Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

Contents lists available at ScienceDirect

Journal of the Mechanical Behavior of

Biomedical Materials
journal homepage: www.elsevier.com/locate/jmbbm

Mechanical properties of the abdominal wall and biomaterials utilized for MARK
hernia repair
⁎
Corey R. Deekena, Spencer P. Lakeb,
a
Covalent Bio, LLC, St. Louis, MO, USA
b
Department of Mechanical Engineering & Materials Science, Washington University in St. Louis, MO, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Abdominal wall hernias are one of the most common and long-standing surgical applications for biomaterials
Abdominal wall engineering. Yet, despite over 50 years of standard use of hernia repair materials, revision surgery is still
Anisotropy required in nearly one third of patients due to hernia recurrence. To date, hernia mesh designs have focused on
Biomaterials maximizing tensile strength to prevent structural failure of the implant. However, most recurrences occur at the
Hernia repair
biomaterial-tissue interface. There is a fundamental gap in understanding the degree to which a mechanical
Mechanics
mismatch between hernia repair materials and host tissue contributes to failure at this interface. This review
Mesh
summarizes the current literature related to the anatomy and mechanics of both human and animal abdominal
wall tissues, as well as the mechanical properties of many commonly-utilized hernia repair materials. The studies
reviewed here reported greater compliance of the linea alba, larger strains for the intact abdominal wall, and
greater stiffness for the rectus sheath and umbilical fascia when the tissues were loaded in the longitudinal
direction compared to transverse. Additionally, greater stresses were observed in the linea alba when loaded in
the transverse direction compared to longitudinal. Given these trends, a few recommendations can be made
regarding orientation of mesh. The most compliant axis of the biomaterial should be oriented in the cranio-
caudal (longitudinal) direction, and the strongest axis of the biomaterial should be oriented in the medial-lateral
(transverse) direction. The human abdominal wall is also anisotropic, with anisotropy ratios as high as 8–9
reported for the human linea alba. Current biomaterial designs exhibit anisotropy ratios in the range of 1–3, and
it is unclear whether an ideal ratio exists for optimal match between mesh and tissue. This is likely dependent on
implantation location as the linea alba, rectus sheath, and other tissues of the abdominal wall exhibit different
characteristics. Given the number of unknowns yet to be addressed by studies of the human abdominal wall, it is
unlikely that any single biomaterial design currently encompasses all of the ideal features identified. More data
on the mechanical properties of the abdominal wall will be needed to establish a full set of guidelines for ideal
mesh mechanics including strength, compliance, anisotropy, nonlinearity and hysteresis.

1. Introduction revision surgery in nearly one in three patients, at a substantial cost to

Hernias are a debilitating and common condition, affecting over 1
million Americans each year (Poulose et al., 2012). Surgical repair of
ventral hernias comes at a tremendous cost of over $3.2 billion/year
and comprises more than 350,000 surgeries annually in the United
States alone making this one of the most common procedures in all of
general surgery (Poulose et al., 2012; Rutkow, 2003). The introduction
of mesh materials to reinforce hernia repairs has improved surgical
outcomes. However, pain, infection, and recurrence are still common
(Burger et al., 2004; Klosterhalfen et al., 2002; Klosterhalfen and
Klinge, 2013; Cavallo et al., 2015). Hernia recurrence alone leads to
the patient in the form of pain, disability, time off work, and procedural
costs (Poulose et al., 2012; Burger et al., 2004).
Thus far, hernia mesh designs have focused primarily on maximiz-
ing tensile strength to prevent structural failure of the implant.
However, the vast majority of hernia recurrences occur at the im-
plant-tissue interface rather than from mechanical failure of the mesh
material. Factors affecting integration at the interface such as insuffi-
cient mesh-defect overlap (Langer et al., 2001; Cobb et al., 2009; Zuvela
et al., 2014; Petro et al., 2015), failure to close the anterior myofascial
layer (Langer et al., 2001; Cobb et al., 2009; Zuvela et al., 2014; Petro
et al., 2015), migration/damage from fixation devices (Petro et al.,

⁎
Correspondence to: Mechanical Engineering & Materials Science, Biomedical Engineering and Orthopaedic Surgery, Washington University in St. Louis, Campus Box 1185, USA, One
Brookings Drive, St. Louis, MO 63130, USA.
E-mail addresses: deekenc@covalentbiollc.com (C.R. Deeken), lake.s@seas.wustl.edu (S.P. Lake).

http://dx.doi.org/10.1016/j.jmbbm.2017.05.008
Received 24 February 2017; Received in revised form 26 April 2017; Accepted 4 May 2017
Available online 06 May 2017
1751-6161/ © 2017 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/).
C.R. Deeken, S.P. Lake
2015; Lerdsirisopon et al., 2011), contracture of the wound
(Klosterhalfen et al., 2002; Klinge et al., 1998), poor tissue ingrowth
(Klosterhalfen et al., 2002; Klosterhalfen and Klinge, 2013; Cavallo
et al., 2015), or sustained inflammatory response (Klosterhalfen et al.,
2002; Klosterhalfen and Klinge, 2013; Cavallo et al., 2015; Klinge et al.,
1999) have all been reported to contribute to the high incidence of
hernia recurrence. Surprisingly, the degree to which mechanical
mismatch between biomaterial and host tissue contributes to failure
has not been evaluated, even though the primary purpose for utilizing
biomaterials in hernia repair is mechanical support and integration
with the native tissue. As a first step towards properly matching the
mechanics of these structures, the full mechanical properties of
abdominal tissues and biomaterials used in hernia repair need to be
quantitatively described and compared. This review paper will address
this topic, summarizing the current literature related to the anatomy
and mechanics of both human and animal abdominal wall tissues, as
well as the mechanical properties of many commonly-utilized hernia
repair materials.
2. Human abdominal wall
2.1. Anatomy and structure of the human abdominal wall
The human abdominal wall is a complex composite structure
composed of various layers which vary depending on specific anato-
mical location (e.g., medial/lateral, above/below the arcuate line). The
central abdominal wall is composed, from superficial to deep, of the
following layers: skin, subcutaneous fat, anterior rectus sheath, rectus
abdominis muscle or linea alba (depending on location), posterior
rectus sheath (if above the arcuate line), preperitoneal fat, and
peritoneum ((Kalaba et al., 2016); Fig. 1). In locations lateral to the
central line, the rectus abdominis is replaced by a muscle layer
composed of the external oblique, internal oblique, and transversalis
abdominis muscles. Several collagenous connective tissues (e.g., fascias,
sheaths, linea alba) integrate the various layers into a functioning
composite structure.
Some of the primary roles of the abdominal wall are mechanical in
nature: provide a mechanical barrier to protect internal organs, support
the intra-abdominal pressures (IAPs) that develop within the abdominal
cavity, and provide/facilitate motion and mobility of the torso. Hernias
represent a breakdown or disruption in the continuity of the abdominal
wall, which (among other complicating issues) impair the mechanical
function of this composite tissue. To fully address such clinical issues, it
is first necessary to understand how the healthy intact abdominal wall
performs its mechanical function. Namely, what are the mechanical
properties of each of the different layers of the abdominal wall and how
do they function together to provide necessary mechanical support and
strength? Answers to such questions are challenging due to (1) the
heterogeneous anatomical configuration of the abdominal wall, where
specific layers of the composite tissue vary by location, (2) experi-
Fig. 1. Schematic showing the various layers of the human abdominal wall (reprinted
with permission from Kalaba et al. (2016)).
412
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
mental difficulties in quantifying the mechanics of the composite
structure, individual layers, and their connections/interactions, and
(3) the complex in vivo loading environment of the abdomen where the
abdominal wall regularly supports multiaxial physiologic loads during
normal function.
Furthermore, specific layers often exhibit unique and complex
compositional and structural properties, which further challenge efforts
to characterize these tissues and fully describe their properties. For
example, the linea alba, a midline band of connective tissue that
separates the two parallel portions of the rectus abdominis muscle, has
been described as a highly structured, three-dimensional meshwork
composed predominantly of type I collagen. In addition to exhibiting
location-specific width and thickness (increasing/decreasing in the
cranio-caudal direction, respectively), the linea alba has several zones
throughout its thickness that exhibit distinct structural properties (Axer
et al., 2001). Specifically, from ventral to dorsal, the linea alba exhibits
sequential layers of intermingling oblique fibers, predominantly trans-
verse fibers, and variable small irregular fibers (Grabel et al., 2005). In
addition to this intricate collagenous organization, elastic fibers have
also been shown to form an interdigitating layer perpendicular to
collagen bundles in human and porcine linea alba, and are hypothe-
sized to contribute to the mechanical properties of this tissue (e.g.,
elastic recoil) (Levillain et al., 2016). Similar to the linea alba, other
tissues of the abdominal wall also exhibit variable and unique structural
organization profiles, which likely correlate directly with mechanical
properties and function, but which complicate mechanical analysis of
individual or composite abdominal tissues. The first sections of this
paper will summarize experimental studies to date that have measured
mechanical properties of specific tissue layers or whole abdominal
walls, of humans and animals, and provide an overview of theoretical
and computational models that have been developed to further
represent and understand fundamental concepts relative to abdominal
wall mechanics.
2.2. Mechanical properties of the human abdominal wall
2.2.1. Mechanical evaluation of individual components of the human
abdomen
Several studies have investigated the mechanical properties of
specific isolated layers of the abdominal wall structure (Table 1). We
note that studies in the literature have used a wide range of different
measures and parameters to report mechanical properties of abdominal
tissues, which can make interpretation and direct comparison challen-
ging. A few of the more common terms merit definition: stiffness is the
slope of the force-elongation curve, modulus is the slope of the stress-
strain curve, compliance is the inverse of modulus (or amount of strain
per given stress), deformation is the change in length or shape, and
strain is the deformation normalized by original geometry (i.e., length
or area).
Uniaxial tensile tests of the linea alba in longitudinal (cranio-
caudal) and transverse (medial-lateral) directions showed anisotropic
properties; higher compliance in the longitudinal direction correlated
well with reported descriptions of microstructural collagen fiber
alignment (Grabel et al., 2005). Transverse stresses in the linea alba
have been reported to be 2–3 times larger than longitudinal stresses
(Levillain et al., 2016; Hollinsky and Sandberg, 2007; Forstemann et al.,
2011), while a study using biaxial tensile testing reported a much larger
anisotropy ratio of 8–9 (Cooney et al., 2016). One study found that
mechanics of the linea alba were significantly stronger (~30%) than
scar tissue (Hollinsky and Sandberg, 2007), which provides some
insight into heightened susceptibility to incisional hernia development
following surgical access through the linea alba (Muysoms et al., 2015).
A recent study reported non-linear viscoelastic anisotropic properties of
human linea alba and showed non-uniform realignment of collagen
fibers in different layers under load, demonstrating the complex nature
of this connective tissue (Levillain et al., 2016).
 Table 1
Mechanical test data of human abdominal tissues (MOD = elastic modulus; UTS = ultimate tensile strength; IR = infrared; abd = abdominal).

