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The American Journal of Surgery (2010) 200, 406 412

Scientific (Exp)/Research

Biomechanical analysis of polypropylene prosthetic


implants for hernia repair: an experimental study
Fabrice Sergent, M.D., Ph.D.a,b,*, Nicolas Desilles, Ph.D.b, Yann Lacoume, Ph.D.a,
Jean-Jacques Tuech, M.D., Ph.D.c, Jean-Paul Marie, M.D., Ph.D.a,
Claude Bunel, Ph.D.b
a

Experimental Surgery Laboratory, Medical Faculty, Rouen University, UPRES EA 3830 GRHV, 22 Bd. Gambetta-76183
Rouen Cedex 1, France; bCNRS FRE 3101, Polymers, Biopolymers, Surfaces, Rouen National Institute of Applied Sciences,
Mont-Saint-Aignan Cedex, France; cDepartment of Digestive Surgery, Rouen University Hospital, Rouen Cedex, France
KEYWORDS:
Abdominal hernia;
Elasticity;
Linear force;
Polypropylene;
Prosthesis;
Retraction

Abstract
BACKGROUND: Although polypropylene (PP) is the most common biomaterial used for ventral and
inguinal hernia repairs, its mechanical properties remain obscure.
METHODS: Retraction, solidity, and elasticity of 3 large pore-size monofilament PP prostheses, 1
heavy-weight PP (HWPP), a second low-weight PP, and a third coated with atelocollagen were evaluated
in a rabbit incisional hernia model. A small pore-size multifilament PP implant (MPP) also was tested.
RESULTS: Unlike pore size, the weight of the prosthesis was not an influencing factor for retraction.
Atelocollagen coating reduced retraction (P .05). HWPP and MPP were less likely to rupture (P .05).
HWPP had comparatively better elasticity (P .05), whereas MPP supported the greatest elastic force (P
.05). Nevertheless, the amount of shrinkage of MPP (30% of the original size) made this prosthesis unusable.
CONCLUSIONS: In this study, HWPP presented the most advantageous biomechanical compromise
for hernia surgery.
2010 Elsevier Inc. All rights reserved.

Each year, there are more than 1 million worldwide mesh


implantations for both incisional and groin hernias.1 Polypropylene (PP) mesh is certainly one of the most frequent biomaterials used in this indication. PP was first introduced in 1958
by Usher et al,2 and was popularized in 1986 by Lichtenstein
and Shulman3 with a tension-free repair technique for inguinal
hernia. The literature shows that use of PP mesh has decreased
the overall recurrence rate of abdominal hernia by 30% to
50%.4 Nevertheless, some complications occur with these
* Corresponding author. Tel.: 33-232-88-87-45; fax: 33-235-9811-49.
E-mail address: Fabrice.Sergent@chu-rouen.fr
Manuscript received January 28, 2009; revised manuscript August 31,
2009

0002-9610/$ - see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2009.09.024

types of prostheses such as infection, seroma, fistula, and


granuloma. Prostheses that have a macroporous structure seem
to reduce these types of complications. In fact, macroporous
prostheses produce the best integration into the surrounding
tissue because pore sizes larger than 75 m between filaments
are required for the entrance of macrophages, fibroblasts, blood
vessels, and collagen fibers. These macroporous prostheses
correspond to the definition of type I or III of Amids5 classification of biomaterials, with regard to monofilament or multifilament shapes.
Mesh contraction after implantation is another documented complication that occurs after hernia repair, associated with discomfort or chronic pain, and restriction of
abdominal wall mobility. According to some investigators,6,7 lightweight meshes with reduced PP content have

F. Sergent et al.
Table 1

Experimental mechanical study of polypropylene implants for hernia repair

407

Main characteristics of tested polypropylene prostheses

Commercial name

Filament structure

Knitting meshes

Pore size, mm

Parietene PP (HWPP)
Parietene PPL (LWPP)
Parietex Ugytex (CPP)
Surgipro SPM (MPP)

Monofilament
Monofilament
Monofilament
Multifilament

Not blocked
Not blocked
Not blocked
Blocked

2.0
1.5
1.5
.7

resulted in less patient complaints of pain and paresthesias


and improved abdominal wall compliance. However, for
other investigators,8 use of lightweight meshes also is associated with an increase in hernia recurrence.
There are only a limited account of data available on the
biomechanical characteristics of the prostheses, particularly for
mesh contraction and its consequences. In an attempt to assess
the status of these biomaterials, we were prompted to perform
various experimental studies. On the basis of an animal model
of an incisional abdominal hernia, we evaluated retraction,
solidity, and elasticity of the principal types of PP prostheses
currently available in abdominal hernia surgery. The aim of
this series was to report the results of our animal model study
and to inform surgeons on the mechanical performance of the
principal types of PP currently used in surgical practice.

