srl) N butyl 2 cyanoacrylate (NBCA) and MS (monoer owned by GEM Srl)
Tacks Helical titanium tacks ProTack (MedTronic) Titanium
Helical nontitanium tacks PermaFix (Bard) Acetal polymer
Absorbable tacks AbsorbaTack (MedTronic) poly(glycolide-co-L-lactide) (PLGA)
Absorbable tacks PermaSorb (Bard) Poly-d,l-lactic Acid (PDLLA)
Absorbable tacks SorbaFix (Bard) Poly(D,L)-lactide (PLA)
Sutures Absorbable sutures Monocryl (J&J) Poliglecaprone
Absorbable sutures Vicryl (J&J) Polyglactin
Absorbable sutures Dexon (N.A) Polyglycolic acid
Absorbable sutures Maxon (Medtronic) Polyglyconate
Absorbable sutures PDS (J&J) Polydioxanone
Nonabsorbable sutures Prolene (J&J) Polypropylene
nonabsorbable sutures Nylon (Dolphin Sutures) Polyamide

Table 3 Table 4
List of criteria for hernia mesh development from Sanders et al by Idrees et al. Categories of mesh pore size [44].
[38].
Pore Type Size (μm)
Criteria
Very Large Pore >2,000
Biocompatibility • Physically and chemically inert Large Pore 1,000-2,000
• Harmless Medium Pore 600-1,000
• Reinforce and resist mechanical Small Pore 100-600
strains Microporous (Foil) <100
• Allow normal physiological
function
• Nonallergic
• Nonmigratory
• Non-adherent to viscera the resistance of the mesh is not compatible with the host tissue [38].
• Capable of causing or predicted This causes discomfort therefore; it is better to use materials with
biological response
low resistance and greater elasticity. A large mesh should be able to
• Non-carcinogenic
withstand around 180 mmHg. The abdominal wall is around 38%
Risk of infection • Resistant to infection elastic at 32N/cm. Light weight meshes have a elasticity in the range
• Not act as a vehicle for infection of 20-35% at 16N/cm41 . Heavy weight meshes have a much lower
transmission
elasticity in the range of 4-16% at 16N/cm. When taking into account
Handling convenience • Easy to handle the maximum abdominal pressure and the Laplace law, the maximum
• Easy to implant theoretical strength per unit width of a hernia mesh should be 32 N/cm
• Not restrict future surgical access and 16N/cm for a large and small hernia respectively [42].
of imaging Pore size is the main factor that affects tissue reaction because it
Socioeconomic • Easy sterilization is proportional to the amount of host tissue incorporation [43]. The
• Easy manufacture porosity of a material is the ratio of open to solid space with respect
to volume, area, or weight [42]. Earle et al. characterized hernia mesh
Longevity • Retains all characteristics in long
pore sizes into 5 types (Table 4) [44]. A pore size bigger than 75 μm can
term
facilitate rapid infiltration of fibroblasts and macrophages because the
cells can penetrate and colonize the mesh more easily [20,38,42]. The
recruited cells will produce collagen that will form the new connective
4.1. Mesh Properties tissue and anchor the mesh. However, this will also easily cause adhe-
sion to the surrounding viscera. When meshes with pore sizes smaller
It is important in the healing process for a hernia mesh to mimic than 800 μm are implanted, a stiff plate forms on the implant site that
the tension and elasticity of the abdominal wall. The tension of the results in a decrease in flexibility. This is because individual granulomas
abdominal wall is calculated using the “Laplace Law”. The law states are formed around the individual mesh fibers which then combine
that in an elastic spherical vessel, in this case, the abdomen, tension, and cover the mesh [45]. Granulomas bridging will occur when they
pressure, wall thickness, and diameter are related with the formula38 : become confluent with each other [42,46]. Pore size larger than 1mm
create more flexible soft tissue growth because of lower granulomas
(𝑑𝑖𝑎𝑚𝑒𝑡𝑒𝑟 × 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒) bridging due to a larger space (Fig. 4C). In conclusion, larger mesh
𝑡𝑒𝑛𝑠𝑖𝑜𝑛 =
4 × 𝑤𝑎𝑙𝑙 𝑡ℎ𝑖𝑐𝑘𝑛𝑒𝑠𝑠 pore sizes cause less foreign body reactions and fibrosis of local tissues
The maximum intra-abdominal pressure is approximately 170 compared to small pores [42]. Additionally, the relationship between
mmHg, caused by coughing and jumping [39,40]. Heavy weight porosity and biofilm formation is also shown to be associated with the
polypropylene (PP) meshes could withstand 10 times this pressure. growth of bacteria on the biofilm. Small pores are associated with more
However, after implantation, the natural elasticity is reduced because biofilm formation because there is less tissue integration compared to

23
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Fig. 4. Representative images of different meshes of different pore size and filament composition adopted from multiple literature: A) Scanning electron microscope
image of Prolene (top row), Ultrapro (middle row), and Bard Soft (bottom row) [89]. Prolene is a monofilament mesh with medium pore size. Ultrapro is a
monofilament mesh with a large pore size. Bard soft is a monofilament mesh with a large pore size. B) Parietex Mesh is a multifilament mesh with large pores from
Ethicon website. C) Large pore granuloma formation vs small pore granuloma formation [46].

Table 5 have a small ratio of collage I to collagen III, leading to mesh instability
Categories of mesh weight [44]. [41,42]. This effect is seen in the healing process in different types
Weight Type Density g/m2 of meshes with different degrees of collagen laid out. Most synthetic
meshes produce varying degrees of foreign body reactions because of
Heavyweight >90
their physiochemical properties on the surface of the mesh. Biological
Medium Weight 50-90
Light Weight 35-50 meshes produce lower foreign body reactions in the long term because of
Ultra-lightweight <35 better tissue integration and the presence of bioactive molecules present
in the biological mesh [48]. The complement system of the immune
system is also seen to be affected by the presence of a mesh. A mesh
creates an inflammatory prone microenvironment at the mesh implant
large pore sizes [47]. Biofilm formation increases bacteria growth on
site [49]. The complement system promotes inflammation, enhances
the mesh, causing more inflammation and infection in the patient [47].
antibodies and phagocytic cells function. PP meshes were found to ac-
The mesh weight is based on polymer weight and its pore size. Earle
tivate the complement system through C5a receptor signaling and that
at al. categorized mesh weights into 4 categories (Table 5) [44]. Heavy
it is also possible to inhibit this reaction to reduce inflammation [49].
weight meshes (>90g/cm2 ) are made of thick polymers with small pore
The constitution of a mesh also affects the rate of infection after
sizes, resulting in high tensile strength. They have a lot of surface area
implantation. The two types of constitution are monofilament and mul-
as well. Heavy weight meshes are known to cause more chronic pain,
tifilament fibers. Monofilament meshes uses one fiber that is weaved
large foreign body reaction, fibrosis, and adhesions, and lead to more
into a knit or woven pattern. Multifilament meshes uses multiple fiber
shrinkage [42]. Light weight meshes have larger pores (>1mm) with
strands twisted together that is weaved into a knot or woven pattern.
thinner filaments, making them more elastic. These meshes usually
Multifilament meshes have a higher infection risk because bacteria
cause less foreign body reaction and even though they have less tensile
can get trapped in the smaller pores of the mesh, making it hard for
strength then heavy meshes, they are still able to withstand pressures
immune cells to get to [45].
higher than the highest intra-abdominal pressure [38]. These properties
Shrinkage is the contracting of the mesh when scar tissue starts to
allow light weight meshes to not develop dense scar tissue while also
build up during tissue remodeling [50]. This contraction causes tension
maintaining sufficient mechanical strength [42]. Light weight meshes
on the hernia defect thus, causing the mesh to loosen, leading to hernia
are also better in reducing long-term complications like chronic pain
recurrence. PP meshes have been observed to have the least shrinkage
and inflammatory responses.
compared to PET meshes [51]. Different PP meshes with different
The biomaterials currently used to develop meshes are physically
weights have been shown to have a very small difference in shrinkage
and chemically inert but, not biologically inert because a foreign body
when compared to each other. Heavy weight PP meshes have a slightly
reaction is activated inside a host. In a normal healing process, imma-
higher shrinkage rate but the difference is small compared to light
ture type III collagen is laid out and then is replaced by type I collagen.
weight PP meshes [50].
In hernia patients, this process is altered causing the abdominal wall to