Number of Mean Age Male Test Method Transverse Longitudinal Oblique Parallel to Perpendicular to Anisotropy Refs.
Donors (range) (Female) fibers fibers
C.R. Deeken, S.P. Lake

Individual Linea alba 60 Uniaxial ~70 kPa MOD ~8 kPa MOD ~8.2 (Forstemann et al.,
Layers Biaxial via simple ~80 kPa MOD ~32 kPa MOD ~2.5 2011)
model
31 (63–95) 16 (15) Uniaxial 0.6 cm/N 1.2 cm/N compliance 2.0 (Grabel et al.,
compliance 2005)
66 77 (17–94) 30 (36) Uniaxial ~9.2 MPa UTS ~4.3 MPa UTS ~2.1 (Hollinsky and
Sandberg, 2007)
3 86 Uniaxial 1.15 MPa stress at 0.5 MPa stress at ~2.3 (Levillain et al.,
stretch = 1.4 stretch = 1.4 2016)
13 > 60 6 (7) Uniaxial 72 MPa MOD 8 MPa MOD 9.0 (Cooney et al.,
Biaxial 335 MPa MOD 23 MPa MOD 14.5 2016)
Anterior rectus 3 78 (74–85) 1 (2) Uniaxial 5.6 MPa (slow) (Ben Abdelounis
sheath 14 MPa (fast) et al., 2013)
66 77 (17–94) 30 (36) Uniaxial ~8.3 MPa UTS 3.4 MPa UTS ~2.4 (Hollinsky and
Sandberg, 2007)
12 46 (18–65) 0 (12) Uniaxial 12.8 MPa UTS 3.4 MPa UTS 3.8 (Martins et al.,
30.3 MPa 10.1 MPa MOD 2012)
MOD
30 83 (62–95) 14 (16) Uniaxial & burst 4.9 MPa UTS (supra- (Rath et al., 1997)
strength arcuate); 7.5 MPa
UTS (infra-arcuate)
Posteror rectus 30 83 (62–95) 14 (16) Uniaxial & burst 6.1 MPa UTS (supra- (Rath et al., 1997)
sheath strength umbilical); 6.5 MPa
UTS (infra-umbilical)

413
66 77 (17–94) 30 (36) Uniaxial ~5.3 MPa UTS ~2.0 MPa UTS ~2.6 (Hollinsky and
Sandberg, 2007)
Umbilical fascia 14 66.5 9 (5) Uniaxial ~9.3 MPa ~2.9 MPa MOD 3.2 (Kirilova et al.,
(46–87) MOD 2011)
Transversalis 14 66.5 9 (5) Uniaxial ~8.9 MPa ~3.0 MPa MOD 3.0 (Kirilova et al.,
fascia (46–87) MOD 2011)
20 hernia 4 19 (1) Uniaxial ~1.5 MPa UTS; ~0.7 MPa UTS; 2.0 (Kureshi et al.,
control ~3.0 MPa MOD ~1.5 MPa MOD 2008)
Rectus 12 45 (17–73) 7 (5) Uniaxial 0.52 MPa (Cardoso, 2012)
abdominis MOD
Transversus 12 45 (17–73) 7 (5) Uniaxial 1.03 MPa (Cardoso, 2012)
abdominis MOD
External oblique 12 45 (17–73) 7 (5) Uniaxial 1.00 MPa (Cardoso, 2012)
MOD
Internal oblique 12 45 (17–73) 7 (5) Uniaxial 0.65 MPa (Cardoso, 2012)
MOD

Composite Ex vivo abd wall 14 68 (48–86) 7 (5) Octagonal tensile ~16% strain ~27% strain ~12% strain (Junge et al.,
Layers test rig 2001)
7 82 (66–97) 3 (4) Linea alba forces ~40–50 N/cm (Konerding et al.,
tension at 200 mbar 2011)
6 76 (66–84) 4 (2) Internal vs external 2.6% int strain at 3.7% int strain at ~5.5% strain 1.4 (Podwojewski
strains 50 mm Hg; 5.0% ext 50 mm Hg; 6.6% ext at 50 mm Hg 1.3 et al., 2014)
strain at 50 mm Hg strain at 50 mm Hg
8 (77–98) 4 (4) 3D imaging/ ~0% strain at 3 kPa ~2.5% strain at (Tran et al., 2014)
elastography pressure 3 kPa pressure
In vivo 41 mesh 58 (37–77) 36 (5) 3D stereography 3.1 cm height; (Muller et al.,
68.6 cm max radius 1998)
21 control 38 (25–52) 12 (9) 5.5 cm height;
41 cm max radius
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

(continued on next page)

C.R. Deeken, S.P. Lake Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

(Tran et al., 2016)

Early evaluation of the anterior and posterior rectus sheath used

(Smietanski et al.,
2006a, 2006b)
dynamometer and burst strength testing to quantify the failure proper-
(Welty et al.,

(Song et al.,
ties of this thin tissue, which surprisingly did not correlate with age, sex
2001) or body build (Rath et al., 1997). Subsequent testing has shown non-

2012)
Refs.

linear and anisotropic mechanical properties (stiffer in longitudinal

direction), greater stability for anterior than posterior rectus sheath,
and a rate-dependent response with greater elasticity at faster rates of
Anisotropy

cyclic loading (Hollinsky and Sandberg, 2007; Martins et al., 2012; Ben
Abdelounis et al., 2013). Consistently, the influence of aging, obesity,
and parity on the mechanics of the rectus sheath again could not be
demonstrated (Martins et al., 2012), however such lack of statistical
Perpendicular to

correlation may be influenced by limited sample numbers. Another thin

connective tissue of the human abdomen is the umbilical fascia, an
internal layer that attaches laterally to the deep layers of the rectus
fibers

sheath and helps protect against umbilical hernias (Oh et al., 2008;
Fathi et al., 2012). Studies of mechanics of the umbilical fascia reported
a non-linear viscoelastic response, similar to the rectus sheath (Kirilova
Parallel to

et al., 2011; Kirilova, 2012). Orthogonal tensile tests of fascia from

different anatomical locations showed relatively homogeneous me-
fibers

chanics (in contrast to the rectus sheath) but significant anisotropy,

where longitudinal samples showed larger mechanical parameters (e.g.,
~3X stiffer), longer relaxation times, and greater dependence on strain
elongation

than transverse samples (Kirilova et al., 2011, 2009; Kirilova, 2012).

Oblique

The transversalis fascia was also evaluated mechanically in uniaxial

20%

tension and was shown to exhibit anisotropy ratios of 2–3, depending

on whether test sample orientation was based on anatomical or collagen
~7 kPa shear MOD

fiber alignment axes (Kirilova et al., 2011; Kureshi et al., 2008).

19.4% elongation

~0.7–0.8 N/mm
resting stiffness
22.5 kPa MOD

Regarding the musculature of the abdominal wall, very few studies

Longitudinal

have examined the mechanics of isolated muscle layers from the human
abdomen. This may be due to experimental challenges, foremost of
which is the inability to evaluate active muscle properties of cadaveric
human muscle tissues; thus, experiments on human tissue have relied
~20 kPa shear MOD

solely on passive characterization. One set of experiments evaluated the

2.5–4.4 cm height

resting stiffness

rectus abdominis, transversus abdominis, external oblique and internal

42.5 kPa MOD

~0.5–1 N/mm
Transverse

oblique muscles using uniaxial and biaxial testing (Cardoso, 2012). A

elongation
5.2–9.4%

few of the interesting results within this large dataset were that (1) the
evaluated muscles were more compliant than abdominal fascia, (2) the
transversus abdominis sustained the largest stress, while the rectus
abdominis supported the lowest stress, and (3) muscles from male
3D stereography

Non-invasive IR

donors exhibited stiffer passive properties than tissues from female

Test Method

3D imaging/
elastography

donors. The dataset wasn’t sufficiently powered to detect significant

3D imaging
imaging

correlations between mechanics and age, sex, or body mass index

(BMI).

2.2.2. Mechanical evaluation of the intact human abdominal wall

(Female)

158 (77)

Since the layers of the abdominal wall do not function in isolation in

Male

9 (9)

6 (2)

8 (3)

the physiological environment, but rather as part of an integrated

composite structure, various studies have examined the mechanical
Mean Age

behavior of the intact abdominal wall (Table 1). Such studies typically
(23–35)

(40–62)
(range)

fall into one of two types of approaches: ex vivo testing of cadaveric

48.5

abdomens or non-invasive evaluation of the abdominal motion of living

56

subjects. We now summarize previous work using these two ap-

Number of

235 mesh

proaches.
Donors

A number of different experimental techniques have been devised to

18

11

evaluate the mechanics of the intact human abdominal wall. Junge

8

et al. (2001) developed a sophisticated multidirectional test configura-

tion with eight actuators arranged in a circular pattern; using this setup,
displacements in different directions were measured at various levels of
applied force. At a reference load of 16 N, the largest strains were found
in the cranio-caudal (~27% average), followed by medial-lateral
Table 1 (continued)

(~16%), and then oblique directions (~12%), with female abdomens

exhibiting increased compliance compared to males. Another experi-
mental approach utilized balloon-insufflation of the abdomen and
sutured gauges in the linea alba to measure forces in the abdominal
wall as a function of IAP (Konerding et al., 2011). This study reported a
nearly-linear increase in force vs. pressure, with a maximum of