Methods
Four models of PP prostheses were tested as follows: (1)
a large pore size (1 mm) of heavy weight (density, 75
g/m2) monofilament material (Parietene PP; Covidien Company, Trvoux, France), which was termed heavy-weight
PP (HWPP); (2) a large pore size of low weight (density,
75 g/m2) monofilament material (Parietene PPL; Covidien
Company, Trvoux, France), which was referred to as lowweight PP (LWPP); (3) a third model (Parietex Ugytex;
Covidien Company, Trvoux, France), whose characteristics were practically identical to the preceding prosthesis
(LWPP), but that was coated with a hydrophilic and absorbable film composed of type I porcine atelocollagen, polyethylene glycol, and glycerol, which was referred to as
collagen PP (CPP); and (4) a small pore size (1 mm) of
heavy-weight multifilament material (Surgipro SPM; Tyco
Healthcare, Plaisir, France), which was referred to as multifilament PP (MPP). The precise characteristics of the prostheses used in this study, are summarized in Table 1.
The principal types of prostheses in PP currently used in
human abdominal wall reconstructive surgery then subsequently were evaluated.
HWPP and LWPP prosthesis characteristics were exactly
identical except in terms of density. CPP was a LWPP
prosthesis with a collagen coating. MPP was different from
the 3 other prostheses by its multifilament weaving and
its pore size. This method made it possible to perform a
2-by-2 comparison of the prostheses, characteristic by
characteristic.

1.7
1.5
1.5
.3

Weight, g/m2

Amids5 classification

75
38
38
85

1
1
1
3

We used 40 female adult rabbits of the same race (New


Zealand), same age (16 18 wk), same weight (3.250 3.500
kg) to test the 4 prostheses in each animal. The Regional
Ethics Committee for animal experimentation of Normandy
approved the study.
We used a validated incisional abdominal hernia model
that was described previously in the rat by Alponat et al9
and adapted to the rabbit by Claerhout et al.10 Rabbits were
anesthetized with an intravenous perfusion of ketamine.
After an aseptic vertical midline skin incision, premuscle
fascia separation was performed to establish 4 incisional
abdominal hernias (2.5 2.5 cm), respecting the peritoneum. The wall was repaired with the 4 different PP prostheses. Prostheses all were prepared in a sterile manner, cut
into squares (3 3 cm), and laid over the parietal defect.
Each prosthetic implant was fixed without tension to the
abdominal wall by 4 PP 4/0 sutures (Prolene; Ethicon,
Johnson-Johnson, Issy les Moulineaux, France) at its 4
corners. Subcutaneous tissue and skin were closed with a
3/0 continuous poliglecaprone 25 suture (Monocryl; Ethicon, Johnson-Johnson, Issy les Moulineaux, France), inaccessible to the animal to preserve healing.
The animals were killed after a direct intravenous lethal
injection of sodium pentothal by groups of 10 rabbits on
days 14, 30, 90, and 180 after prosthesis implantation. The
prostheses were isolated and excised with all the thickness
of the tissues that had been integrated. The surface of each
prosthesis was measured in millimeters using a ruler (Fig.
1). The surface loss, expressed as a percentage of the initial

Figure 1

Measure of residual prosthetic surfaces.

408

The American Journal of Surgery, Vol 200, No 3, September 2010

a
c
S

Tension

Prosthesis

b
Tension

Figure 2 Principle of the mechanical study performed on the Instron tensiometer. a: sample length, interjaw distance, 10 mm; b: sample
width, 10 mm; c: sample thickness, variable depending on the type of prosthesis; S: sample section subjected to tensile strength, b c.