24
C. Wang See, T. Kim and D. Zhu
Fig. 5. Mechanisms of MAST complex formation.
4.2. Mesh Reinforcement in Tissue
The purpose of using a mesh is to provide a platform for native tissue
to colonize through fibrotic reactions in the tissue [52,53]. A strong
mesh aponeurosis scar tissue (MAST) complex reinforces the weakened
abdominal tissue when implanted. MAST formation happens when
connective tissue is deposited onto the mesh pores and filament (Fig. 5)
[38,44]. The newly formed MAST tissue takes about 6 months to attain
70-80% of mechanical strength of native tissue [44]. When the MAST is
formed on the mesh, the scar tissue causes shrinkage. Around 80-90%
of articles observe shrinkage in their results [38]. Three factors need to
25
Engineered Regeneration 1 (2020) 19–33
be taken into consideration between mesh and native tissue interaction:
tissue reaction thickness, fibroblastic activity, and cell density [38].
5. Prosthetic Mesh for Abdominal Wall Repair
There are around 70-80 types of commercially available meshes for
hernia repair [38]. Current hernia treatment uses one of the two main
types of meshes, synthetic and biological. In recent years, composite
meshes that have two different surface properties on each side are
being tested and show promising results. The first generation meshes
are synthetic and biological meshes because some are currently used
C. Wang See, T. Kim and D. Zhu
in treatments while the more recently developed meshes are consid-
ered second generation meshes. The next section will be devoted to
highlighting recent advances in each of these types of meshes and the
direction the research is heading towards.
5.1. Synthetic Meshes for Abdominal Wall Repair
There is a wide variety of synthetic meshes available on the market.
Non-absorbable synthetic meshes are commonly made of polypropy-
lene (PP), expanded polytetrafluoroethylene (ePTFE), and polyester
(PET) [42,54,55]. Absorbable synthetic meshes are commonly made
of biodegradable polymers or combinations of poly lactic-co-glycolic
acid (PLGA) and polyglycolide (PGA) [55]. First generation synthetic
meshes were based on PP systems with three different categories:
macroporous meshes, microporous meshes and macroporous meshes
with multifilament or microporous components [20] (Fig. 4 A-B).
Synthetic meshes come in two different structures: knitted and woven.
Knitted meshes are more flexible and more porous while woven meshes
have a higher fiber density. This higher density causes creates poor
tissue integration [55]. Macroporous meshes have a pore size larger
than 75μm. Microporous meshes have smaller pore sizes around 10μm.
Multifilament macroporous meshes with microporous components have
plaited multifilamentary threads in their composition. The threads
are less than 10μm apart and the mesh pore size is larger than 75μm.
Table 6 shows a comprehensive review of commercially available
first-generation synthetic hernia meshes. [20]
Non-absorbable synthetic meshes are permanent meshes that are
associated with numerous risks. The mechanical strength of synthetic
meshes are much greater than native abdominal tissue. This property
is associated with high inflammation, immune reactions and loss of
elasticity, thus causing more adhesion formation due to mesh shrinkage
[42,55]. PP meshes are inexpensive however they are mostly associated
with chronic pain, but they have great tissue integration with the host.
In a clinical study, comparing a PP mesh and a low-cost synthetic
mosquito mesh, around 30% of both meshes resulted in postoperative
complications [56]. When compared to a biological mesh, PP mesh have
a higher pain trend by 2% in another clinical study [57]. PET meshes are
less commonly used because there are conflicting views on their clinical
performance [55]. Records indicate that PET meshes are more cyto-
compatibile because less inflammation and foreign body responses are
observed in patients, thus, leading to better tissue ingrowth and histolog-
ical properties [58]. However, patients are more suspectable to infection
over a long period of time [58]. The use of a (PET) mosquito mesh is
shown to produce low infection rates (2.4%) and low seroma formations
(7.2%) [59]. Compared to PP and PET meshes, ePTFE meshes are associ-
ated with worst tissue integration but have less adhesions [42,55]. This
lack of tissue integration is associated with higher hernia reoccurrences.
A clinical study has shown that 4.4% patients experienced recurrence
and 44% of patients experience comorbidities [60]. In another clinical
study, ePTFE is found to have low adhesions with 91% of the cases with
no or filmy adhesions but also have poor tissue integration [61]. Gener-
ally, each type of non-absorbable synthetic mesh has their advantages
and disadvantages based on their material and interactions in vivo.
Absorbable synthetic meshes are designed to limit inflammatory
responses by promoting tissue integration and then minimizing the
amount of material left in the body. Non-absorbable meshes cause
more inflammation because the mesh provides a material for bacteria
to proliferate [62]. Kalaba et al. give a comprehensive summary of
common absorbable meshes and their advantages and disadvantages
[42]. Briefly, absorbable meshes are more resistant to infection than
nonabsorbable meshes and can provide good mechanical support in
the short term. However, mechanical stability is lost too soon due to
degradation, thus, leading to possible hernia recurrences [58,63]. A
PLGA absorbable mesh caused 16% of patients to experience chronic
pain after 3 years with no hernia recurrences [64]. However, the rapid
degradation of PGA produced mechanical instability at the hernia de-
26
Engineered Regeneration 1 (2020) 19–33
fect, causing high reoccurrence rates [58]. Overall, absorbable meshes
are more effective against infections but their lack in mechanical
strength long term is questionable.
5.2. Biological Meshes for Abdominal Repair
Biological scaffolds, developed after synthetic meshes, are extracel-
lular matrix (ECM)-based scaffolds derived from allogenic or xenogenic
origins. Allogenic origin grafts can be autografts or allografts. Table
7 is a list of biological meshes on the market. The mesh usually
consist of human porcine orfetal bovine dermis that is decellularized.
Decellularization leaves the complex collagen structure of the dermis.
Porcine small intestine submucosa and bovine pericardium is also
commonly used. Costa et al. extensively describes the composition of
biological meshes in their review [7]. The mesh is designed for the
host tissue to recolonize with cells and promote tissue growth, leading
up to reabsorbtion [65]. Compared to synthetic meshes, biological
meshes are more biocompatible and trigger less inflammatory response
from the body, but they are associated with more hernia recurrences
because of their lower mechanical strength compared to synthetic
meshes. In a clinical study comparing a skin graft mesh and a PP
mesh, 12% of patients experienced hernia recurrence in total for the
skin graft mesh compared to no recurrences in the PP mesh [66]. The
production of these meshes are very high therefore, it is unfeasible for
mass production, slowing its application in hernia repair. Additionally,
there is little evidence to support the usage of biological meshes with
its clinical performance to support their high costs [67].
Cross-linking strengthens the mechanical properties of the ECM and
slows down degredation [68,69]. Although the properties of the mesh
is improved, slower degradation rate creates a slower release of growth
factors (GFs) and other cell proliferation molecules in the biological
mesh [70]. Furthermore, cross-linking is associated with increased
toxicity and inflammation possibly due to the presence of the crosslink-
ing agents [69]. Non-cross linked meshes are shown to have better
non-adhesion rates when implanted in rats [71]. A retrospective study
that compared Permacol (crosslinked porcine dermis) and Strattice
(non-crosslinked) showed that overall, Strattice meshes cause less post-
operative infections at 21% compared to 35% in Permacol meshes [72].
5.3. Composite Meshes for Abdominal Repair
Although the first generation meshes of synthetic or biological
meshes were approved clinically, there were still a lot of complications
involved with first generation meshes described in Table 6 and Table
7. Complications included hernia recurrence, infection, and adhesions
continue to predominate. In order to try to mitigate these complica-
tions, a second generation of meshes were developed that had different
properties on each side of the mesh (Table 8). The different properties
are generally achieved by combining different materials together.
The visceral side of the mesh is generally is smooth/micropourous to
prevent adhesion while the other side facing the abdominal tissue is
rough/macropourous to encourage tissue infiltration [20,73]. These
meshes usually have a PP backbone with another synthetic/ natural
polymer material to improve its non-adhesive properties [20]. Different
layers of synthetic material were incorporated to provide a different
surface that would interact with different layers of the abdominal wall
to promote less adhesion. As a result, these meshes are implanted in a
specific orientation. Generally, the side of the mesh that will be facing
the visceral side of the body is degradable to avoid adhesion. The
addition of another synthetic material, like poliglecaprone 35 in the
Ultrapro mesh, significantly lowers tissue reaction and reduced foreign
body reaciton [41].
There are a variety of non-adhesive coatings used for composite
mesh fabrication with various results. Some of the common costings
used are chitosan, cellulose, and collagen. The use of chitosan coating
on a PP mesh and Proceed mesh (cellulose coating) are found to
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Table 6
Table of synthetic meshes.