414
C.R. Deeken, S.P. Lake
~40–50 N/cm at 200 mbar IAP. Consistent with other studies, trans-
verse tensile forces in linea alba did not correlate with donor demo-
graphics (e.g., weight, height, BMI). A recent study simultaneously
evaluated strains on the internal and external surfaces of excised human
abdominal walls subjected to varying amounts of air pressure for three
different states: intact, incised (i.e., simulated hernia), and repaired
(Podwojewski et al., 2014). Strains on the external surface were
homogeneous while strain maps on the internal surface appeared to
relate to heterogeneities of the underlying anatomy. Interestingly,
external surface strains were 2X larger than internal surface strains,
suggesting that predictions of internal strains deduced from measure-
ments acquired of the external abdominal wall may not be reliable.
Finally, one study utilized an ex vivo experimental setup to test full-
thickness abdominal walls at different pressures after a series of
sequential dissections to determine the relative degree to which specific
tissues contribute mechanically (Tran et al., 2014). Consistent with
studies of individual wall layers, this study reported larger strains in the
longitudinal direction compared to transverse (particularly for poster-
ior rectus sheath and linea alba), and results also demonstrated the
relative mechanical importance of the anterior rectus sheath within the
composite abdominal wall.
Several studies over the past twenty years have devised approaches
to measure motion/deformation of the abdominal wall in human
subjects using non-invasive means. The first published technique used
a three-dimensional (3D) stereography technique wherein a light grid
was projected on subjects’ abdomens and images captured at different
stages of respiration were analyzed to extract measurements of
abdominal wall motion based on how the light grid deformed between
paired images (Klinge et al., 1998). This technique showed reduced
abdominal wall mobility/compliance for patients with a mesh-aided
hernia repair compared to healthy controls, but no difference in the
state of the abdominal wall at rest between these two groups (Muller
et al., 1998). The 3D stereography technique was also used to measure
the relative motion of abdominal walls of patients after surgical repair
with one of three different meshes of varying weights (Welty et al.,
2001). In this study, all meshes increased abdominal wall stiffness
relative to control; since stiffness increased with increasing mesh
weight, the authors suggested that reducing the amount of mesh
material used in hernia repair would be beneficial. Taking a different
approach, Song et al. (2006a, 2006b) developed a non-invasive infrared
(IR) camera imaging system to measure in vivo elasticity of the
abdominal wall during laparoscopic surgery. For this technique, a
three-camera IR system tracked the 3D position of twelve markers
attached to the patient's abdominal wall at different IAPs. Results
showed that the initial cylindrical shape of the abdomen became more
dome-like during insufflation, with most shape change occurring in the
sagittal plane (demonstrating an anisotropic response). Overall average
expansion was ~15–20% at 12 mm Hg IAP, with male patients
exhibiting a slightly stiffer response. A similar approach used a two-
camera system to track a grid of markers on the external surface of the
abdominal wall of healthy subjects to determine elongations during
three different torso motions: rotations to both sides, leaning to both
sides, and leaning forwards/backwards (Smietanski et al., 2012).
Although reported measurements in this study include some very large
(perhaps unrealistic) elongations, overall results suggest that strong
mesh fixation should be used in hernia repair to accommodate large
abdominal wall deformations. A recent study utilized a four-camera
system to track abdominal surface markers combined with shear wave
ultrasound elastography during four typical physiological activities
(Tran et al., 2016). While this technique offers exciting potential, the
large coefficients of variation and lack of repeatability in this study
suggest that further refinement of this technique is warranted.
2.3. Mechanical modeling of the human abdomen
The experimental studies outlined in the previous section have
415
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
yielded valuable information describing the mechanical properties of
human abdominal tissues. However, even with extensive and sophisti-
cated experimental analyses, not all aspects of biomechanical para-
meters within a given system can be realized solely with experimental
investigations. In addition, acquisition of human cadaveric tissue can be
challenging and expensive. Thus, some research efforts have focused on
developing models to further elucidate structure-function properties of
the human abdomen and enable predictions of biomechanical behavior
under other loading scenarios.
To overcome difficulties in acquiring and handling human cadaveric
tissues, a few studies have developed synthetic model systems to
explore tissue-level relationships (e.g., microstructural organization
and mechanical function) and evaluate surgical procedures (e.g.,
suturing techniques) that are relevant for abdominal tissues and hernia
repair. One such study created rubber-cotton composite materials by
adding cotton fibers to a latex rubber-oil composite (van Os et al.,
2006). After evaluating a variety of different formulations, the authors
designed a composite material with a specific mixture of latex rubber,
oil (cis-cis linoleic acid) and eight layers of cotton thread in an ordered
stacking sequence that yielded mechanical properties highly similar to
the human linea alba. Another study created an in vitro model system
with synthetic mesh and elastomeric matrix to represent an explanted
mesh-tissue composite (Rohrnbauer and Mazza, 2013). Mechanical test
results from uniaxial tensile tests and biaxial ball inflation tests showed
that the composite material was different from dry mesh or elastomer
alone, and was able to closely approximate the response of explanted
mesh-tissue composites from animal tests. While these studies rely on
several simplifications and approximations, they offer potentially
effective tools to characterize the properties of abdominal tissue and/
or meshes in physiologically relevant environments.
The majority of modeling studies of the human abdominal wall have
sought to develop theoretical or computational approaches based on
experimental data that are capable of yielding novel insights and/or
enabling predictive simulations. One model used segmented magnetic
resonance imaging (MRI) slices of a patient's torso and a large set of
experimental tests of the linear alba to develop a 3D-contour model of
the abdominal wall (Forstemann et al., 2011). In addition to computing
average biaxial radii of curvature (transverse = 201 mm; longitudingal
= 470 mm), this study also computed a relationship between IAP and
plane states of stress and found, among other results, that stresses were
2X greater in the transverse compared to longitudinal direction.
Another study utilized a hyperelastic, fiber-reinforced, almost-incom-
pressible constitutive model to compute abdominal wall displacements
for IAPs corresponding to specific activities (standing, standing cough,
jump) (Pachera et al., 2016). This model represented a significant
advancement as it included nonlinear anisotropy of abdominal tissues
and considered the mechanical state at large strains, both of which are
often neglected in soft tissue modeling. Both of these studies were
formulated for the intact (non-herniated) abdominal wall, yet modeling
approaches also offer a useful tool for considering mechanical function
following injury and surgical repair.
A signficant amount of work on computational modeling of hernia-
repaired abdominal walls has been completed by Hernandez-Gascon,
Calvo and colleagues. Using finite element (FE) models of the abdomen
with one of three synthetic meshes, this group found that surgical repair
does not restore normal physiological conditions in the abdominal wall
(Hernandez-Gascon et al., 2011). Results of a follow-up study indicated
that post-repair mechancial function depends on the orientation of the
implanted mesh, and that anisotropic meshes need to be positioned
with the most compliant axis of the mesh positioned along the cranio-
caudal (i.e., longitudinal) direction (Hernandez-Gascon et al., 2013). A
subsequent iteration of this model utilized a large deformation aniso-
tropic hyperelastic formulation and was the first model to define
realistic geometry of the entire human abdomen (obtained from full
torso MRI) including different anatomical structures to simulate passive
mechanical behavior under different physiological loads (Hernandez-
 C.R. Deeken, S.P. Lake

Table 2
Mechanical testing data for animal abdominal tissues (MOD = elastic modulus; UTS = ultimate tensile strength; int = internal; ext = external; obl = oblique; trans = transversus; abd = abdominal or abdominis).

Species Number of Age or Sex Test method Transverse Longitudinal Parallel to fibers Perpendicular to Aniotropy Ref.
animals Weight fibers

Individual Linea alba Pig 20 26–28 weeks mixed Uniaxial 61 MPa MOD 7 MPa MOD 8.7 (Cooney et al., 2015)
Layers Biaxial 240 MPa MOD 30 MPa MOD 8
Pig 4 4 months Uniaxial 2.1 MPa stress at 0.85 MPa stress at ~2.5 (Levillain et al.,
stretch = 1.4 stretch = 1.4 2016)
Anterior rectus Pig 20 26–28 weeks mixed Uniaxial ~80 MPa MOD ~8 MPa MOD ~10 (Lyons et al., 2014)
sheath Biaxial ~130 MPa MOD ~25 MPa MOD ~5.2
Rat 18 450–510 g male Uniaxial 49 N/cm MOD 2.2 N/cm MOD ~22 (Anurov et al., 2012)
Posterior rectus Rat 18 450–510 g male Uniaxial 18.5 N/cm MOD 2.0 N/cm MOD ~9.3 (Anurov et al., 2012)
sheath
Rectus abdominis Rabbit 7 2150 g male Uniaxial ~6.5 MPa MOD (Hernandez et al.,
2011)
Transversus Dog 11 15–23 kg Uniaxial/ ~10 MPa MOD ~75 MPa MOD ~0.1 (Hwang et al., 1985)

416
abdominis Biaxial
External oblique Rabbit 7 2150 g male Uniaxial ~13.3 MPa MOD ~2 MPa MOD ~6.6 (Hernandez et al.,
2011)
Internal oblique Rat 7 250–300 g male Uniaxial 0.41 N/mm stiffness (DuBay et al., 2007)
0.17 MPa max stress
Dog 11 15–23 kg Uniaxial/ ~15 MPa MOD ~35 MPa MOD ~0.4 (Hwang et al., 1985)
Biaxial

