Int Surg 2005;90:510-512

Are Meshes With Lightweight Construction

Strong Enough?
Joerg L. Holste
ETHICON GmbH, R&D Europe, 0-22841, Norderstedt, Germany

The use of mesh has become essential in the repair of abdominal wall incisional hernias.
Suture techniques, reapplied after failure of a primary repair, are characterized by recur­
rence rates of up to 50 percent, whereas the reinforcement of the abdominal wall with
surgical mesh has significantly decreased these rates to <10 percent. This article describes
the background for the development of mesh with lightweight construction and physio­
logical biomechanical performance.

Key words: Hernia repair - Mesh - Lightweight construction - Strength requirements

he use of mesh has become essential in the repair
T of abdominal wall incisional hernias. Suture
techniques, reapplied after failure of a primary re­
pair, are characterized by recurrence rates of up to
50%, whereas the reinforcement of the abdominal
wall with surgical mesh has significantly decreased
these rates to <10%.1
Today, mesh is widely used throughout the world
despite the fact that the construction of the most
popular polypropylene meshes have remained
largely unchanged for >20 years.
ETHlCON, a leader in polymer technology, has re­
cently used its proprietary materials to develop several
mesh materials of alternate construction that allow ad­
patient quality of life.
equate support of the abdominal wall while substan­
bination of thinner filament size, larger pore size, and a
percentage of absorbable materials and have the capa­
bility of being more closely aligned with the physio­
logic properties of the abdominal wall.
This paper will review the data on the pressures
of the abdominal wall and compare it to the relative
strength of surgical meshes currently commercially
available. It will conclude that so-called lightweight
construction mesh possesses the physical biome­
chanical strength to withstand the pressures and
forces on the abdominal wall while offering the ad­
vantage of a substantial reduction in foreign body
implant material and, ultimately, an improvement in

tially reducing the amount of foreign body material Physiological Reconstruction

implanted into the patient. This new type of mesh­

which has become commonly known as "lightweight Generally, the task of a surgical mesh implant is to

construction" or "reduced mass" mesh-offer a com- provide biomechanical strength to the attenuated

Reprint requests: Joerg L. Holste, DVM, ETHICON GmbH, R&D Europe, 0-22841 Norderstedt, Germany.

510 In! SUl'g 2005;90

ARE MESHES WlTH LIGHTWElGHT CONSTRUCTION STRONG ENOUGH? HOLSTE

r.. _····~···~··· .__._,..- - - . _ . ---_ - ---- _ _----­

Comparison of Abdominal Pressure with Mesh Burst
Strength'

:1500 ;

1 100; +-' ---l----,--'+--------;o;;:;--I--i

Pn.."-:.....;!Jfl: In i1lxJall-.i~ul. ~
!
Q.Jlty
~
500 +4 13 44 59 110150

.~ ~1},. 'r~ "l;>q. "'1'0 I

~~ ~('o ~ ('1-~ ({:~'"
, ~ 't
...... .. ......._ ...... '.1'..

··Measured after absorption of the absorbable componenlS.

Fig. 2 Comparison of abdominal pressure with mesh burst

strength.
Fig. 1 Illustration of La Place's Law.