Product Composition Pore size Absorbable Weight Filament Mechanical Properties Advantages Disadvantage
(Manufacturer) (mm) (g/m2 )

Vicryl (Ethicon) Polyglactin 0.4 Yes 56 Multifilament Tensile strength of Lower risk of infectious High probability of hernia
[20,42] 78.2 ±10.5 N/cm in disease transmission, recurrence after complete
longitudinal able to maintain absorption. Inflammation
direction & mechanical stability and scar tissue fonnation
45.5±13.5 N/cm
Dexon (Syneture) Poly glycolic 0.75 Yes 56 Multifilament N.A Adhesion decreases when It is controversial whether the
[20,42] acid the mesh is absorbed, fibrous ingrowth into the
little inflammation and prothesis is enough to
moderate fibrosis accomplish proper healing.
Sefil (B- Baun) Poly glycolic 0.75 Yes 56 Multifilament N.A High anatomic adaptability Retains 50% of its mechanical
[20] acid and lower risk of late strength for 20 days
secondary infection
Marlex (Bard) PP 0.8 No 80-100 Monofilament Tensile strength of High tensile strength Chronic inflammatory reaction
[20] 58.8 N/cm
3D Max (Bard) PP 0.8 No 80-100 Monofilament Tensile strength of Reduced patient pain Adhesion risks
[7,20] 124.7 N/cm
Polysoft (Bard) PP 0.8 No 80-100 Multifilament Burst strength of Low infection rate Produces dense adhesions in
[20] 558Nand stiffness of extraperitoneal spaces
52.9 N/cm therefore not recoimnended
Prolene (Ethicon) PP 0.8 No 80-100 Monofilament Tensile strength of Facilitates fibrovascular Adhesion risks
[7,20] 156.5 N/cm ingrowth, infection
resistant. Mesh
compliance is improved
Surgipro PP 0.8 No 80-100 Multifilament Tensile strength of High tensile strength with Difficult complete wound
(Autosuture) [20] N/cm in longitudinal ease of handling and healing because of mesh
direction and N/cm position. Retains structure
in transverse properties post
direction operation.
Prolite (Atrium) PP 0.8 No 80-100 Monofilament Tensile strength of 138 Monofilaments aligned in Adhesion risks
[20] N/cm parallel spaced angles to
maximize material
flexibility in two
dimensions and produce
a smooth uniform open
architecture
Trelex (Meadox) PP 0.8 No 80-100 Multifilament N.A Low infection risk Dense adhesions produced in
[20] extraperitoneal spaces
therefore not recommended
Atrium (Atrium) PP 0.8 No 80-100 Monofilament Tensile strength of High tolerance to infection Adhesion risks
[20] 56.2 N/cm
Premilene (B- PP 0.8 No 80-100 Monofilament Tensile strength of Mesh can adapt to the Adhesion risks
Braun) [20] N/cm in longitudinal longitudinal and
direction and N/cm latitudinal axes of the
in transverse connective tissues where
direction implanted. Rapid healing
and tissue penetration
Serapren PP 0.8 No 80-100 Multifilament N.A. Low infection rate Dense adhesions produced in
(smooth) [20] extraperitoneal spaces
therefore not recommended
Parietene PP 0.8 No 80-100 Multifilament Tensile strength of Low infection rate Dense adhesions produced in
(Coviden) [20] 38.9± 5.2 N/cm in extraperitoneal spaces
longitudinal therefore not recommended
direction and
26.6±4.2 N/cm in
transverse
Prolene Light PP 1.0-3.6 No 36-48 Monofilament Tensile strength of 20 Great flexibility Dense adhesions produced in
(Coviden) [20] N/cm intraperitoneal spaces
therefore not recommended
Optilene (B- PP 1.0-3.6 No 36-48 Monofilament Tensile strength of 58 Soft, thin, and pliable. Dense adhesions produced in
Baun) [20] N/cm Reduces chronic pain in extraperitoneal spaces
inguinal hernia therefore not recommended
Merilene POL 1.0-2.0 No 40 Multifilament Tensile strength of 19 Low infection risk Causes aggressive macrophage
(Ethicon) [20] N/cm and giant cell rich
inflammatory reaction with
dense fibrous ingrowth
Dulex (Bard e-PTFE Up to 0.5 No N.A N.A N.A. Minimize adhesion Hernia recurrence
DAvol) [20]
Goretex (Gore) e-PTFE 0.003 No Heavy Multifilament Minimum tensile Smooth and strong Causes chronic inflammatory
[20] weight strength of 16 N/cm reaction
Vitamesh PP 2.4 ±0.4 No 52 ±8 Monofilament 28.8N No signs of shrinkage, no Severe adhesions.
(Atrium)[100] mm2 seroma fonnation
PP: Polypropylene, e-PTFE: Expanded polytetrafluoroethylene, N.A: no information in literature.

27
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Table 7
Table of biological meshes commercially available.

Product (Manufacturer) Composition (source) Tensile Strength Advantages Disadvantages

Surgisis (Cook) [20] Small intestine submucosa 4 MPa Refrigeration not required. Long history of Requires hydration and
(Porcine) reported safety susceptible to collagenases
FlexHD (J&J) [7,20] Acellular dermis (Human) 10 MPa No refrigeration required and rehydration N.A.
AlloMax (Davol) [7,20] Acellular dermis (Human) 23 MPa No refrigeration required and rehydration. Hydration required
Available in large sizes
CollaMend (Davol) [7,20] Xenogenic acellular dermis 11 MPa No refrigeration required and rehydration. N.A.
(Procine/bovine) Available in large sizes
Strattice (LifeCell) [7,20] Xenogenic acellular dermis 18 MPa Available in large sizes Limited long-term follow up
(Procine/bovine)
Permacol (Covidien) [7,20] Xenogenic acellular dermis 39 MPa No refrigeration required and rehydration. N.A.
(Procine/bovine) Available in large sizes
XenMatrix (Davol) [20] Xenogenic acellular dermis 14 MPa Available in large sizes Limited long-term follow up
(Procine/bovine)
AlloDerm (LifeCell) [7,20] Dermis (Human) 84.3 ± 5.1 N/cm vascularization and remodeled by Great implant-defect at
[101] autologous cells and to resist infection interface
[102]
Peri-Guard (Synovis Surgical Pericardium (Bovine) 56.5 ± 6.1 N/cm N.A. Shrinkage
Innovations) [7,20] [101]
Surgimed (TEI) [103] Acellular dermal tissue N.A Low recurrence N.A
(Bovine)
Tutomesh (Tutogen) [104] Pericardium (Bovine) N.A No rehydration required, no refrigeration, N.A
no evidence of recurrence
Veritas (Synovis) [105] Pericardium (Bovine) N.A No adhesions Hernia recurrence

N.A.: no information in literature.