Composite Ex vivo whole abd Pig 6 4–5 months female int vs ext 5.3% int principal strain (Podwojewski et al.,
Layers wall strains 13.7% ext principal strain 2013)
Ext Obl; Int Obl; Rabbit 7 2150 g male Uniaxial ~4.7 MPa MOD ~1.4 MPa MOD ~3.4 (Hernandez et al.,
Trans Abd 2011)
Ext Obl; Int Obl ~5.7 MPa MOD ~1.35 MPa MOD ~4.2
Int Obl; Trans Abd ~1.1 MPa MOD ~0.7 MPa MOD ~1.6
In vivo intact abd Rabbit 4 2–2.3 kg Tracked 3.0–22.4% strain 1.3–8.7% strain at (Simon-Allue et al.,
wall surface at 12 mm Hg 12 mm Hg 2015)
markers
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
C.R. Deeken, S.P. Lake
Gascon et al., 2013). When used to evaluate the mechanical response to
different activities (e.g., Valsalva maneuver, standing cough, jumping),
this model demonstrated that the stiffest tissues, particularly the linea
alba, are the most important structures that contribute to mechanical
stability of the abdominal wall. Most recently, this FE model was used
to examine the immediate post-repair response using hernia meshes of
different sizes (Simon-Allue et al., 2016a). When evaluating IAP
magnitudes corresponding to a jumping motion, the meshes showed
varying wall displacements, thereby demonstrating that the mechanical
match of mesh to tissue is an important consideration that influences
post-operative deformation. Lastly, this group compared two simple
theoretical models, namely a beam model and a membrane model, each
with a different balance of precision and computational expense
(Hernandez-Gascon et al., 2014). Consistent with the more complex
FE formulations, these models showed that the distribution of stresses is
modified when a surgical mesh is placed in a healthy abdominal wall
and that surgical repair does not restore normal physiological condi-
tions. In the future, extending these models to include simulations of
tissue remodeling may yield insights into the long-term behavior of the
abdominal wall following mesh implantation.
One other group developed mathematical models of post-hernia
repair abdominal tissues with mesh implants (Lubowiecka, 2013a,
2013b). These studies used a membrane-based model to consider the
connection points between implanted mesh and host tissue and to
examine the effect of mesh placement and orientation on mechanical
response. These studies showed that optimal mesh orientation is highly
dependent on hernia location and demonstrated that validated model
simulations can estimate the repair persistance of meshes placed in
varying orientations.
2.4. Limitations of previous studies of human abdominal wall mechanics
The studies summarized in the previous sections have yielded
significant insight regarding the mechanical properties and function
of individual layers of the human abdomen as well as the intact
abdominal wall. However, results of these studies should be considered
in the context of a number of limitations and approximations. For
experimental ex vivo studies, limiting issues include: (1) the use of
previously frozen human specimens without considering the effects of
freezing on the measured mechanical response, (2) issues of dehydra-
tion and rigor mortis in sample preparation, (3) the evaluation of
cadaver tissues from aged donors, which may not approximate the
mechanical response of younger tissues, (4) variable test conditions
(e.g., fixturing technique, loading rate, strain/stress/tension levels
evaluated) making comparisons across studies difficult, and (5) the
inherent issue that ex vivo post-mortem testing may not adequately
replicate the in vivo physiologic loading environment. For the in vivo
experiments, several of the issues inherent in ex vivo testing are not
applicable, however such studies are impacted by other limitations.
Primary among these concerns is that these studies often measure
abdominal wall motion on the external skin surface, which may not
approximate deformations occuring at the level of hernia-related tissue
disruption or location of implanted mesh during hernia repair
(Podwojewski et al., 2014). Other potential issues for non-invasive in
vivo studies are the limited validation of experimental techniques and
variability across different subjects, making it difficult to draw broad
conclusions from study results. Finally, mathematical and computa-
tional modeling studies are often limited by flawed assumptions (e.g.,
isotropic properties of tissues, uniform thickness of wall or layers, linear
mechanical properties) and the lack of experimental data to properly
motivate mathematical representations of physical phenomena (e.g.,
interactions between layers of the abdominal wall). Many areas of
opportunity remain to further elucidate the mechanical properties and
behavior of the human abdominal wall.
417
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
3. Animal abdominal walls
3.1. Mechanical properties of animal abdominal walls
Animal models offer a variety of advantages for evaluating the
mechanical environment and function of the abdominal wall. For
example, animal studies provide: (1) the ability to conduct studies that
are not possible in humans, (2) greater control over experimental
design (e.g., age, time-points, injury state), (3) greater consistency
across different animals than is possible within human cohorts, and (4)
lower costs. Although several inherent limitations reduce the degree to
which animal results can be translated directly to human care (e.g.,
different mechanical loading between bipeds and quadrupeds), the
advantages of such approaches have led several investigators to use
animal models to examine fundamental concepts in abdominal wall
mechanics. A summary of these studies is provided in the subsequent
sections and in Table 2.
3.1.1. Mechanical evaluation of individual components of animal abdomens
A number of animal species have been utilized to quantify the
mechanical properties of individual layers of the abdominal wall. A
study that examined the rectus sheath of Wistar rats found similar
results to human tissue, namely that anterior rectus sheath was much
stronger than posterior sheath and that both sheaths exhibited larger
moduli in transverse loading compared to longitudinal (Anurov et al.,
2012). Another study utilized Sprague-Dawley rats to investigate the
effect of hernia on a specific muscle response (DuBay et al., 2007). In
this study, internal oblique muscles from herniated abdominal walls
showed changes similar to those seen in mechanically-unloaded
muscles, specifically pathologic fibrosis, disuse atrophy, and muscle
fiber changes, which led to decreased compliance of the abdominal
wall.
In a rabbit model, the transversus abdominis and rectus abdominis
were isolated and tested using uniaxial longitudinal and transverse
tensile tests; results were compared to tests of composite samples of
multiple muscle layers (Hernandez et al., 2011). Mechanical anisotropy
was greater for separated muscles than any composite tissue testing and
collagen was found to be responsible for passive mechanical strength of
different layers. Among abdominal muscles in the rabbit, the external
oblique was stiffer in the transverse direction than longitudinal, while
the internal oblique was stiffer in longitudinal than transverse; con-
sidered together, these contrasting results help explain the more
isotropic response for composite samples. More recently, a study
evaluated the active properties of individual muscles and multi-layered
muscle composites from the rabbit abdomen (Grasa et al., 2016). Using
experimental analysis and computational simulations, this study eval-
uated how directions of muscle and collagen fibers in each layer
contribute to active muscle contraction force. Importantly, this appears
to be the first study to evaluate active muscle properties in considering
abdominal wall mechanics; more work in this area is desperately
needed. As such measurements are difficult in human tissues, animal
studies provide a useful tool for future investigations.
Several studies have evaluated tissues from porcine abdomens. In
uniaxial and biaxial tensile testing of the linea alba, the transverse
direction was shown to be ~8x stiffer than the longitudinal direction,
such that deformation occured predominantly in the longitudinal
direction (Cooney et al., 2015). Compared to their previous data of
human linea alba tested using similar protocols (Cooney et al., 2016),
this group found no significant differences for uniaxial data and
transverse biaxial loading, and only slight differences in biaxial long-
itudinal response between porcine and human tissues. Other studies
have also reported anisotropic behavior of the porcine linea alba, but
not to the same degree; an analysis of a small number of animals
showed a ratio of ~2.5 for transverse-longitudinal stress (Levillain
et al., 2016). Another study compared the properties of porcine and
human linea alba tested in uniaxial tension and reported non-linear
C.R. Deeken, S.P. Lake Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

Table 3
Permanent synthetic biomaterials for hernia repair applications.

Bare Barriers & Coatings Reinforced

3D Max (Bard/Davol Inc.)a Permanent Resorbable Fibers

3D Max Light (Bard/Davol Inc.)a
Bard Mesh (Bard/Davol Inc.)
Bard Soft Mesh (Bard/Davol Inc.)
DynaMesh-CICAT (FEG Textiltechnik mbH)
DynaMesh-ENDOLAP (FEG Textiltechnik mbH)
DynaMesh-IPOM (FEG Textiltechnik mbH)
DynaMesh-Lichtenstein (FEG Textiltechnik mbH)
DynaMesh-PP Light (FEG Textiltechnik mbH)
DynaMesh-PP Standard (FEG Textiltechnik mbH)
EASY PLUG PATCH SYSTEM (Apside/BG Medical)a
Freedom Octomesh (Insightra Medical)
INFINIT Mesh (W.L. Gore & Assoc. Inc.)
Kugel Patch/Modified Kugel Patch (Bard/Davol Inc.)
Marlex (Bard/Davol Inc.)
MERSILENE Mesh (Ethicon Inc.)
MK Hernia Patch (Bard/Davol Inc.)
MotifMesh (Proxy Biomedical)
Omyra Mesh (B Braun)
Optilene Mesh (B Braun)
Optilene Mesh Elastic (B Braun)
Optilene Mesh LP (B Braun)
Optilene Mesh Plug (B Braun)
Parietene (Covidien)
Parietex Anatomic Mesh (Covidien)
Parietex Flat Sheet 2D Weave (TEC) Mesh (Covidien)
Parietex Flat Sheet 3D Weave (TET) Mesh (Covidien)
Parietex Folding Mesh (Covidien)
Parietex Easegrip Mesh (Covidien)
Parietex Lightweight Monofilament Polyester Mesh (Covidien)
Parietex ProGrip Self-Fixating Mesh (Covidien)
Parietex Plug and Patch System (Covidien)a
PerFix Light Plug (Bard/Davol Inc.)a
PerFix Plug (Bard/Davol Inc.)a
Polysoft Hernia Patch (Bard/Davol Inc.)
Premilene Mesh (B Braun)
Premilene Mesh Plug (B Braun)
PROLENE 3D Patch (Ethicon Inc.)a
PROLENE Mesh (Ethicon Inc.)
PROLENE Polypropylene Hernia System (Ethicon Inc.)a
PROLENE Soft Mesh (Ethicon Inc.)
ProFlor (Insightra Medical)a
ProLite Mesh (Atrium Medical Corp.)
ProLite Ultra Mesh (Atrium Medical Corp.)
ProLoop Mesh (Atrium Medical Corp.)a
Rebound HRD (MMDI)
Rebound HRD V (MMDI)
SURGIMESH WN (Apside/BG Medical)
Surgipro Polypropylene Monofilament (Covidien)
Surgipro Multifilament Polypropylene (Covidien)
Surgipro Polypropylene Open Weave (Covidien)
Versatex (Covidien)
VISILEX Mesh (Bard/Davol Inc.)
VITAMESHTM (Atrium Medical Corp.)
VITAMESHTM BLUE (Atrium Medical Corp.)
SERAMESH PA (Serag Wiessner)
Permanent Barrier, Non-Composite ULTRAPRO Hernia System (Ethicon Inc.)a
CRURASOFT Patch (Bard/Davol Inc.) ULTRAPRO Mesh (Ethicon Inc.)
DUALMESH Biomaterial (W.L. Gore & Assoc. Inc.) ULTRAPRO Plug (Ethicon Inc.)a
DUALMESH PLUS Biomaterial (W.L. Gore & Assoc. Inc.) VYPRO Mesh (Ethicon Inc.)
DULEX Mesh (Bard/Davol Inc.) VYPRO II Mesh (Ethicon Inc.)
MYCROMESH Biomaterial (W.L. Gore & Assoc. Inc.)
MYCROMESH PLUS Biomaterial (W.L. Gore & Assoc. Inc.)
Reconix Reconstruction Patch (Bard/Davol Inc)
Permanent Barrier, Composite
Composix (Bard/Davol Inc.)
Composix E (Bard/Davol Inc.)
Composix E/X (Bard/Davol Inc.)
Composix Kugel Patch (Bard/Davol Inc.)
Composix L/P (Bard/Davol Inc.)
CK Parastomal Hernia Patch (Bard/Davol Inc.)
SURGIMESH XB (Apside/BG Medical)
VENTRALEX Hernia Patch (Bard/Davol Inc.)
VENTRIO Hernia Patch (Bard/Davol Inc.)
Permanent Coating
TIMESH Extralight (Biomet Biologics/GfE Med. GmbH)
TIMESH Light (Biomet Biologics/GfE Med. GmbH)
TIMESH Strong (Biomet Biologics/GfE Med. GmbH)
Resorbable
Resorbable Barrier, Composite
Adhesix (Cousin Biotech)
C-QUR Mesh (Atrium Medical Corp.)
C-Qur Mosaic Mesh (Atrium Medical Corp.)
C-QUR TacShield (Atrium Medical Corp.)
C-QUR V-Patch (Atrium Medical Corp.)
GORE® SYNECOR Biomaterial (W.L. Gore)
Parietex Composite (PCO) Mesh (Covidien)
Parietex Composite Hiatal (PCO 2H) Mesh (Covidien)
Parietex Composite Open Skirt (PCO OS) Mesh (Covidien)
Parietex Composite Parastomal (PCO) Mesh (Covidien)
Parietex Composite Ventral Patch (Covidien)
PHYSIOMESH (Ethicon Inc.)
PROCEED Surgical Mesh (Ethicon Inc.)
PROCEED Ventral Patch (PVP) (Ethicon Inc.)
Sepramesh (Bard/Davol Inc.)
Sepramesh IP COMPOSITE (Bard/Davol Inc.)
Symbotex (Covidien)
VENTRALEX ST Hernia Patch (Bard/Davol Inc.)
VENTRALIGHT ST Mesh (Bard/Davol Inc.)
VENTRIO ST Hernia Patch (Bard/Davol Inc.)
Resorbable Coating
C-QUR FX Mesh (Atrium Medical Corp.)
C-QUR Lite Mesh (Atrium Medical Corp.)
C-QUR CENTRIFX (Atrium Medical Corp.)a