of 12.6 in, and at a pressure of 2.9 psi, the calculated

fascial structures. Surgical mesh is designed to with­
tensile strength on the abdominal wall is a maximum
.stand the tension forces acting on the abdominal
of 9.13 lb/in (150 mmHg). This tensile strength is
wall. Furthermore, the mesh must not impede and,
calculated at a wall thickness of 0.03 in (0.08 em).
ideally, should facilitate the healing process of the
Note that the tension decreases with increasing wall
hernia defect by encouraging ingrowth of the body's
thickness.
own connective tissue by the induction of strong
Given that the maximum tensile strength of the
collagen tissue around the mesh fibers. 2 The advan­
abdominal wall is 150 mmHg, traditional heavy­
tage that large pore size mesh offers over traditional
weight, small pore meshes are shown to be consid­
small pore mesh is that tissue is able to grow through
erably oversized. For example, to rupture PROLENE
the large pores of the mesh and create a thinner,
(ETHICON GmbH, Germany) polypropylene mesh,
more integrated scar instead of the thicker, less flex­
an intra-abdominal pressure of > 10 times the maxi­
ible scar that is created with mesh of minimal pore
mum pressure would be required (Fig. 2).
size. Ultimately, this creates a more elastic scar and
surrounding tissue for the patient.
Suture Pullout Force
Strength Requirements
The suture pullout force of a lightweight construc­
tion mesh is determined at the weakest point in
Surgical mesh must also provide sufficient biome­
mesh fixation: the posterior rectus sheath with a
chanical strength to meet physiological requirements
tensile strength of 15 N/cm (8.561b/in).4
to permanently protect the fascial defect.
Furthermore, MERSILENE (ETHICON GmbH,
The tension on the abdominal wall and the re­
Germany) polyester mesh, with a suture pullout
quired tensile strength of the fascia closure is a func­
force of 15 N/cm (8.6 Ib/in), has been used as the
tion of the intra~abdominal pressure, which ranges
benchmark because of its long clinical history.
from 1.55 mmHg in patients lying supine to 150
mmHg maximum peak pressure in coughing pa­
tients. 3 Comparison of Mesh Construction
The tension force on the abdominal wall is calcu­
lated according to Laplace's Law. This states that, in The strength of the traditional microporous or
an elastic spherical vessel, like the abdominal cavity, heavyweight mesh is derived from the use of a large
the tension on the wall, pressure, wall thickness, and mass of material, which in turn contributes to stiff­
wall diameter have a definitive relationship as fol­ ness, excessive scar plate formation, and abdominal
lows: Tension T = Diameter X Pressure/4 X Wall wall restriction, leading to reduced patient comfort
Thickness (Fig. 1). and chronic pain. Although the reinforcement and
To determine the maximum tensile strength re­ strengthening of the abdominal wall to prevent re­
quired for the abdominal wall at an assumed currence is the main task of a mesh, functional re­
39.37-in circumference, abdominal cavity diameter strictions can impair quality of life.

Int Surg 2005;90 Sl1

HOLSTE ARE MESHES WlTH LIGHTWEIGHT CONSTRUCTION STRONG ENOUGH?
According to recent reports, about one-half of the
patients with a large mesh prosthesis within the
abdominal wall express complaints such as paresthe­
sia at the palpable stiff edges of the mesh and the
physical restriction of abdominal wall mobility.l
Physical capacity and, therefore, patient quality of
life is fundamentally affected by the integrity of the
abdominal wall.
Restoring the physiological properties of the ab­
dominal wall must take into account the complex
interactions of the anatomic structures and must also
focus in particular on the resulting tensile strength
and elasticity. Mesh materials with large pores and
reduced mass of material have been associated with
a markedly reduced rate of patient complaints or
impairment of abdominal wall mobility, both of
which correspond to a pronounced decrease in in­
flammation and scar formation.
From this, it may be assumed that the flexibility of
the abdominal wall is restricted by implantation of
extensive foreign material, and to a greater degree,
by excessive scar tissue formation. In addition, the
nonphysiological, low stretching capability, and rel­
ative stiffness of heavyweight mesh materials con­
trast with the highly elastic abdominal wall and can
give rise to shearing forces. These forces favor the
formation of weak scar tissue, and thus, recurrence
at the edges of the mesh implant.
512
Summary
In summary, lightweight construction meshes such
as PROCEED (ETHICON Inc., USA) surgical mesh,
PROLENE (ETHICON Inc., USA) soft mesh, and
ULTRA PRO (ETHICON GmbH, Germany) mesh
possess adequate strength to repair the abdominal
wall. Furthermore, compared to heavyweight mesh,
reduced mass, large pore size mesh provides advan­
tages such as greater elasticity, less foreign body
material implanted, and a more flexible scar tissue,
leading to improvements in patient quality of life
with almost physiological abdominal wall mobility
and fewer patient complaints.
References
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Schumpelick V. Elasticity of the anterior abdominal wall and
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plants, Hernia 2001;5:113-118
2. Junge K, Klinge V, Rosch R, Klosterhalfen B, Schumpelick V.
Functional and morphologic properties of a modified mesh
for inguinal hernia repair World J Surg 2002;26:1472-1480
3. Klinge V, Conze J, Limberg W, Bruecker C, Oettinger AP,
Schumpelick V. Pathophysiologie der bauchdecken. Chintrg
1996;67:229-233
4. Seidel W, Tauber R, Hoffschulte KH. Messungen zur festigkeit
der bauchdeckennaht. Chirurg 1974;45:266-272
Inl Surg 2005;90