have similar efficiency however, there was significant inflammatory
responses in both groups [74]. An oxidized collagen/chitosan coating
that was developed by Pascual et al. also showed favoring anti-adhesion
effects and showed good tissue infiltration like the Physiomesh and
Ventralight mesh [75]. The disadvantage was that there were intense
macrophage reactions in all three groups with Ventralight mesh the
highest [75]. Collagen coatings are also seen to significantly reduce
adhesions and do not create complications in rats [76]. Commercially
available meshes like Perietene Composite (collagen coating), Parietex
Composite (collagen coating), C-Qur Edge mesh (omega-3 fatty acids
coating), Sepramesh IP (cellulose coating), and Intramesh T1 (monofil-
ament PP coating) all had low adhesion rates showing that a coating is
needed to prevent adhesions however, the chemical properties seem to
be less important [77]. Similarly, to previous studies, each of these com-
posites meshes had various degrees of inflammation. Other uncommon
anti-adhesion proteins used are mussel adhesion proteins copolymer
developed by Hu et al [78]. The mussel inspired coating demonstrated
great biocompatibility and lower adhesion rates with minimum chronic
inflammation; a comprising new candidate for preventing adhesion
[78]. Overall, composite meshes decrease adhesion problems however,
inflammation is still a reigning problem with these meshes.
5.4. Which Mesh is Better?
All three types of meshes have their own benefits and drawbacks,
and therefore, all of them are used clinically. Mesh choice is based on
the surgeon’s preference thus, there is no consensus on which mesh is
optimal. There is also no universal way to test the mechanical strength
of meshes because there is a wide range of methods that could be used.
Most studies use uniaxial tensile testing and biaxial tensile testing;
however, there are other techniques like ball burst, suture retention
strength, and tear resistance testing [79].
In summary all three types of commercially available meshes (syn-
thetic, biologic, and composite) all have their advantages and disadvan-
tages as seen from studies in the previous section. Non-absorbable syn-
thetic meshes have great mechanical strength however cause adhesion,
inflammation and pain. Absorbable synthetic meshes limit inflammation
responses in exchange for limited mechanical strength in the long term
that may lead to hernia recurrence. Biological meshes trigger less inflam-
matory responses but like absorbable synthetic meshes, have low me-
chanical strength. Composite meshes have low adhesion rates but have
varying degrees of inflammation, causing chronic pain and discomfort.
Previous review articles have showed how studies done on biolog-
ical meshes was poorly executed with poor standards [80]. There is a
consensus that biological meshes are better at preventing infection in
a contaminated field. However, in a systematic review of synthetic and
biologic meshes, authors found no evidence that supported the supe-
riority of biological meshes over non-absorbable synthetic meshes in
a contaminated field; thus, there are still conflicting opinions [81-83].
Biological meshes are also known to be weaker than synthetic meshes in
terms of strength; therefore, the placement of biological meshes affect
recurrence rates. The onlay position and bridging the gap position is
the least favorable position to place a biological mesh due to its lack
of mechanical strength. Recurrence rates of 28.6% and 29.1% were
observed in onlay and bridging positions, respectively, with biological
meshes [84]. Biological meshes are more suitable for abdominal wall
reconstruction but not recommended for certain locations of repair as
shown before, and is more suitable in contaminated fields [85]. There is
also no significant difference with the usage of biological meshes in re-
currence, hematoma, and postoperative pain for inguinal hernia repair
[86]. A systematic review done by Muysoms et al. concluded that there
was not enough evidence to show that biological meshes are better than
synthetic meshes in preventing incisional hernia [87]. A study done
by Scott et al. with an absorbable poly-4-hydroybutyrate composite
mesh showed that absorbable meshes with a longer resorption rate may
provide better mechanical properties compared to biological meshes
[88]. Overall, biological mesh performance is shown to be similar to
that of synthetic meshes, but the lack of high standard comparative
studies fail to give a definitive answer to which type of mesh is optimal
[80]. The experience of surgeons also play a role in the outcome of
surgeries, making these mesh studies more difficult to determine the
optimal type of mesh [7,57]. It is generally agreed that synthetic
meshes are preferred for clean, low grade hernias. Contaminated, high
grade hernias should be treated with biological meshes [7].
The development of hernia meshes have advanced enough to have
a general idea of what criteria and properties the ideal mesh should
have. Based on synthetic mesh results mentioned before, heavy weight
meshes are not preferred because they have a higher shrinkage rate,
causing unneeded tension on the repair site. A non-adhesive coating is
also necessary to not cause any adhesion to internal organs. The mesh

28
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Table 8
Table of Composite Meshes.

Product Composition Pore size Absorbable Weight Filament Mechanical Properties Advantages Disadvantage
(Manufacturer) (mm) (g/m2 )

Vypro, VyproII PP/polyglactin >3 Partially 25&30 Multifilament Tensile strength of 16 Significantly decrease Higher rate of hernia
(Ethicon) [7,20] 910 N/cm rate of chronic pain recurrence
Gore-Tex Dual e-PTFE (Corduroy 0.003- No Heavy Multifilament Minimum tensile Promote host tissue Risk of infection
Mesh, Dual Mesh surface & smooth 0.022 weight strength os 16 N/cm growth and reduces
Plus (Gore) [20] surface) and 157.7 N/cm adhesion
Parietex POL/collagen >3 Partially 75 Multifilament Elasticity of 3.5 at 16N Anti-adhesion property Greater infection rate (57%)
(Covidien) [20] for short term
Composix EX PP/e-PTFE 0.8 No Light Monofilament N.A. Minimum adhesion Infection risk
Dulex (Bard) [20] Weight and optimal tissue
ingrowth
Proceed PP/cellulose 2 mm Partially 45 Monofilament Tensile strength of Low hernia recurrence Risk of adhesions
(Ethicon) 56.6 N/cm (3.7%)
[7,20,106]
DynaMesh IPOM PP/PVDF 1-2 Partially 60 Monofilament Tensile strength of Lihle foreign body Adhesion risk
(FEG 11.1±6.4 N/cm in reaction
Textiltechnik) longitudinal
[20,106] direction and
46.9±9.7 N/cm in
transverse
Sepramesh PP/sodium 1-2 Partially 102 Monofilament N.A Reduce adhesion and Sticky consistency - hard to
(Genzyme) [7,20] promote optimal handle
tissue ingrowth
Ultrapro PP/PGC-25 >3 Partially 28 Monofilament Tensile strength of 55 Lower inflammatory Adhesion risk
(Ethicon) [7,20] N/cm response
Ti-Mesh (GfE) PP/titanium >1 No 16&35 Monofilament Tensile strength of 12 Lower inflammatory Low tensile strength
[20] N/cm (at 16 g/m2 ) response
and 47 N/cm (at 35
g/m2 )
C-Qur (Atrium) PP/omega 3 >1 Partially 50 Monofilament Ball burst strength of Anti-adhesion property No difference in adhesion
[7,20] 170±20.1N for short term grade with other meshes
Physiomesh PP/poliglecap 5.006 ± Partially Light Monofilament N.A Mild adhesion rates Seroma formation, hernia
(Ethicon) rone 25 0.155 weight recurrence, quality of tissue
[75,107,108] mm2 is low compared to other
composite meshes
Ventralight PP/sodium 0.134 ± Partially Monofilament N.A Vascularization of Seroma formation, increase in
(Bard) [108] Hyaluronate- 0.019 medium mesh cytokine expression
carboxymethyl- mm2 weight
cellulose and
PGA
Parietene DS PP/ collagen base 1.5 xl.7 Partially 73 Monofilament Tensile strength of 42 Low adhesion Low shrinkage (-14%)
composite layer N/cm
(Covidicn)
[7,77,106]
PP: Polypropylene, e-PTFE: Expanded polytetrafluoroethylene, POL: Polyester, PVDF: Polyvinylidene fluoride, PGC-25: poliglecaprone 25, N.A: no information in
literature.

must maintain enough mechanical strength, of maximum abdominal
pressure (170 mmHg), throughout the whole healing process or else
hernia recurrence is likely based on absorbable synthetic and biological
mesh results. The theoretical max tensile strength should be 32 N/cm
and 16N/cm as stated previously in mesh properties. Macropourous
meshes are also preferred for the side opposite of the visceral side to
promote collagen deposition.
5.5. Recent Meshes: Drug Loaded Meshes and Beyond
Hernia treatment relies heavily on the development of the bioma-
terials used to make meshes. Currently, the usage of composite meshes
solve the adhesion problems produced by synthetic meshes. Synthetic
meshes are great for low grade hernias with low cost. Biological
meshes are great for high grade hernias but are subject to untimely
degradation, leading to hernia recurrence and are expensive to produce.
A new type of mesh with drugs loaded into the mesh network is a
recent advancement in the field. Most synthetic meshes are made with
a hydrophobic material that makes it difficult to load drugs into it [90].
New methods of modification on hydrophobic meshes or drug loading
vehicles are developed and summarized on Table 9. Reinbold et al.
tested a PP mesh loaded with degradable poly(lactide-co-glycolide acid)
microspheres with rifampicin, a antibacterial agent [91]. Rifampicin
released by the mesh was able to stop infections caused by S. Aureus in
vivo. The incorporation of antibacterial drug/ coating is starting to be
researched to protect against the current clinical problem of infection
and inflammation. The use of carboxymethylcellulose gel loaded with
chlorhexidine in a PP mesh showed that it reduces chlorhexidine toxic-
ity in vivo but it also maintains its antibacterial effect at the defect area.
This demonstrated that antibacterial gel-coated PP meshes can prevent
bacteria from attaching to the mesh surface and have no effects on
wound repair [92]. PP mesh has also been loaded with hexamethylene
diisocyanate and 𝛽-cyclodexrins as antimicrobial agents [90]. Most
studies load antibacterial drugs to prevent infection and inflammation
after implantation and engineered different possible ways to load drugs
on to a mesh. These loading techniques open more possibilities like
loading other types of substances, not just antibiotics, such as growth
factors (GFs) and cytokines. Loading GFs and other key molecules can
help recruit stem cells to start colonizing the mesh and start the healing
process. Wang et al. generated a mesh using electrospun PLLA loaded
with growth factors bFGF to inhibit inflammatory reactions to promote
healing [93]. This promoted fibroblast proliferation, improved collagen
expression, and regulated immune-related cytokines [93]. In a hydrogel
model, Qin et al. fabricated a hydrogel loaded with a ani-inflammatory

29
C. Wang See, T. Kim and D. Zhu Engineered Regeneration 1 (2020) 19–33

Table 9
Table of drug loaded meshes.