Biological Tissue-Derived Barrier

ZenaproTM (Cook Medical)

a
Available in preformed shapes.

viscoelastic anisotropic responses for both tissues, with ~1.5x stiffer
response for the porcine linea alba compared to human (Levillain et al.,
2016). The porcine anterior rectus sheath was also examined using
uniaxial/biaxial tests aligned parallel and perpendicular to the collagen
fiber direction; results showed a highly anisotropic response with the
fiber direction exhibiting higher stiffness and failure stress than the
cross-fiber direction (Lyons et al., 2014).
A single study has examined canine adbominal tissues as an animal
model. In this study, the mechanics of the transversus abdominis and
internal oblique muscles were evaluated individually and also together
as a composite structure (Hwang et al., 1985). The composite samples
were less compliant than the isolated muscles in the direction of the
muscle fibers, but more compliant in the direction perpendicular to the
fibers. Interestingly, the anisotropy of composite samples was less
pronounced than individual muscle samples, likely because the fiber
directions in these two muscles are not coincident and balance each
other. While perhaps obvious, this observation demonstrates the
importance of not only evaluating mechanical properties of individual
layers within the abdominal wall, but to also consider the functional
behavior of the composite structure when all layers are combined in the
anatomical environment.

418
C.R. Deeken, S.P. Lake Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

Table 4 2016; Cooney et al., 2015)) have also shown greater transverse stiffness
Resorbable synthetic biomaterials for hernia repair applications. compared to the longitudinal direction, so other factors specific to the
test setup or the rabbit model itself may be responsible.
Bare Barriers & Coatings

BIO-A Tissue Reinforcement (W.L. Gore & Resorbable Barrier, Composite

Assoc. Inc.)
BIO-A Hernia Plug (W.L. Gore & Assoc. Inc.) PhasixTM ST Mesh (Bard/Davol Inc.)
DEXON Mesh (Covidien)
Safil Mesh (B Braun)
Seri Scaffold (Sofregen Medical)
TIGR Matrix Surgical Mesh (Insightra
Medical)
VICRYL Knitted/Woven Mesh (Ethicon Inc.)
Phasix (Bard/Davol Inc.)
3.1.2. Mechanical evaluation of intact animal abdominal walls
For similar reasons as outlined previously for human tissue, several
studies have examined the mechanical behavior of the intact abdominal
wall in animal models. Namely, the in vivo mechanical function of the
abdominal wall relies on the integration and cooperation of the various
layers of the composite tissue structure rather than on actions of
individual tissues. One group developed an experimental test method
to measure the deformation and strains on both the internal and
external surfaces of an excised porcine abdominal wall under pressure
applied via air or a spherical indenter (Podwojewski et al., 2013). Using
this setup, speckle patterns were applied to the internal and external
abdominal surfaces and 3D strain fields were computed for both
surfaces of pressurized abdominal walls in intact, defect, and repaired
states. Similar to results obtained using this system for human tissue
(Podwojewski et al., 2014), external surface strains were ~2.5X greater
than internal strains and, importantly, the stiffness and strains of the
repaired walls were not different from the intact state. Another group
developed a non-invasive analysis technique to measure the in vivo
deformation of the surface of the abdominal wall of anesthetized rabbits
at different IAPs (Simon-Allue et al., 2015). This procedure was utilized
to evaluate healthy and hernia-repaired rabbits (using SurgiproTM, a
high-density non-absorbable polypropylene mesh), which showed that
max displacements were ~30% lower for repaired abdomens. Interest-
ingly, in this study the longitudinal direction appeared to be stiffer than
transverse, which disagrees with much of the literature. The authors
suggest that this may be partially due to biped vs. quadruped animals,
however even studies in other quadrupeds (e.g., pigs (Levillain et al.,
3.2. Mechanical modeling of animal abdomens
Although not as common as the work that has been done for human
tissues, some theoretical and computational models have been devel-
oped to provide deeper analyses and enable predictive responses of
animal abdomens. Simon-Allue et al. (2015) expanded upon their
previously described technique to measure the elasticity of the rabbit
abdominal wall, then evaluated the ability of two distinct inverse
analysis procedures to predict region-specific mechanics (i.e., shear
modulus and non-linearity parameter) from the measured deformations
and known IAPs (Simon-Allue et al., 2016b). This study utilized a 3D FE
model with an isotropic two-parameter constitutive model and demon-
strated a stiffer region in the center of the abdominal wall correspond-
ing to linea alba and fascia layers. While this study was for the intact
rabbit abdomen, a few other studies have developed mathematical
models of rabbit tissues following mesh implantation. Hernandez-
Gascon et al. (2011) formulated a FE model of repaired abdominal
wall tissue, which showed smaller displacements and higher stresses in
implanted abdominal wall compared to the intact wall. As the simula-
tion of repair with three representative meshes led to very different
mechanics of abdominal wall compared to the intact case, the authors
suggested that no mesh can reproduce the displacements of the healthy
abdominal wall. While this conclusion may be overly broad after
examination of only a small subset of possible meshes, it does highlight
the difficulty in properly matching properties of implanted synthetic
meshes to the mechanics of the complex, composite abdominal wall.
Another study by this group utilized the rabbit animal model to
examine the mechanics of defect repair using three different meshes,
evaluated at three different post-operative time points (Hernandez-
Gascon et al., 2012). This study found that the ingrowth of collagen into
implanted meshes seemed to somewhat unify the mechanics of mesh-
tissue explants, thereby indicating that detailed characterization of pre-
implantation synthetic meshes without considering changes that occur
following repair is likely not sufficient to optimize mesh-tissue mechan-
ical match.
An extensive study using a porcine animal model evaluated various
combinations of synthetic meshes of varying properties attached via
one of several different types of connectors (i.e., fixation methods)

Table 5
Biological tissue-derived biomaterials for hernia repair applications.

Bare Barriers & Coatings Reinforced

AlloDerm Tissue Matrix (LifeCell Corp.) Antibacterial Coating Permanent Fibers

AlloMax Surgical Graft (Bard/Davol Inc.) XenMatrixTM AB Surgical Graft (Bard/Davol Inc.) OviTex Reinforced BioScaffold with Permanent Polymer (TELA Bio)
CollaMend Implant (Bard/Davol Inc.)
CollaMend FM Implant (Bard/Davol Inc.) Permanent Fibers + Barrier
DermaMatrix Acellular Dermis (Synthes Inc.) OviTex 1S Reinforced BioScaffold with Permanent Polymer (TELA Bio)
FlexHD Acellular Dermis (MTF/Ethicon Inc.) OviTex 2S Reinforced BioScaffold with Permanent Polymer (TELA Bio)
Fortiva (RTI Biologics)
MatriStem (ACell, Inc.) Resorbable Fibers
Medeor Matrix (Kensey Nash Corp.) OviTex Reinforced BioScaffold with Resorbable Polymer (TELA Bio)
Meso BioMatrix Scaffold (Kensey Nash Corp.)
Miromesh Biologic Matrix (Miromatrix Medical Inc.) Resorbable Fibers + Barrier
Peri-Guard Repair Patch (Synovis) OviTex 1S Reinforced BioScaffold with Resorbable Polymer (TELA Bio)
Permacol Surgical Implant (Covidien) OviTex 2S Reinforced BioScaffold with Resorbable Polymer (TELA Bio)
Strattice Reconstructive Tissue Matrix (LifeCell Corp.)
Supple Peri-Guard Repair Patch (Synovis)
SurgiMend Collagen Matrix (TEI Biosciences Inc.)
Surgisis/Biodesign Hernia Grafts (Cook Medical)
Surgisis FM/Biodesign Hernia Grafts (Cook Medical)
Veritas® Collagen Matrix (Insightra)
XCM Biologic Tissue Matrix (Ethicon)
XenMatrixTM Surgical Graft (Bard/Davol Inc.)

