The decision to utilize a biologic mesh is generally predicated on the individual patient characteristics, risk factors and the planned procedure. I most commonly utilize biologic mesh materials in cases of ventral abdominal wall hernias and in the repair of large paraesophageal and hiatal hernias. In the case of ventral abdominal wall hernias, biologic mesh is typically reserved for patients with contamination or infection. Most commonly, this includes patients who are undergoing concomitant gastrointestinal or genitourinary procedures at the time of hernia repair. In this group of patients, the alternative would be either avoid the utilization of a mesh (accepting a higher rate of hernia recurrence) or to utilize a synthetic mesh which carries a risk of prosthetic infection.
Other patient groups in which a biologic mesh may be employed are patients with chronic “low-grade” infection or abdominal wall contamination. In these patients, the bacterial burden is sufficiently low to allow for adequate bacterial clearance in the presence of the biologic graft. The most common situation in which I utilize a biologic mesh is in patients in which an infected synthetic mesh is being removed.
In situations in which there is active infection or significant contamination, biologic grafts may not be appropriate as they deteriorate as a result of the bacterial collagenases. If a biologic graft is required, a more suitable approach might consist of a staged operation in which the patient is returned to the operating room several days following the initial procedure for definitive closure and placement of the biologic graft. This will allow for a reduction of the bacterial counts and optimize the chances for success.
The utilization of biologic grafts in patients with risk factors for wound complications has been an area of great debate. Some patients populations such as the morbidly obese, active smokers, or immunosuppressed patients may be at increased risk for postoperative wound complications. Predicting the likelihood of a patient developing a wound complication is a significant challenge. The presence of a constellation of multiple risk factors may result in my decision to utilize a biologic graft rather than a synthetic graft in high risk patients.
Although a biologic graft adds significant expense without additional reimbursement (for inpatient procedures), in the event of an infection, a synthetic graft infection may result in significant morbidity for the patient and necessitate further procedures. Following a biologic graft placement, most infectious complications can be treated without the need for graft removal. The cost of biologic mesh relative to synthetic mesh cannot be underestimated. Current inpatient reimbursement systems do not compensate facilities for the additional costs of biologic meshes which may be several fold more costly. Either decreased profits or losses associated with utilizing the biologic meshes are absorbed by hospitals, not patients or insurers. As a result, the financial implications of utilizing a biologic mesh over a synthetic are often considered.