Composition (Author, year) Drug loaded vehicle (purpose) Results

PP (Reinbold et al, 2017) [91]
PP (Pérez-Köhler et al, 2019) [92]
PP (Sanbhal et al, 2018) [90]
Polycaprolactone electrospun fibers
(Hall Barrientos et al, 2017) [109]
Plasma functionalization of PP (Labay
et al. 2015) [110]
Polyester (Blatnik etal. 2017) [111]
3D printed PP and PVA mesh (Qamar
et al. 2019) [112]
Electrospun PLLA (Wang et al. 2019)
[93]
Rifampicin (antibacterial agent)
Chlorhexidine (antiseptic) loaded
carboxymethylcellulose gel
levofloxacin (antibiotic) loaded in
hexamethylene diisocyanate and
𝛽–cyclodexrins
Irgasan (antibacterial agent) or
levofloxacin (antibiotic)
Ampicillin (antibiotic)
Vancomycin (antibiotic) loaded in
cyclodextrin-based polymer
ciprofloxacin HCl (antibiotic)
Basic fibroblast growth factor (bFGF)
Reduce and provide protection from postoperative infection and biofilm formation in
vivo.
Gel reduced toxicity of chlorhexidine without affecting its antibacterial behavior.
Macrophage reaction was reduced compared to control group. Prevent bacterial
adhesion on mesh surface and has no detrimental effects on wound repair.
Antibiotic loaded meshes sustained antibacterial properties for 7 and 10 days
against gram +/- bacteria. Mesh demonstrated sustained drug release.
Levofloxacin exhibited a burst release profile and irgasan showed sustained release.
Both drugs successfully inhibited growth of E. coli and S. aureus.
Plasma functionalization improves wettability of PP mesh and led to a 3-fold higher
antibiotic loading capability.
Prevented synthetic mesh infection in pig model. Antibiotic-resistant bacteria were
cleared. Polymer coating did not compromise the strength if hernia repair.
PVA meshes showed slightly faster release of drug. Both types of meshes showed no
signs of implant rejection and adhesions to the visceral tissue was mild to
moderate. Ciprofloxacin loaded meshes in vivo showed fewer fluctuations in body
temperature and faster wound healing.
Promoted fibroblast proliferation, increase collagen expression, regulated immune
response cytokines

Fig. 6. Summary of all reviewed elements of hernia repair.

drug, Puerarin, that was able to inhibit inflammatory responses and
promote tissue regeneration [94]. Cell loading may also be a possibility,
which has already been shown to benefit other types of scaffolds. An
example of this is a scaffold loaded with stromal vascular fraction
cells for breast cancer reconstruction. This combination resulted in an
increase in vascularization and helping the graft last longer in vivo [95].
The next step in mesh development could lead into the field of
smart biomaterials. Environmental stimuli (pH change, temperature,
etc.) causes the smart biomaterial to change configurations, leading
to drug release, changes in the material or cell recruitment. Smart
biomaterials developed for cartilage and neural tissue engineering has
improved cell loading and coculture, osteoblast proliferation, and drug
delivery [96]. Controlled drug delivery and stem cell recruit would be
helpful in the field of hernia repair because abdominal tissue is thick
with many microenvironments around the implant, thus calling for
more complex meshes. However, there is currently no known smart
biomaterial developed for hernia repair.
Biomimetic materials are a growing interest in other fields to repair
tissues with self-healing materials that mimic the healing process of
biological systems. Biotechnology is trying to mimic biological systems
in their steps in sealing and healing the wound once there is damage
for various medical applications [97]. Recently, a layer by layer film
have been developed that mimic human epidermis that can self-heal
with high stiffness and hardness [98]. Self-healing is induced when the
different layers mix when damaged and it has antibacterial properties
like skin. Self-healing hydrogels have also been developed by using
mussel proteins that are triggered by pH changes [99]. Such biomimicry
can be useful in developing a mesh that can replace the abdominal
tissue inside a patient because it can mimic the active healing properties
like healthy native abdominal wall tissue.
6. Future Direction of Hernia Treatment
Hernia treatment predominately relies on a mesh prosthetic to treat
patients. Therefore, a lot of research focuses on developing new types of
mesh that can reduce post-operative complications and promote tissue
regeneration in the defect area. Although a lot of research is devoted
to mesh development, mesh complications result from a multitude of