419
C.R. Deeken, S.P. Lake
Fig. 2. Classification system for biomaterials utilized for hernia repair applications.
(Tomaszewska et al., 2013). Evaluation included a total of 57 different
configurations, corresponding to over 200 total individual experiments,
to repair two sizes of surgically-created hernia defects (5 or 8 cm).
Some predictable results were confirmed (e.g., larger diameter hernias
correspond to larger forces, stiffer implants led to larger tearing forces
on the connectors), and other unique insights into the relative strength
of fixation methods were provided (e.g., trans-abdominal sutures carry
highest load). This study also introduced a simple FE model of
implanted mesh, yielding results that compared favorably to experi-
mental data.
3.3. Limitations of previous studies of animal abdominal wall mechanics
As noted previously for studies of human tissues, there are a number
of limitations which should be considered when interpreting results and
conclusions from the studies that have utilized animal model systems
and tissues to examine abdominal wall mechanics. Applicable limita-
tions that were described previously include (1) inconsistencies in how
tissues are preserved/treated (e.g., live tissue vs. fresh post-mortem vs.
frozen/thawed, relative state of hydration, effect of rigor mortis), (2)
variable test conditions and protocols across different studies (e.g.,
loading rate, type of mechanical test, such as uniaxial vs. biaxial vs. ball
burst, specifics of test setup), and (3) flawed assumptions in mathema-
tical modeling formulations (e.g., isotropic tissue properties, homo-
geneous structure/mechanics, uniform thickness of wall or layers). A
few additional issues specific to animal models should also be con-
sidered, namely (4) relevance of each particular animal species to
humans (e.g., biped vs. quadruped loading patterns, variations in
anatomical structures and interactions), and (5) relevance of compar-
isons across different animal species and different muscle types (e.g.,
relative consistency of results across rat, rabbit, pig or dog tissues),
making it difficult to ascertain whether each species is unique or if data
can be compared and/or combined across different species.
4. Biomaterials for hernia repair
4.1. Classification system
The environment of the biomaterial-tissue interface is dictated by
both the biomaterial chosen and the host tissue. Patient-to-patient
variability in muscle mass, fat mass, sex and age, as well as hernia
defect size and location create a wide range of environments into which
a hernia mesh may be placed. Though the host environment is a fixed
factor, the particular biomaterial selected for repair is not. Currently,
nearly 150 biomaterial designs exist for hernia repair applications
(Tables 3–5).
Historically, several classification systems have been proposed to
organize biomaterial designs into practical categories with similar
features (Amid, 1997; Earle and Mark, 2008). However, many of these
systems are now outdated with the development of more sophisticated
devices in recent years. An updated classification system is presented
here in Fig. 2. This system groups meshes in a hierarchical fashion,
beginning with the structural “mesh” component, which is typically
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Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
comprised of either a permanent synthetic material (e.g. polypropylene,
polytetrafluoroethylene, polyester) (Deeken et al., 2011b, 2011c), a
biological tissue-derived material (e.g. dermis, pericardium, rumen, or
small intestine submucosa derived from human, porcine, bovine, or
ovine sources) (Deeken et al., 2012; Ferzoco, 2016b), or a resorbable
synthetic material (e.g. poly-4-hydroxybutyrate, polyglycolic acid,
trimethylene carbonate) (Deeken and Matthews, 2013b; Martin et al.,
2013; Hjort et al., 2012). These structural meshes are also often paired
with anti-adhesion barriers/coatings (Deeken et al., 2012), antibacter-
ial coatings (Cohen et al., 2016; Majumder et al., 2016), or reinforcing
fibers (Sahoo et al., 2014; Ferzoco, 2016a).
As shown in Tables 3–5, some important nuances exist in the
classification of the biomaterials available today. Composite barrier
meshes are comprised of two discrete layers, the structural mesh and
the anti-adhesion barrier. The two layers are sewn or vacuum pressed
together. Non-composite barrier meshes are comprised of a single layer
of material that exhibits anti-adhesion characteristics on one side and
tissue ingrowth features on the other side. Anti-adhesion coatings, on
the other hand, merely surround the individual mesh fibers but do not
form a barrier layer that bridges across the interstices between fibers.
To date, antibacterial coatings have only been applied to porcine
dermis, forming a layer on the surface of the underlying biological
tissue-derived scaffold (Cohen et al., 2016; Majumder et al., 2016).
Additional fibers are also often added to reinforce basic structural
meshes (Sahoo et al., 2014; Ferzoco, 2016). The function of these fibers
is to provide a gradual transfer of load back to the native tissue as the
repair site heals and regenerates native tissue. This is accomplished
when permanent synthetic fibers are used to reinforce biological tissue-
derived materials or when resorbable fibers are used to reinforce
permanent synthetic meshes. One component is gradually resorbed,
while the other component remains intact.
In addition to knowledge of material composition, understanding
the mechanical characteristics of these devices is also critical to
selecting the biomaterial design and orientation that is optimal for
the mechanical environment of a patient's specific hernia. A variety of
techniques have been utilized to assess the mechanics of hernia repair
materials, including biomechanical testing, animal models, and com-
puter simulations.
4.2. Biomechanical characterization
Several biomechanical testing techniques have been described for
characterizing hernia repair materials, including suture retention
(Deeken et al., 2011b, 2011c, 2012; Todros et al., 2017), tear resistance
(Deeken et al., 2011b, 2011c, 2012; Todros et al., 2017), uniaxial
tension (Deeken et al., 2011b, 2011c, 2012; Todros et al., 2017;
Hollinsky et al., 2008; Saberski et al., 2011), ball burst (Deeken et al.,
2011b, 2011c, 2012; Todros et al., 2017), and biaxial testing (Todros
et al., 2017; Deeken et al., 2014; Cordero et al., 2016). In suture
retention testing, a stainless steel wire is passed through the material at
a fixed distance to the edge to simulate a suture. Tension is applied to
the material, and suture retention strength is recorded as the maximum
load sustained prior to failure at the suture point (Deeken et al., 2011b,
C.R. Deeken, S.P. Lake Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

Table 6
Physical characteristics of biomaterials utilized for hernia repair applications.

Diameter of Area of Pores Diameter of Thickness Density Refs.

Pores (mm) (mm2) Fibers (µm) (mm) (g/m2)

PERMANENT SYNTHETIC
Bare
Bard Mesh 0.44–0.58 185.7 0.73–0.76 102.4–105 (Deeken et al., 2011c; Martin et al., 2013)
Bard Soft Mesh 2.5 44 (Kalaba et al., 2016; Schug-Pass et al., 2010)
Dyna-Mesh 4.16 36 (Cordero et al., 2016)
INFINIT 4 116.2 0.16 65.6–70 (Deeken et al., 2011c; Cordero et al., 2016)
Marlex 0.46 0.63 95 (Kalaba et al., 2016; Hollinsky et al., 2008; Klinge
et al., 2002; Cobb et al., 2005)
MERSILENE Mesh 1.0 33–40 (Kalaba et al., 2016; Brown and Finch, 2010; Conze
et al., 2005)
Optilene Mesh 1.0 7.64 36–48 (Kalaba et al., 2016; Cordero et al., 2016; Schug-
Pass et al., 2010; Pascual et al., 2008)
Parietene 1.0–1.6 0.53 77–78 (Kalaba et al., 2016; Hollinsky et al., 2008;
Langenbach and Sauerland, 2013)
Parietene Light 1.5–1.7 0.36 36–38 (Kalaba et al., 2016; Hollinsky et al., 2008; Schug-
Pass et al., 2010; Hollinsky et al., 2009)
Parietex Flat Sheet 2D 2.0 1.75 338.8 0.52–0.53 100–119.2 (Deeken et al., 2011c; Hollinsky et al., 2008)
Mesh (TEC)
Parietex (TECR) 2.0 0.53 120 (Hollinsky et al., 2008)
PROLENE Mesh 0.8–1.6 0.39 130.4 0.51–0.53 79.5–108 (Kalaba et al., 2016; Deeken et al., 2011c; Hollinsky
0.8–1.6 et al., 2008; Cobb et al., 2005; Brown and Finch,
2010; Langenbach et al., 2008)
ProLite Mesh 0.8 0.33 151.2 0.47 85–90 (Kalaba et al., 2016; Deeken et al., 2011c; Cobb
et al., 2005; Orenstein et al., 2012)
ProLite Ultra Mesh 0.34 99.0 0.39 50.1 (Deeken et al., 2011c)
Serapren 0.08–0.1 116 (Kalaba et al., 2016; Langenbach et al., 2008)
Surgipro 0.8 0.26 0.57 84–110 (Kalaba et al., 2016; Hollinsky et al., 2008; Cordero
et al., 2016; Cobb et al., 2005)
Trelex 0.35–0.6 95 (Kalaba et al., 2016; Brown and Finch, 2010;
Orenstein et al., 2012)
Permanent Barrier, Non-Composite
DUALMESH Biomaterial 0.003/0.022 n/a n/a 1.18 320–420 (Kalaba et al., 2016; Deeken et al., 2011b; Doctor,
2006; Voskerician et al., 2010)
MYCROMESH 0.025/0.3 (Kalaba et al., 2016; Voskerician et al., 2006)
Permanent Barrier, Composite
Composix E/X 0.43 183.70 0.89 255.80 (Deeken et al., 2011b)
Composix L/P 6.07 163.20 0.69 187.40 (Deeken et al., 2011b)
Permanent Coating
TIMESH Extralight 1.24 0.21 16 (Hollinsky et al., 2008)
TIMESH Light 1.24 0.29 33 (Hollinsky et al., 2008)
Resorbable Barrier, Composite
C-QUR Mesh 0.33 151.2 0.56 321.0 (Deeken et al., 2011b)
Parietex Composite (PCO) 3.68 160.20 0.76 155.90 (Deeken et al., 2011b)
PROCEED 5.46 96.85 0.57 189.50 (Deeken et al., 2011b)
Sepramesh IP Composite 0.40 155.70 0.82 240.60 (Deeken et al., 2011b)
Resorbable Coating
C-QUR Lite Mesh (≤6 in. 0.34 99.00 0.28 69.19 (Deeken et al., 2011c)
size mesh)
C-QUR Lite Mesh (> 6 in. 0.33 151.20 0.46 128.70 (Deeken et al., 2011c)
size mesh)
Reinforced - Resorbable Fibers
ULTRAPRO 2.28 3.45–4.10 102.5 0.44–0.5 28–58 (Deeken et al., 2011c; Hollinsky et al., 2008;
Cordero et al., 2016)
VYPRO 3.0 0.34 26 (Hollinsky et al., 2008)
VYPRO II 2.6 0.39 40 (Hollinsky et al., 2008)