surface before implantation, thus was deduced. This corresponded to our definition of the prosthetic retraction.
All the prostheses then were cut again, preserving only
the middle part of the prosthesis, so that their width corresponded to 1 cm. They were maintained in the traction jaws
of an Instron tensiometer (model 5543; Instron SAS, lancourt, France) with the interjaw distance fixed at 1 cm (Fig.
2). Prostheses were subjected to an elongation of 5 mm/min
until rupture. For each prosthesis, we obtained a curve of the
linear force (expressed in N/cm) to which the prosthesis was
subjected per unit of width, depending on its deformation
(expressed in % of the initial length).
Elasticity is the physical capacity of a body to return to
its initial shape after suppression of the deformation. A body
is perfectly elastic if it completely returns to its original
form after suppression of the traction. It is partially elastic
if the deformation produced by the external forces does not
completely disappear when traction is stopped. The relationship between the force applied to the body, in this case
the prosthesis (per section unit), and the deformation shown,
remain constant, as long as the deformation is small and the
elastic limits of the material are not reached. This is
Hookes law: E (F/S)/, with E as the constant indicated
by Youngs modulus or elastic modulus; F as the force
applied to the body; S, its section; and , its deformation.
Youngs modulus is the reflection of body elasticity. Any
body, whatever it is, has a certain degree of elasticity.
However, a body with a high Youngs modulus is known as
stiff. In contrast, a body with a low Youngs modulus is
known as supple.
The force of maximum traction, by width unit expressed in
N/cm, to which each prosthesis could be opposed before its
rupture point, its corresponding deformation expressed in percentage of initial length (fixed here at 1 cm), its elasticity
(which corresponded to the Youngs elastic modulus), expressed in megapascals, were calculated (Fig. 3). Based on
prosthesis elastic modulus and the maximum elastic deformation calculations, once known, and according to Hookes law,
it was possible to deduce the maximum traction force value

that should not be exceeded without the risk for the prosthesis
to leave its elastic range and to damage it permanently.
The results were reported by using medians and ranges.
For a given group (day 14, 30, 90, and 180), the 4 types of
prostheses were compared pairwise using the Wilcoxon test,
corrected by the Friedman test. To establish a comparison
between each group, the KruskalWallis test was used,
corrected by the Holm-Bonferroni test. P values less than
.05 were considered statistically significant. The statistical
analyses were performed using SAS software (version 8;
SAS Institute, Cary, NC).

Results
Among the 160 ventral incisional hernia repairs, no defect was observed. Intestinal adherence around prostheses

Figure 3 Results of the mechanical tests expressed in the form


of linear curve of force to which the prosthesis was subjected
according to the deformation of the latter. A, linear force at the
rupture (at the culminating point that precedes prosthesis rupture);
B, deformation at the rupture (at the culminating point that precedes prosthesis rupture).

F. Sergent et al.

Experimental mechanical study of polypropylene implants for hernia repair

Figure 4 Prosthetic retraction after implantation. Data are


expressed as median values (ranges). P .05 for 1HWPP
versus CPP, 2HWPP versus MPP, 3LWPP versus MPP, and
4
CPP versus MPP.

was not found. Two prostheses, one in CPP and the other in
MPP, were exposed on the same rabbit in the 90-day group.
Half of the MPP prostheses (5 of 10) were not integrated in
the 14-day group. Twelve abscesses (7.5% of the prostheses) were observed. This included all types of prostheses: 2
for HWPP, 2 for LWPP, 3 for CPP, and 5 for MPP prostheses.
On the 160 implanted prostheses, 115 (72%) retracted,
without any difference between heavy and low weight, collagen coated, monofilament, or multifilament forms. There was
stability over the period (day 14, 30, 90, and 180) in the
number of the retracted prostheses, except for MPP prostheses
ranging from 10% to 80%, for which the maximum retraction
proportion was observed later in the 90- and 180-day groups.

409

With regard to retraction intensity, in the percentage of


prosthetic surface loss, when all the prostheses were considered over all the periods, CPP prostheses retracted less
than HWPP or LWPP prostheses: 8% vs 12% and 15%,
respectively (P .05). In detail, depending on the period,
there was a shrinkage stability, for any given biomaterial,
except MPP prostheses (Fig. 4). For MPP prostheses, the
maximum retraction intensity was observed later in the 90and 180-day groups (P .05).
MPP was the most retracted biomaterial, 30% of the
initial implanted surface, for the day 90 and 180 groups.
Extreme values of surface loss could reach as high as 78%
of the initial surface for MPP, 65% for LWPP, and approximately 45% for HWPP and CPP.
With regard to the maximum linear force at the rupture
(Fig. 5) for any given biomaterial we did not observe a
statistically significant difference, according to the period,
except for MPP at day 180 (P .05). MPP was the material
that resisted better to the highest strength (60 80 N/cm1),
followed by HWPP (3550 N/cm1), then LWPP (20 40
N/cm1), and CPP (10 20 N/cm1). Heavy forms (HWPP
and MPP) resisted better to rupture than the lighter ones
(LWPP and CPP).
A statistically significant difference, with regard to
deformation of any given material at the rupture according to time, was not observed (Fig. 5). HWPP and LWPP
were the materials that became more stretched (150%
220%), compared with CPP (130%180%) and MPP
(50%100%).