30
C. Wang See, T. Kim and D. Zhu
factors. Consequently, just focusing on mesh development may not be
enough to solve postoperative complications. Factors, like surgical tech-
nique, mesh location, mesh fixation method, surgeon experience also
play a role in the outcome. Current meshes all have their own advan-
tages and disadvantages which lead to the usage of different treatment
methods, fixation method or type of mesh, based on the circumstances
of the patient. Fig. 6 is a summary of the components of hernia repair
discussed in this review. The current types of materials (biologic or
synthetic) still perform unsatisfactorily therefore the field should head
towards using new types of materials and other combinations of loaded
meshes that can recruit cells and fight infection. Multiple types of assays
could be loaded on meshes to combat infection and recruit cells. There
are countless possibilities in the development of a hernia mesh with the
advances of recent research. Hernia repair requires the combination of
multiple biomaterials and steps, like the correct combination of surgical
technique and biomaterials, to produce a smooth recovery.
Declaration of interests
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
CRediT authorship contribution statement
Carmine Wang See: Writing - original draft, Conceptualization,
Writing - original draft. Tiffany Kim: Writing - review & editing.
Donghui Zhu: Conceptualization, Supervision, Writing - review & edit-
ing.
References
[1] A Birindelli, et al., 2017 update of the WSES guidelines for emergency repair
of complicated abdominal wall hernias, World J Emerg Surg 12 (2017) 37,
doi:10.1186/s13017-017-0149-y.
[2] J. Montgomery, J.B. Dimick, D.A. Telem, Management of Groin Hernias in Adults-
2018, JAMA 320 (2018) 1029–1030, doi:10.1001/jama.2018.10680.
[3] R.W Luijendijk, et al., A comparison of suture repair with mesh repair for incisional
hernia, N Engl J Med 343 (2000) 392–398, doi:10.1056/NEJM200008103430603.
[4] M.G. Franz, The biology of hernia formation, Surg Clin North Am 88 (2008) 1–15
vii, doi:10.1016/j.suc.2007.10.007.
[5] C.A. Beadles, A.D. Meagher, A.G. Charles, Trends in emergent hernia repair in the
United States, JAMA Surg 150 (2015) 194–200, doi:10.1001/jamasurg.2014.1242.
[6] V Shubinets, et al., Incisional Hernia in the United States: Trends in Hospital En-
counters and Corresponding Healthcare Charges, Am Surg 84 (2018) 118–125.
[7] A Costa, et al., Biological Scaffolds for Abdominal Wall Repair: Future in Clinical
Application? Materials (Basel) 12 (2019), doi:10.3390/ma12152375.
[8] A.M Ibrahim, et al., Properties of meshes used in hernia repair: a comprehensive
review of synthetic and biologic meshes, J Reconstr Microsurg 31 (2015) 83–94,
doi:10.1055/s-0034-1376886.
[9] K.M.F.I.R Fitzgibbons, Appraoch to Groin Hernia, JAMA Network Insights (2019),
doi:10.1001/jamasurg.2018.5564.
[10] A.S. Morena Burati, Luca Andrea Fumagalli, Francesco Gabrielli, Marco Chiarelli,
Mesh Fixation Methods in Groin Hernia Surgery, Hernia Surgery (2019),
doi:10.5772/intechopen.89732.
[11] C. Nikkolo, U Lepner, Chronic pain after open inguinal hernia repair, Postgrad Med
128 (2016) 69–75, doi:10.1080/00325481.2016.1121090.
[12] S. Kumar, R.G. Wilson, S.J. Nixon, I.M. Macintyre, Chronic pain after laparo-
scopic and open mesh repair of groin hernia, Br J Surg 89 (2002) 1476–1479,
doi:10.1046/j.1365-2168.2002.02260.x.
[13] A. Park, D.W. Birch, P Lovrics, Laparoscopic and open incisional hernia re-
pair: a comparison study, Surgery 124 (1998) 816–821 discussion 821-812,
doi:10.1067/msy.1998.92102.
[14] J.A. Warren, W.S. Cobb, J.A. Ewing, A.M. Carbonell, Standard laparoscopic ver-
sus robotic retromuscular ventral hernia repair, Surg Endosc 31 (2017) 324–332,
doi:10.1007/s00464-016-4975-x.
[15] Laparoscopic versus open repair of groin hernia: a randomised
comparison, The Lancet 354 (1999) 185–190 https://doi.org/,
doi:10.1016/S0140-6736(98)10010-7.
[16] L. Lydeking, N. Johansen, J. Oehlenschlager, M. Bay-Nielsen, T Bisgaard,
Re-recurrence and pain 12 years after laparoscopic transabdominal preperi-
toneal (TAPP) or Lichtenstein’s repair for a recurrent inguinal hernia:
a multi-centre single-blinded randomised clinical trial, Hernia (2020),
doi:10.1007/s10029-020-02139-0.
[17] K.M Itani, et al., Comparison of laparoscopic and open repair with mesh for the
treatment of ventral incisional hernia: a randomized trial, Arch Surg 145 (2010)
322–328 discussion 328, doi:10.1001/archsurg.2010.18.
31
Engineered Regeneration 1 (2020) 19–33
[18] D.C. Chen, J. Morrison, State of the art: open mesh-based inguinal hernia repair,
Hernia 23 (2019) 485–492, doi:10.1007/s10029-019-01983-z.
[19] S. Gottlieb, Open surgery better than laparoscopic for repair of inguinal hernia,
BMJ 328 (2004) 1033 -1033.
[20] K Baylon, et al., Past, Present and Future of Surgical Meshes: A Review, Membranes
(Basel) 7 (2017), doi:10.3390/membranes7030047.
[21] J.G. Han, S.Z. Ma, J.K. Song, Z.J. Wang, Operative treatment of ventral hernia using
prosthetic materials, Hernia 11 (2007) 419–423, doi:10.1007/s10029-007-0248-x.
[22] M. Walgenbach, T. Mathes, R. Siegel, M. Eikermann, Mesh fixation techniques in
primary ventral or incisional hernia repair, Cochrane Database of Systematic Re-
views (2015), doi:10.1002/14651858.CD011563.
[23] N Katkhouda, et al., Use of fibrin sealant for prosthetic mesh fixation in la-
paroscopic extraperitoneal inguinal hernia repair, Ann Surg 233 (2001) 18–25,
doi:10.1097/00000658-200101000-00004.
[24] R. Miller, J.C.R. Wormald, R.G. Wade, D.P. Collins, Systematic review of
fibrin glue in burn wound reconstruction, Br J Surg 106 (2019) 165–173,
doi:10.1002/bjs.11045.
[25] M.S. Karafin, C.D. Hillary, B.H. Shaz, Transfusion of plasma and plasma derivatives,
Hematology (2018) 1744–1758, doi:10.1016/b978-0-323-35762-3.00115-3.
[26] S.N. Ayyıldız, A Ayyıldız, Cyanoacrylic tissue glues: Biochemical properties and
their usage in urology, Turk J Urol 43 (2017) 14–24, doi:10.5152/tud.2017.09465.
[27] M. Matikainen, J. K., S. Silvasti, T. Hulmi, H. Paajanen, Randomized Clinical Trial
Comparing Cyanoacrylate Glue Versus Suture Fixation in Lichtenstein Hernia Re-
pair: 7-Year Outcome Analysis, World J Surg 41 (2017) 108–113 https://doi.org/,
doi:10.1007/s00268-016-3801-x.
[28] H.S. Colvin, A. Rao, M. Cavali, G. Campanelli, A.I. Amin, Glue versus suture fixation
of mesh during open repair of inguinal hernias: a systematic review and meta-
analysis, World J Surg 37 (2013) 2282–2292, doi:10.1007/s00268-013-2140-4.
[29] B de Goede, et al., Meta-analysis of glue versus sutured mesh fixation for Lichten-
stein inguinal hernia repair, Br J Surg 100 (2013) 735–742, doi:10.1002/bjs.9072.
[30] Z. Shi, X. Fan, S. Zhai, X. Zhong, D. Huang, Fibrin glue versus staple for mesh
fixation in laparoscopic transabdominal preperitoneal repair of inguinal her-
nia: a meta-analysis and systematic review, Surg Endosc 31 (2017) 527–537,
doi:10.1007/s00464-016-5039-y.
[31] K.A. LeBlanc, Tack hernia: a new entity, JSLS 7 (2003) 383–387.
[32] E. Reynvoet, F. Berrevoet, Pros and cons of tacking in laparoscopic hernia repair,
Surg Technol Int 25 (2014) 136–140.
[33] Y.W Chan, et al., Comparison of mesh fixation devices for laparoscopic ventral
hernia repair: an experimental study on human anatomic specimens, Surg Endosc
32 (2018) 3158–3163, doi:10.1007/s00464-018-6031-5.
[34] I Jeroukhimov, et al., Reduced postoperative chronic pain after tension-free in-
guinal hernia repair using absorbable sutures: a single-blind randomized clinical
trial, J Am Coll Surg 218 (2014) 102–107, doi:10.1016/j.jamcollsurg.2013.09.010.
[35] G.M Grimsby, et al., Non-absorbable sutures are associated with lower recurrence
rates in laparoscopic percutaneous inguinal hernia ligation, J Pediatr Urol 11
(2015) 275 e271-274, doi:10.1016/j.jpurol.2015.04.029.
[36] S Harslof, et al., Effect of fixation devices on postoperative pain after laparo-