RESORBABLE SYNTHETIC
Bare
BIO-A Tissue 33.8 1.57 (Ebersole et al., 2012)
Reinforcement
TIGR Matrix Surgical 1 ~13 ~0.5 (Cordero et al., 2016; Ebersole et al., 2012)
Mesh
VICRYL 13.1 0.07 (Ebersole et al., 2012)
PHASIX Mesh 0.26 0.51 182 (Martin et al., 2013)

BIOLOGICAL TISSUE-DERIVED
Bare
AlloDerm Tissue Matrix n/a n/a n/a 2.02 n/a (Deeken et al., 2012)
AlloMax Surgical Graft n/a n/a n/a 1.29 n/a (Deeken et al., 2012)
CollaMend Implant n/a n/a n/a 1.22 n/a (Deeken et al., 2012)
CollaMend FM Implant n/a n/a n/a 1.34 n/a (Deeken et al., 2012)
FlexHD Acellular Dermis n/a n/a n/a 1.15 n/a (Deeken et al., 2012)
Peri-Guard Repair Patch n/a n/a n/a 0.47 n/a (Deeken et al., 2012)
Permacol Surgical n/a n/a n/a 0.91 n/a (Deeken et al., 2012)
(continued on next page)

421
C.R. Deeken, S.P. Lake
Table 6 (continued)
Diameter of Area of Pores Diameter of
Pores (mm) (mm2) Fibers (µm)
Implant
Strattice Reconstructive n/a n/a n/a
Tissue Matrix
SurgiMend Collagen n/a n/a n/a
Matrix
Surgisis/Biodesign Hernia n/a n/a n/a
Grafts
Veritas Collagen Matrix n/a n/a n/a
XenMatrix Surgical Graft n/a n/a n/a
2011c, 2012; Todros et al., 2017). To assess tear resistance, a small tear
of a defined length is initiated in the material. Tension is applied to
either side of the tear, and the tear resistance value is recorded as the
maximum load sustained prior to propagation of the tear (Deeken et al.,
2011b, 2011c, 2012; Todros et al., 2017). In ball burst testing, a
stainless steel ball is applied to the material in compression, simulating
intraabdominal pressure on the material (Deeken et al., 2011b, 2011c,
2012; Todros et al., 2017). A variety of values can be calculated from
the data generated during ball burst testing, including ultimate tensile
strength and strain, but this method does not assess anisotropy and
other important characteristics of hernia repair materials. In uniaxial
tensile testing, a strip of material is subjected to tension in a single
direction (Deeken et al., 2011b, 2011c, 2012; Todros et al., 2017;
Hollinsky et al., 2008; Saberski et al., 2011), while in biaxial tensile
testing, the material is subjected to tension in two orthogonal directions
(Todros et al., 2017; Deeken et al., 2014; Cordero et al., 2016). Both
methods assess the strength and stiffness of the material and character-
istics such as anisotropy, but biaxial testing more realistically simulates
the mechanics of the human abdomen. A recent study revealed
dramatic variation in anisotropy, non-linearity, and hysteresis when
several commonly-utilized hernia repair materials were assessed via
planar biaxial testing, underscoring the importance of understanding
the characteristics of these materials prior to implantation (Deeken
et al., 2014; Cordero et al., 2016).
Several groups have utilized biomechanical techniques to charac-
terize biomaterials for hernia repair applications (Deeken et al., 2011b,
2011c, 2012; Todros et al., 2017; Hollinsky et al., 2008; Saberski et al.,
2011; Cordero et al., 2016), and the results are summarized in Tables
6–7. Differences in experimental procedures (e.g., specific test setup,
testing rate, orientation, specimen dimensions) and methods of data
analysis have led to inconsistencies in values reported by different
groups. Many of the materials shown in Tables 6–7 demonstrate
characteristics that meet the guidelines suggested for failure properties
of materials utilized for hernia repair applications (Deeken et al.,
2011b, 2011c, 2012). However, there are currently no established
guidelines for more nuanced aspects of mechanical properties such as
anisotropy, nonlinearity, and hysteresis, leading to an incomplete
description of mechanical characteristics.
In a series of previous publications, we recommended that hernia
repair materials exhibit suture retention strength and tear resistance
values greater than 20 N, ball burst strength greater than 50 N/cm, and
strain in the range of 10–30% (Deeken et al., 2011b, 2011c, 2012).
These suggested failure properties were based on previous animal
studies or theoretical calculations. For example, Melman et al. (2010)
conducted a study in which polypropylene sutures (size 0) were utilized
to attach hernia meshes to porcine abdominal wall tissue, and the entire
construct was then subjected to lap shear testing. The maximum load
sustained prior to failure was approximately 20 N per fixation point,
with three sutures utilized in each construct. Failure occurred in the
porcine abdominal wall tissue while the mesh and suture material
remained intact. In another study, intraabdominal pressure and
abdominal circumference values were varied to demonstrate the impact
422
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
Thickness Density Refs.
(mm) (g/m2)
1.76 n/a (Deeken et al., 2012)
0.84 n/a (Deeken et al., 2012)
1.37 n/a (Deeken et al., 2012)
0.80 n/a (Deeken et al., 2012)
1.95 n/a (Deeken et al., 2012)
on tensile stress within the abdominal wall when the abdomen was
assumed to behave as a thin-walled pressure vessel (Deeken et al.,
2011b, 2011c). In the most extreme scenario, with the highest
intraabdominal pressure and greatest abdominal circumference, the
resulting tensile stress was 47.8 N/cm, leading to the recommendation
that biomaterials possess a tensile strength of at least 50 N/cm when
used in hernia repair applications (Deeken et al., 2011b, 2011c). When
human abdominal wall tissues were subjected to tensile testing, Junge
et al. (2001) reported a strain of 10–30%, leading to the recommenda-
tion that hernia repair materials should possess similar strain values in
order to approximate the mechanics of the human abdominal wall.
4.3. Preclinical implantation studies
In the field of hernia repair, a number of animal models have been
developed utilizing rats (Anurov et al., 2012; DuBay et al., 2005),
rabbits (Hernandez-Gascon et al., 2012; Konerding et al., 2012; Peeters
et al., 2013), monkeys (Ferzoco, 2016a, 2016b; Xu et al., 2008), sheep
(Hjort et al., 2012), dogs (Greca et al., 2001), and pigs (Cavallo et al.,
2015; Deeken and Matthews, 2013a, 2012, 2013b; Deeken et al.,
2011a; Jenkins et al., 2011; Melman et al., 2011; Scott et al., 2016).
Many of these models are very similar, involving surgical creation of
hernia defects with subsequent mesh repair and evaluation of mechan-
ical and histological characteristics after a period of implantation. In
many of these models, the hernia defects are repaired immediately
while the wound is still in an acute healing phase (Anurov et al., 2012;
Hernandez-Gascon et al., 2012; Ferzoco, 2016a, 2016b; Deeken and
Matthews, 2013a, 2013b; Hjort et al., 2012; Konerding et al., 2012;
Peeters et al., 2013; Xu et al., 2008; Greca et al., 2001; Scott et al.,
2016). In other models, the meshes are implanted after a 4–5 week
“maturation” period, allowing the wound to reach a chronic state prior
to mesh implantation (Cavallo et al., 2015; DuBay et al., 2005; Deeken
et al., 2011a; Jenkins et al., 2011; Melman et al., 2011). Thus, chronic
models more closely recreate the wound environment encountered in
the clinical setting. Hernia repair technique is another variable; meshes
may be implanted in the onlay (Hjort et al., 2012), inlay (Hernandez-
Gascon et al., 2012; Ferzoco, 2016a, 2016b; Deeken and Matthews,
2013b; Xu et al., 2008; Greca et al., 2001), sublay (Cavallo et al., 2015;
Anurov et al., 2012; Deeken et al., 2011a; Jenkins et al., 2011; Melman
et al., 2011; Scott et al., 2016), or underlay (DuBay et al., 2005;
Konerding et al., 2012; Peeters et al., 2013; Deeken and Matthews,
2012; Jenkins et al., 2011; Scott et al., 2016) position. The fascia is
closed, and the mesh is placed on the anterior fascia when implanted in
the onlay position. For inlay repairs, the mesh is placed within the
defect and is sutured to the edges of the defect, leading to what is
commonly referred to as a “bridged” repair without closure of the
fascia. In a sublay repair, the mesh is placed in a retrorectus or
preperitoneal position, and the underlay repair refers to intraperitoneal
mesh implantation. In rats, rabbits, dogs, and monkeys, relatively small
meshes are typically utilized due to the small size of these animals
compared to humans. The porcine abdomen is much larger, comparable
in size to the human abdomen. Thus, clinically relevant hernia defect
 Table 7
Mechanical properties of biomaterials utilized for hernia repair applications (L = longitudinal, T = transverse testing orientation).

Suture Retention Tear Resistance (N) Uniaxial Tensile Ball Burst Planar Biaxial Tensile
(N) Strength (MPa)
C.R. Deeken, S.P. Lake

L T L T L T Tensile Strain (%) Stiffness (N/cm) Stiffness (N/cm) Anisotropy Refs.