Figure 5 Prosthetic solidity and elasticity. Data are expressed as median values (ranges). P 0.05 for 1HWPP versus LWPP, 2HWPP
versus CPP, 3HWPP versus MPP, 4LWPP versus CPP, 5LWPP versus MPP, and 6CPP versus MPP.

410

The American Journal of Surgery, Vol 200, No 3, September 2010

Concerning Youngs modulus (Fig. 5), for any given


material, regardless of the period assessed, we did not observe any significant difference, except for MPP, which was
more flexible after implantation (P .05). Nevertheless,
MPP was the most rigid of all the tested biomaterials.
HWPP, LWPP, and CPP elastic characteristics all were
similar.
However, for any given biomaterial, in terms of maximum elastic force, when not extending beyond the elastic
range of the prosthesis (Fig. 5), we did not find a statistically
significant difference, except for MPP before implantation
(P .05). After implantation, MPP was the prosthesis that
supported the greatest force while at the same time remaining in its elastic range. HWPP, LWPP, and CPP had similar
maximum elastic forces.

Comments
All 4 types of tested PP prostheses retracted. For any
given prosthesis, the severity of shrinkage was not predictable. Therefore, this could be a problem when prostheses
are inserted into the abdominal wall. It is possible that the
retraction produced pain. Nevertheless, retraction was not
equal between the different types of PP prostheses. According to Konstantinovic et al,11 in a rat incisional hernia
model, retraction appears maximum at day 14. In our study
at day 14, CPP retracted to a lesser extent compared with the
other monofilament prostheses and also globally compared
with all the prostheses over the sum of all the periods.
To date, published studies have correlated the increase in
prosthesis retraction with prosthesis weight. However, these
comparative studies were not homogeneous with regard to
the structure of the weave of the prosthesis filaments. Klinge
et al12 compared monofilament PP tight meshes of .46-mm
pore size that weighed 95 g/m2 with MPP broad meshes of
2.8-mm pore size, combined with polyglactin 910 that
weighed 55 g/m2. The investigators noted more retraction
with the heavy-weight prostheses but they completely ignored pore size, which was different. Similarly, Scheidbach
et al13 compared 4 different PP meshes of different pore
sizes, of which 1 prosthesis incorporated polyglactin 910.
However, 2 prostheses with different weights, 36 and 16
g/m2, both with pore size greater than 1 mm, had similar
retraction rates of 7% and 5%.
In our study, HWPP and LWPP had the same characteristics, except for weight, which became the only variable.
However, HWPP and LWPP retracted identically. Therefore, our study clearly shows that the weight itself does not
have any impact on the retraction, if pore size and meshes
remain constant.
In our experiment, with nearly equal weight, multifilament prosthesis of .3-mm pore size (MPP) retracted more
than monofilament prosthesis of 1.7-mm pore size (HWPP).
According to Klinge et al,12 who found more retraction for
monofilament prostheses of .46-mm pore size than multi-

filament prostheses of 2.8-mm pore size, it could be deduced that it was not the structure of the prosthesis but
primarily its pore size that influenced its retraction. For
Cobb et al,7 the fibrosis bridges, which are established
between prosthesis filaments and are at the origin of their
retraction, would be facilitated in fact when meshes are
tight.
Other studies have shown that for PP, pore size could
have a role on local inflammatory reaction and fibrosis
generated by prosthesis. In a more recent study, Klinge et
al14 found more macrophages, granulocytes, cell infiltrates,
and fibrous reactions in contact with tight mesh prostheses
than those with broad meshes. Recently, Weyhe et al15 also
confirmed these data and found more fibrosis with tight
mesh prostheses.
In our study, CPP prostheses had the weakest retraction.
Similar to LWPP prostheses, their performance should be
equivalent. Also, the atelocollagen and polyethylene glycol glycerol coating, which is proposed to reduce severe
visceral adherences in abdominal wall or vaginal surgeries,
by favoring a fast and small inflammatory tissue integration,16,17 could be a factor that interferes in the retraction.
Retraction appeared quickly for the 3 tested monofilament prostheses. It did not apparently worsen thereafter,
confirming other studies.11 The delayed integration of the
MPP prosthesis subsequently resulted in a late retraction.
Reduced pore size, certainly by the means of inflammatory
reaction,13 delayed the prosthetic integration. In Amids5
classification of biomaterials, a pore size cut-off value of 75
m to define the capacity of prosthesis tissue integration
must be completed. Tissue integration of a prosthesis whose
pore size exceeds just 75 m is definitely not identical to a
prosthesis whose pore size is greater than 1 mm.
Clinical evidence reported by many investigators seems
to indicate that for a similar material, reduction in its content
decreases its complications. Therefore, the current trend
increasingly is to use low-weight prosthetic materials.18
This evolution must be opposed to the forces to which the
prostheses will be subjected, and which in fact remain
constant. These forces correspond to those of intra-abdominal pressure.
For most investigators, in a human adult population of
normal weight, the maximum physiologic linear force that can
be exerted on the abdominal enclosure is classically 16
N/cm.11,19 For some investigators, it could even reach 27
N/cm.20
In our experimental study, once implanted, all the heavy
prostheses (HWPP and MPP) were able to oppose maximum
linear forces of 16 N/cm and even of 27 N/cm. Nevertheless,
it was not possible for the light prostheses (LWPP and CPP).
This means that light prostheses, approximately 40 g/m2, could
be insufficient in terms of solidity to manage hernia durably. In
fact, in the field of prosthetic hernia repair, O= Dwyer et al8
confirmed these data by recording failure rates of 5.6% for
light PP prostheses of 32 g/m2 versus .4% for heavy PP
prostheses of 85 g/m2 (P .05) at 12 months.