scopic ventral hernia repair: a randomized clinical trial of permanent tacks, ab-
sorbable tacks, and synthetic glue, Langenbecks Arch Surg 403 (2018) 529–537,
doi:10.1007/s00423-018-1676-z.
[37] D.L. Sanders, A.N. Kingsnorth, Prosthetic mesh materials used in hernia surgery,
Expert Rev Med Devices 9 (2012) 159–179, doi:10.1586/erd.11.65.
[38] S. Idrees, S. Jindal, M. Gupta, R. Sarangi, Surgical meshes- The search continues,
Current Medicine Research and Practice (2018), doi:10.1016/j.cmrp.2018.08.005.
[39] W.S Cobb, et al., Normal intraabdominal pressure in healthy adults, J Surg Res 129
(2005) 231–235, doi:10.1016/j.jss.2005.06.015.
[40] B.L. De Keulenaer, J.J. De Waele, B. Powell, M.L. Malbrain, What is nor-
mal intra-abdominal pressure and how is it affected by positioning, body mass
and positive end-expiratory pressure? Intensive Care Med 35 (2009) 969–976,
doi:10.1007/s00134-009-1445-0.
[41] B. Klosterhalfen, K. Junge, U. Klinge, The lightweight and large porous
mesh concept for hernia repair, Expert Rev Med Devices 2 (2005) 103–117,
doi:10.1586/17434440.2.1.103.
[42] S Kalaba, et al., Design Strategies and Applications of Biomaterials and Devices for
Hernia Repair, Bioact Mater 1 (2016) 2–17, doi:10.1016/j.bioactmat.2016.05.002.
[43] R.A. White, The effect of porosity and biomaterial on the healing and long-term
mechanical properties of vascular prostheses, ASAIO Trans 34 (1988) 95–100,
doi:10.1097/00002480-198804000-00004.
[44] D.B. Earle, L.A. Mark, Prosthetic material in inguinal hernia repair: how do I
choose? Surg Clin North Am 88 (2008) 179–201 x, doi:10.1016/j.suc.2007.11.002.
[45] C.N. Brown, J.G. Finch, Which mesh for hernia repair, Ann R Coll Surg Engl 92
(2010) 272–278, doi:10.1308/003588410X12664192076296.
[46] A. Rastegarpour, C. M., M. Vardhan, MM Ibrahim, CE Butler, H. Levinson, Surgical
mesh for ventral incisional hernia repairs: Understanding mesh design, Plast Surg
24 (2016) 41–50.
[47] A.S.W Jacombs, et al., Biofilms and effective porosity of hernia mesh: are they
silent assassins? Hernia 24 (2020) 197–204, doi:10.1007/s10029-019-02063-y.
[48] O Guillaume, et al., Emerging Trends in Abdominal Wall Reinforcement: Bring-
ing Bio-Functionality to Meshes, Adv Healthc Mater 4 (2015) 1763–1789,
doi:10.1002/adhm.201500201.
[49] I Kourtzelis, et al., Inhibition of biomaterial-induced complement activation atten-
uates the inflammatory host response to implantation, FASEB J 27 (2013) 2768–
2776, doi:10.1096/fj.12-225888.
[50] A.C. Silvestre, G.B. de Mathia, D.J. Fagundes, L.R. Medeiros, M.I. Rosa, Shrink-
age evaluation of heavyweight and lightweight polypropylene meshes in in-
C. Wang See, T. Kim and D. Zhu
guinal hernia repair: a randomized controlled trial, Hernia 15 (2011) 629–634,
doi:10.1007/s10029-011-0853-6.
[51] B. Socea, L.I Socea, OG. Bratu, B. Mastalier, M. Dimitriu, A. Carap, VD. Constantin,
Recurrence rate and mesh shrinkage after polypropylene vs. polyester mesh hernia
repair in complicated hernias, Materiale Plastice 55 (2018) 79–81.
[52] L. Zogbi, A.O. Portella, M.R. Trindade, E.N. Trindade, Retraction and fibroplasia in
a polypropylene prosthesis: experimental study in rats, Hernia 14 (2010) 291–298,
doi:10.1007/s10029-009-0607-x.
[53] L.F. Rossi, M.R.M. Trindade, D.A. AJ, L.Peritoneal Adhesions Type I Meurer,
Iii and Total Collagen on Polypropylene and Coated Polypropylene
Meshes: Experimental Study in Rats, Arq Bras Cir Dig 30 (2017) 77–82,
doi:10.1590/0102-6720201700020001.
[54] S. Todros, P.G. Pavan, A.N. Natali, Synthetic surgical meshes used in abdominal
wall surgery: Part I-materials and structural conformation, J Biomed Mater Res B
Appl Biomater 105 (2017) 689–699, doi:10.1002/jbm.b.33586.
[55] J.F. FitzGerald, A.S. Kumar, Biologic versus Synthetic Mesh Reinforcement:
What are the Pros and Cons? Clin Colon Rectal Surg 27 (2014) 140–148,
doi:10.1055/s-0034-1394155.
[56] J Lofgren, et al., A Randomized Trial of Low-Cost Mesh in Groin Hernia Repair, N
Engl J Med 374 (2016) 146–153, doi:10.1056/NEJMoa1505126.
[57] G.V Bochicchio, et al., Biologic vs synthetic inguinal hernia repair: 1-year re-
sults of a randomized double-blinded trial, J Am Coll Surg 218 (2014) 751–757,
doi:10.1016/j.jamcollsurg.2014.01.043.
[58] T.N. Robinson, J.H. Clarke, J. Schoen, M.D. Walsh, Major mesh-related complica-
tions following hernia repair: events reported to the Food and Drug Administration,
Surg Endosc 19 (2005) 1556–1560, doi:10.1007/s00464-005-0120-y.
[59] J Rouet, et al., Polyester mosquito net mesh for inguinal hernia repair: A feasible
option in resource limited settings in Cameroon? J Visc Surg 155 (2018) 111–116,
doi:10.1016/j.jviscsurg.2017.10.006.
[60] T Unek, et al., The results of expanded-polytetrafluoroethylene mesh re-
pair in difficult abdominal wall defects, Asian J Surg 42 (2019) 131–143,
doi:10.1016/j.asjsur.2017.12.001.
[61] R.H Koehler, et al., Minimal adhesions to ePTFE mesh after laparoscopic ventral
incisional hernia repair: reoperative findings in 65 cases, Zentralbl Chir 128 (2003)
625–630, doi:10.1055/s-2003-41365.
[62] P.K. Amid, Classification of biomaterials and their related complications in abdom-
inal wall hernia surgery, Hernia 1 (1997) 15–21, doi:10.1007/BF02426382.
[63] M.E. Franklin Jr., J.J. Gonzalez Jr., R.P. Michaelson, J.L. Glass, D.A. Chock, Pre-
liminary experience with new bioactive prosthetic material for repair of hernias in
infected fields, Hernia 6 (2002) 171–174, doi:10.1007/s10029-002-0078-9.
[64] F. Ruiz-Jasbon, J. Norrby, M.L. Ivarsson, S. Bjorck, Inguinal hernia repair using a
synthetic long-term resorbable mesh: results from a 3-year prospective safety and
performance study, Hernia 18 (2014) 723–730, doi:10.1007/s10029-014-1249-1.
[65] L. Zogbi, The use of biomaterials to treat abdominal hernias, Biomaterials applica-
tion for nanomedicine (2011), doi:10.5772/24313.
[66] V. Holmdahl, B. Stark, L. Clay, U. Gunnarsson, K. Strigard, One-year out-
come after repair of giant incisional hernia using synthetic mesh or full-
thickness skin graft: a randomised controlled trial, Hernia 23 (2019) 355–361,
doi:10.1007/s10029-019-01900-4.
[67] S. Huerta, A. Varshney, P.M. Patel, H.G. Mayo, E.H. Livingston, Biological Mesh
Implants for Abdominal Hernia Repair: US Food and Drug Administration Approval
Process and Systematic Review of Its Efficacy, JAMA Surg 151 (2016) 374–381,
doi:10.1001/jamasurg.2015.5234.
[68] B. Ma, X. Wang, C. Wu, J. Chang, Crosslinking strategies for preparation of extra-
cellular matrix-derived cardiovascular scaffolds, Regen Biomater 1 (2014) 81–89,
doi:10.1093/rb/rbu009.
[69] L.M. Delgado, K. Fuller, D.I. Zeugolis, (∗ ) Collagen Cross-Linking: Biophysical, Bio-
chemical, and Biological Response Analysis, Tissue Eng Part A 23 (2017) 1064–
1077, doi:10.1089/ten.TEA.2016.0415.
[70] A Costa, et al., Mechanical strength vs. degradation of a biologically-derived surgi-
cal mesh over time in a rodent full thickness abdominal wall defect, Biomaterials
108 (2016) 81–90, doi:10.1016/j.biomaterials.2016.08.053.
[71] R Kaufmann, et al., Non-Cross-Linked Collagen Mesh Performs Best in a
Physiologic, Noncontaminated Rat Model, Surg Innov 26 (2019) 302–311,
doi:10.1177/1553350619833291.
[72] A.W. Cheng, M.A. Abbas, T. Tejirian, Outcome of abdominal wall hernia repair
with biologic mesh: Permacol versus Strattice, Am Surg 80 (2014) 999–1002.
[73] U. Aydemir Sezer, et al., Polypropylene composite hernia mesh with anti-adhesion
layer composed of polycaprolactone and oxidized regenerated cellulose, Mater Sci
Eng C Mater Biol Appl 99 (2019) 1141–1152, doi:10.1016/j.msec.2019.02.064.
[74] S.T Jayanth, et al., A randomized controlled experimental study comparing chi-
tosan coated polypropylene mesh and Proceed mesh for abdominal wall defect clo-
sure, Ann Med Surg (Lond) 4 (2015) 388–394, doi:10.1016/j.amsu.2015.10.002.
[75] G Pascual, S. Sotomayor, M Rodriguez, Y Bayon, J. Bellon, Bahavior of a new com-
posite mesh for the repair of full-thickness abdominal wall defects in rabbit model,