Strength Index
(N/cm)

PERMANENT SYNTHETIC MESHES

Bare
Bard Mesh 50.78 66.8 46.84 38.36 11.64 0.16 157.7 10.76 75.69 37.53 2.03 (Deeken et al., 2011c,
2014)
Bard Soft Mesh 124.53 52.89 2.36 (Deeken et al., 2014)
Dyna-Mesh 190.1 100.1 1.84 (Cordero et al., 2016)
INFINIT 26.71 32.36 14.29 16.35 13.6 7.36 9.25 n/a 168.40–479.1 119.83–139.7 1.42–3.37 (Deeken et al., 2011c,
2014; Cordero et al.,
2016)
Optilene Mesh 191.1 100.1 1.82 (Cordero et al., 2016)
Parietex Flat Sheet 2D Mesh 51.4 58.38 32.66 28.6 6.63 15.51 112.90 3.49 (Deeken et al., 2011c)
(TEC)
PROLENE Mesh 61.2 70.49 33.66 39.33 0.76 16.06 156.60 5.27 180.04 143.42 1.26 (Deeken et al., 2011c,
2014)
ProLite Mesh 48.75 57.71 33.35 33.10 11.64 0.16 138.00 9.61 106.19 82.97 1.29 (Deeken et al., 2011c,
2014)
ProLite Ultra Mesh 36.07 23.89 19.27 17.84 11.40 4.90 50.72 16.35 92.24 76.36 1.21 (Deeken et al., 2011c,
2014)
Surgipro 148.7 128.5 1.18 (Cordero et al., 2016)
Permanent Barrier, Non-Composite

423
DUALMESH Biomaterial 65.18 72.95 30.47 41.28 7.52 5.52 97.76 10.24 137.59 125.97 1.08 (Deeken et al., 2011b,
2014)
Permanent Barrier, Composite
Composix E/X 70.47 60.28 30.14 48.75 1.44 10.74 237.8 9.62 (Deeken et al., 2011b)
Composix L/P 34.04 48.58 32.76 16.96 6.10 1.48 76.77 11.06 (Deeken et al., 2011b)
Resorbable Barrier, Composite
C-QUR Mesh 41.78 62.75 25.79 30.79 1.73 4.74 144.30 9.07 177.00 177.78 1.00 (Deeken et al., 2011b,
2014)
Parietex Composite (PCO) 28.15 36.32 19.74 16.21 2.56 1.03 38.87 6.46 178.13 119.34 1.50 (Deeken et al., 2011b,
2014)
PHSIOMESH 168.91 151.62 1.12 (Deeken et al., 2014)
PROCEED 34.06 41.62 19.84 20.19 4.44 4.78 52.60 7.25 129.72 128.34 1.01 (Deeken et al., 2011b,
2014)
Sepramesh IP Composite 99.22 85.89 51.07 54.18 4.38 2.64 200.7 3.68 (Deeken et al., 2011b)
Ventralight ST 123.57 50.82 2.43 (Deeken et al., 2014)
Resorbable Coating
C-QUR Lite Mesh (≤6 in) 22.86 33.83 19.36 18.35 1.11 2.56 50.53 13.22 (Deeken et al., 2011c)
C-QUR Lite Mesh (> 6 in) 61.83 40.00 35.04 42.77 13.75 3.52 170.00 11.32 (Deeken et al., 2011c)
Biological Tissue-Derived Barrier
OviTex 1S ~60 (Ferzoco, 2016a)
OviTex 2S ~75 (Ferzoco, 2016a)
Resorbable Fibers
ULTRAPRO 15.08 16. 10.47 5.07 13.52 0.08 35.50 16.23 98.63–171.2 53.01–79.6 1.87–2.17 (Deeken et al., 2011c,
2014; Cordero et al.,
2016)

RESORBABLE SYNTHETIC
Bare
BIO-A Tissue Reinforcement ~45 16.6 ~4.5 74.9 7.3 (Ebersole et al., 2012)
TIGR Matrix Surgical Mesh ~45 59.0 ~30 33.3 ~7 0.2 86.5 < 10 409.2 272.4 1.47 (Cordero et al., 2016;
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427

(continued on next page)

 Table 7 (continued)

Suture Retention Tear Resistance (N) Uniaxial Tensile Ball Burst Planar Biaxial Tensile
(N) Strength (MPa)

L T L T L T Tensile Strain (%) Stiffness (N/cm) Stiffness (N/cm) Anisotropy Refs.

C.R. Deeken, S.P. Lake

Strength Index
(N/cm)

Ebersole et al., 2012)

VICRYL 39.4 ~25 145.2 ~70 5.8 (Ebersole et al., 2012)
PHASIX Mesh 59.2 49.1 30.3 29.5 140.7 15.4 (Deeken and Matthews,
2013b)

BIOLOGICAL TISSUE-DERIVED
Bare
AlloDerm Tissue Matrix 127.2 84.73 20.32 1028.00 17.02 (Deeken et al., 2012)
AlloMax Surgical Graft 29.09 16.86 14.36 290.80 26.22 (Deeken et al., 2012)
CollaMend Implant 47.90 17.13 11.48 110.3 5.85 (Deeken et al., 2012)
CollaMend FM Implant 37.53 13.21 10.65 86.18 13.58 (Deeken et al., 2012)
FlexHD Acellular Dermis 55.34 31.05 14.36 929.50 21.20 (Deeken et al., 2012)
Peri-Guard Repair Patch 30.54 14.34 21.51 99.05 20.05 (Deeken et al., 2012)
Permacol Surgical Implant 23.75 10.1 8.22 66.23 13.1 (Deeken et al., 2012)
Strattice Reconstructive 63.76 27.54 9.92 270.5 9.59 (Deeken et al., 2012)
Tissue Matrix
SurgiMend Collagen Matrix 87.85 27.86 28.54 432.4 6.41 (Deeken et al., 2012)
Surgisis/Biodesign Hernia 50.29 32.13 2.53 200.2 13.57 (Deeken et al., 2012)
Grafts
Veritas Collagen Matrix 23.92 15.06 9.38 128.6 25.6 (Deeken et al., 2012)
XenMatrix Surgical Graft 99.74 24.5 11.95 377.0 11.59 (Deeken et al., 2012)
Reinforced

424
Permanent OviTex Reinforced ~42 (Ferzoco, 2016a)
Fibers BioScaffold with Permanent
Polymer
Resorbable OviTex Reinforced ~42 (Ferzoco, 2016a)
Fibers BioScaffold with Resorbable
Polymer
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
C.R. Deeken, S.P. Lake
and mesh sizes can be utilized in the porcine abdomen, and similar
intraabdominal pressures are encountered (Gudmundsson et al., 2002;
Cobb et al., 2005), making this the preferred preclinical model for
device evaluation, especially for mechanical characterization.
5. Conclusions
Most of the datasets reviewed in this paper were not sufficiently
powered to detect significant correlations between tissue mechanics of
the human abdominal wall and patient demographics such as age, sex,
BMI, and parity. However, a few studies showed that abdominal wall
tissue specimens procured from male subjects were stiffer or less
compliant than those procured from female subjects (Cardoso, 2012;
Junge et al., 2001; Song et al., 2006a, 2006b). This trend was
demonstrated in mechanical evaluations of both cadaveric samples
(Cardoso, 2012; Junge et al., 2001) and living subjects (Song et al.,
2006a, 2006b). Thus, it is critical that future studies are undertaken
with larger numbers of human abdominal wall specimens to determine
whether other factors are also influential and deserve consideration
when selecting an appropriate biomaterial for hernia repair applica-
tions.
The human abdominal wall is a complex composite structure
composed of many layers which vary depending on specific anatomical
location. The studies reviewed here reported greater compliance of the
linea alba (Grabel et al., 2005), larger strains for the intact abdominal
wall (Junge et al., 2001), and greater stiffness for the rectus sheath and
umbilical fascia (Hollinsky and Sandberg, 2007; Martins et al., 2012;
Ben Abdelounis et al., 2013; Kirilova et al., 2011, 2009; Kirilova, 2012)
when the tissues were loaded in the longitudinal direction compared to
transverse. Additionally, 2–3x greater stresses were observed in the
linea alba (Levillain et al., 2016; Hollinsky and Sandberg, 2007;
Forstemann et al., 2011) when loaded in the transverse direction
compared to longitudinal. Given these trends, a few recommendations
can be made regarding orientation of mesh. For instance, the most
compliant axis of the biomaterial should be oriented in the cranio-
caudal, or “longitudinal”, direction (Hernandez-Gascon et al., 2013),
and the strongest axis of the biomaterial should be oriented in the
medial-lateral, or “transverse”, direction. It is also clear from the
literature that the human abdominal wall is anisotropic, with anistropy
ratios as high as 8–9 reported for the human linea alba (Cooney et al.,
2016). Current biomaterial designs exhibit anisotropy ratios in the
range of 1–3 (Deeken et al., 2014), and it is unclear whether an ideal
ratio exists for optimal match between mesh and tissue. It is likely
dependent on implantation location, since the linea alba, rectus sheath,
and other tissues of the abdominal wall exhibit extremely different
characteristics. Given the number of unknowns yet to be addressed by
current studies of the human abdominal wall, it is unlikely that any
single biomaterial design currently encompasses all of the ideal features
identified. In addition, nearly all studies to date that have evaluated
mechanics of individual muscles or layered structures have soley
considered passive muscle properties; future work must also address
mechanical implications of active muscle contration on abdominal wall
function.
Several other aspects of biomaterial design also deserve considera-
tion, but fall outside the scope of the current review. These character-
istics include low risk of adhesions, resistance to bacterial colonization
and infection, and low cost to support a broad range of applications.
Although subjective and driven by surgeon preference and experience,
hernia repair materials must also possess appropriate handling char-
acteristics for ease of implantation and fixation to the abdominal wall.
Perhaps most important, hernia repair materials must support an
appropriate host tissue response leading to integration within the
native abdominal wall and regeneration of host tissue with character-
istics similar to the intact abdominal wall prior to mesh implantation.
Although current studies have provided important insights into the
characteristics of the human abdominal wall, many aspects remain
425
Journal of the Mechanical Behavior of Biomedical Materials 74 (2017) 411–427
incompletely understood. Future studies should address a number of
topics, including: 1) additional tissue characterization studies involving
greater numbers of fresh human tissue specimens, 2) evaluation of
active muscle mechanics using animal studies and computer simula-
tions to determine how contractile forces contribute, along with passive
properties of tissues and biomaterials, to the mechanical function of the
composite abdominal wall, 3) better computational models that more
closely approximate the human abdomen with appropriate assumptions
regarding anisotropy, thickness, etc., and 4) external means of evaluat-
ing mesh-tissue mechanics in living subjects, in both humans and
animals.
Disclosures
Dr. Deeken is an employee of, and Dr. Lake is a consultant for,
Covalent Bio, LLC (St. Louis, MO) which received funding for this work
from TELA Bio, Inc. (Malvern, PA).
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