F. Sergent et al.

Experimental mechanical study of polypropylene implants for hernia repair

Except for the MPP late group (day 180), there was no
benefit in solidity after tissue integration of the prostheses.
Indirectly, our study on nonabsorbable prostheses confirms
that only synthetic meshing of the prosthesis renders solidity to the prosthesis and not the tissue that will colonize it,
which is unable to reproduce the biomechanical characteristics of native tissues. Recent data in the urogynecological
literature agree with this concept.21,22
Prosthesis deformation and elasticity specifically were
studied in stress urinary incontinence with suburethral
slings.23 For abdominal wall surgery, ideally the repaired
abdomen should be able to change its shape while breathing.
Theoretically, all the 3 monofilament prostheses, and especially HWPP, were satisfactory. Nevertheless, deformation
of a prosthesis is interesting only if it remains elastic. Once
the forces involving the prosthesis are removed, the prosthesis must return to its initial dimensions. In practice,
beyond 5 to 10 N/cm, these 3 prostheses became irreversibly deformed. Thus, the prostheses were unable to remain
within their respective elastic range with the maximum
abdominal pressure forces to which they could be subjected
(16 27 N/cm). Paradoxically, MPP, which was supposedly
the most stiff biomaterial, was in fact the most appropriate
to remain within the elastic range.
We agree that there were many time points measured,
and the results were not always statistically significant at
each time point, but it was an experimental study with only
40 rabbit models. However, prosthetic solidity and elasticity
remained constant.
Although MPP showed the most interesting biomechanical characteristics (force of maximum traction, deformation,
and maximum elastic force), considerable amount of shrinkage of this prosthesis made it unusable. After MPP, HWPP
was undeniably the best prosthesis for the force at the
rupture. Of the 3 remaining prostheses, HWPP was the only
one able to support the intra-abdominal pressure, and therefore met the requirements of durable hernia repair.

Conclusions
Based on our current knowledge regarding available
prosthetic materials, PP remains the biomaterial of reference in abdominal hernia surgery. Nevertheless, the results
of our experimental study concerning rabbits suggest that all
PP materials are not equivalent.
Retraction was influenced by pore size meshes and appeared rapidly after prosthesis integration. In fact, prosthesis weight did not have any impact on retraction. Atelocollagen coating decreased retraction.
With regard to rupture prosthesis, the synthetic meshing
of the prosthesis alone gives solidity to the prosthesis and
not the tissue that will colonize it. Therefore, low-weight
prostheses could be insufficient in solidity to manage hernias durably.
With regard to elasticity, heavy-weight MPP prostheses
were the most appropriate to remain within the elastic range.

411

When all the biomechanical parameters were assessed


comparatively, HWPP was considered to have the most
advantageous properties for hernia surgery.
Of course, it is difficult to extrapolate these conclusions
from an animal study using a hernia model to human beings.
However, similar experiments in human beings to confirm
our results are not possible. To confirm our findings, with
credible arguments, additional animal studies are warranted
but with different types of animals.

Acknowledgments
The authors thank Richard Medeiros, Rouen University
Hospital Medical Editor, for editing the manuscript. The
authors also are grateful for the gift of PP prostheses from
Covidien Company (Trvoux, France).

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