PLoS One 8 (2013), doi:10.1371/journal.pone.0080647.
[76] A. Lukasiewicz, J. Skopinska-Wisniewska, A. Marszalek, S. Molski, T. Drewa,
Collagen/Polypropylene composite mesh biocompatibility in abdomi-
nal wall reconstruction, Plast Reconstr Surg 131 (2013) 731e–740e,
doi:10.1097/PRS.0b013e3182865d2c.
[77] M.H Schreinemacher, et al., Coated meshes for hernia repair provide compa-
rable intraperitoneal adhesion prevention, Surg Endosc 27 (2013) 4202–4209,
doi:10.1007/s00464-013-3021-5.
[78] W Hu, et al., Mussel-inspired copolymer-coated polypropylene mesh with anti-
adhesion efficiency for abdominal wall defect repair, Biomater Sci 7 (2019) 1323–
1334, doi:10.1039/c8bm01198b.
32
Engineered Regeneration 1 (2020) 19–33
[79] S. Todros, P.G. Pavan, P. Pachera, A.N. Natali, Synthetic surgical meshes used in
abdominal wall surgery: Part II-Biomechanical aspects, J Biomed Mater Res B Appl
Biomater 105 (2017) 892–903, doi:10.1002/jbm.b.33584.
[80] F Kockerling, et al., What is the evidence for the use of biologic or biosyn-
thetic meshes in abdominal wall reconstruction, Hernia 22 (2018) 249–269,
doi:10.1007/s10029-018-1735-y.
[81] L Lee, et al., A systematic review of synthetic and biologic materials for abdomi-
nal wall reinforcement in contaminated fields, Surg Endosc 28 (2014) 2531–2546,
doi:10.1007/s00464-014-3499-5.
[82] J.J. Atema, F.E. de Vries, M.A. Boermeester, Systematic review and meta-analysis
of the repair of potentially contaminated and contaminated abdominal wall defects,
Am J Surg 212 (2016) 982–995 e981, doi:10.1016/j.amjsurg.2016.05.003.
[83] J Chamieh, et al., Synthetic versus Biologic Mesh in Single-Stage Repair of Complex
Abdominal Wall Defects in a Contaminated Field, Surg Infect (Larchmt) 18 (2017)
112–118, doi:10.1089/sur.2016.106.
[84] M. Sosin, M.Y. Nahabedian, P. Bhanot, The Perfect Plane: A Systematic Review of
Mesh Location and Outcomes, Update 2018, Plast Reconstr Surg 142 (2018) 107S–
116S, doi:10.1097/PRS.0000000000004864.
[85] S.M. Yousuf, F. Akbar, I. Bain, Biological meshes in complex anterior abdominal
wall reconstructions and hernia repair in contaminated fields, Pak J Surg 33 (2017)
102–109.
[86] X Nie, et al., Comparison of Porcine Small Intestinal Submucosa versus Polypropy-
lene in Open Inguinal Hernia Repair: A Systematic Review and Meta-Analysis, PLoS
One 10 (2015) e0135073, doi:10.1371/journal.pone.0135073.
[87] F.E Muysoms, et al., Prevention of Incisional Hernias with Biological
Mesh: A Systematic Review of the Literature, Front Surg 3 (2016) 53,
doi:10.3389/fsurg.2016.00053.
[88] J.R. Scott, C.R. Deeken, R.G. Martindale, M.J. Rosen, Evaluation of a fully
absorbable poly-4-hydroxybutyrate/absorbable barrier composite mesh in a
porcine model of ventral hernia repair, Surg Endosc 30 (2016) 3691–3701,
doi:10.1007/s00464-016-5057-9.
[89] C.A.L Utrabo, et al., Tensiometric Analysis of Meshes Used in Abdomi-
nal Ventral Wall Defects in Rats, Arq Bras Cir Dig 30 (2017) 165–168,
doi:10.1590/0102-6720201700030001.
[90] N Sanbhal, et al., Controlled Levofloxacin Release and Antibacterial Properties of
beta-Cyclodextrins-Grafted Polypropylene Mesh Devices for Hernia Repair, Poly-
mers (Basel) 10 (2018), doi:10.3390/polym10050493.
[91] J Reinbold, et al., Biodegradable rifampicin-releasing coating of surgical meshes for
the prevention of bacterial infections, Drug Des Devel Ther 11 (2017) 2753–2762,
doi:10.2147/DDDT.S138510.
[92] B Perez-Kohler, et al., Experimental study on the use of a chlorhexidine-loaded car-
boxymethylcellulose gel as antibacterial coating for hernia repair meshes, Hernia
23 (2019) 789–800, doi:10.1007/s10029-019-01917-9.
[93] Y Wang, et al., Immunomodulated electrospun fibrous scaffolds via bFGF cam-
ouflage for pelvic regeneration, Applied Materials Today 15 (2019) 570–581
https://doi.org/, doi:10.1016/j.apmt.2019.04.005.
[94] M Qin, et al., In situ inflammatory-regulated drug-loaded hydrogels for pro-
moting pelvic floor repair, Journal of Controlled Release 322 (2020) 375–389
https://doi.org/10.1016/j.jconrel.2020.03.030.
[95] P. Gentile, D. Casella, E. Palma, C. Calabrese, Engineered Fat Graft Enhanced with
Adipose-Derived Stromal Vascular Fraction Cells for Regenerative Medicine: Clini-
cal, Histological and Instrumental Evaluation in Breast Reconstruction, J Clin Med
8 (2019), doi:10.3390/jcm8040504.
[96] F. Khan, M. Tanaka, Designing Smart Biomaterials for Tissue Engineering, Int J Mol
Sci 19 (2017), doi:10.3390/ijms19010017.
[97] O. Speck, T. Speck, An Overview of Bioinspired and Biomimetic Self-Repairing
Materials, Biomimetics (Basel) 4 (2019), doi:10.3390/biomimetics4010026.
[98] X Qi, et al., An Epidermis-like Hierarchical Smart Coating with a Hardness of Tooth
Enamel, ACS nano 12 (2018) 1062–1073, doi:10.1021/acsnano.7b05478.
[99] M. Krogsgaard, M.A. Behrens, J.S. Pedersen, H. Birkedal, Self-healing mussel-
inspired multi-pH-responsive hydrogels, Biomacromolecules 14 (2013) 297–301,
doi:10.1021/bm301844u.
[100] A.H Petter-Puchner, et al., Human vital amniotic membrane reduces adhesions
in experimental intraperitoneal onlay mesh repair, Surg Endosc 25 (2011) 2125–
2131, doi:10.1007/s00464-010-1507-y.
[101] L Melman, et al., Early biocompatibility of crosslinked and non-crosslinked biologic
meshes in a porcine model of ventral hernia repair, Hernia 15 (2011) 157–164,
doi:10.1007/s10029-010-0770-0.
[102] L.H. Holton 3rd, et al., Comparison of acellular dermal matrix and synthetic mesh
for lateral chest wall reconstruction in a rabbit model, Plast Reconstr Surg 119
(2007) 1238–1246, doi:10.1097/01.prs.0000254347.36092.9c.
[103] C.F. Bellows, A. Smith, J. Malsbury, W.S. Helton, Repair of incisional hernias with
biological prosthesis: a systematic review of current evidence, Am J Surg 205
(2013) 85–101, doi:10.1016/j.amjsurg.2012.02.019.
[104] A Cavallaro, et al., Use of biological meshes for abdominal wall reconstruc-
tion in highly contaminated fields, World J Gastroenterol 16 (2010) 1928–1933,
doi:10.3748/wjg.v16.i15.1928.
[105] J.N. Limpert, A.R. Desai, A.L. Kumpf, M.A. Fallucco, D.L. Aridge, Repair of ab-
dominal wall defects with bovine pericardium, Am J Surg 198 (2009) e60–e65,
doi:10.1016/j.amjsurg.2009.01.027.
[106] C. Schug-Pass, F. Sommerer, A. Tannapfel, H. Lippert, F. Kockerling, The use of
composite meshes in laparoscopic repair of abdominal wall hernias: are there differ-
ences in biocompatibily?: experimental results obtained in a laparoscopic porcine
model, Surg Endosc 23 (2009) 487–495, doi:10.1007/s00464-008-0085-8.
C. Wang See, T. Kim and D. Zhu
[107] R.R Vogels, et al., Long-term evaluation of adhesion formation and foreign
body response to three new meshes, Surg Endosc 29 (2015) 2251–2259,
doi:10.1007/s00464-014-3936-5.
[108] G. Pascual, S. Sotomayor, M. Rodriguez, Y. Bayon, J.M. Bellon, Tissue integration
and inflammatory reaction in full-thickness abdominal wall repair using an innova-
tive composite mesh, Hernia 20 (2016) 607–622, doi:10.1007/s10029-015-1383-4.
[109] I.J. Hall Barrientos, et al., Fabrication and characterisation of drug-loaded electro-
spun polymeric nanofibers for controlled release in hernia repair, Int J Pharm 517
(2017) 329–337, doi:10.1016/j.ijpharm.2016.12.022.
[110] C Labay, et al., Antibiotic-loaded polypropylene surgical meshes with suitable bi-
ological behaviour by plasma functionalization and polymerization, Biomaterials
71 (2015) 132–144, doi:10.1016/j.biomaterials.2015.08.023.
33
Engineered Regeneration 1 (2020) 19–33
[111] J.A Blatnik, et al., Infection prevention using affinity polymer-coated, syn-
thetic meshes in a pig hernia model, J Surg Res 219 (2017) 5–10,
doi:10.1016/j.jss.2017.05.003.
[112] N.A. Nadia Qamar, Muhammad Irfan, Amjad Hussain, Muhammad Sohail Ar-
shad, Sumera Latif, Faisal Mehmood, Muhammad Usman Ghori, Personalized
3D printed ciprofloxacin impregnated meshes for the management of hernia,
Journal of Drug Delivery Science and Technology 53 (2019) https://doi.org/,
doi:10.1016/j.jddst.2019.101164.