Slowly absorbable mesh in contaminated incisional hernia repair: results of a French multicenter study



To analyze the postoperative morbidity and 1-year recurrence rate of incisional hernia repair using a biosynthetic long-term absorbable mesh in patients at higher risk of surgical infection in a contaminated surgical field.


All patients undergoing incisional hernia repair in a contaminated surgical field with the use of a biosynthetic long-term absorbable mesh (Phasix®) between May 2016 and September 2018 at six participating university centers were included in this retrospective cohort and were followed-up until September 2019. Regarding the risk of surgical infection, patients were classified according to the modified Ventral Hernia Working Group classification. Preoperative, operative and postoperative data were collected. All patients’ surgical site infections (SSIs) and occurrences (SSOs) and recurrence rates were the endpoints of the study.


Two hundred and fifteen patients were included: 170 with mVHWG grade 3 (79%) and 45 with mVHWG grade 2 (21%). The SSI and SSO rates at 12 months were 22.3% and 39.5%, respectively. According to the Dindo–Clavien classification, 43 patients (20.0%) had at least one minor complication, and 57 patients (26.5%) had at least one major complication. Among the 121 patients (56.3%) having at least 1 year of follow-up, the clinical recurrence rate was 12.4%. Multivariate analysis showed that a concomitant gastrointestinal procedure was an independent risk factor for surgical infection (OR = 2.61), and an emergency setting was an independent risk factor for major complications (OR = 11.9).


The use of a biosynthetic absorbable mesh (Phasix®) is safe in a contaminated surgical field, with satisfying immediate postoperative and 1-year results.

Trial registration

The study is registered on Clinical Trial ID: NCT04132986.

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Availability of data and material

The study is registered on Clinical Trial ID: NCT04132986.


  1. 1.

    Holihan JL, Alawadi Z, Martindale RG et al (2015) Adverse events after ventral hernia repair: the vicious cycle of complications. J Am CollSurg 221:478–485

    Google Scholar 

  2. 2.

    Luijendijk RW, Hop WC, van den Tol MP et al (2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343:392–398

    CAS  Article  Google Scholar 

  3. 3.

    Burger JWA, Luijendijk RW, Hop WCJ et al (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–583; discussion 583–585

  4. 4.

    Carbonell AM, Criss CN, Cobb WS et al (2013) Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am CollSurg 217:991–998

    Google Scholar 

  5. 5.

    Choi JJ, Palaniappa NC, Dallas KB et al (2012) Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases. Ann Surg 255:176–180

    Article  Google Scholar 

  6. 6.

    Rosen MJ, Krpata DM, Ermlich B et al (2013) A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 257:991–996

    Article  Google Scholar 

  7. 7.

    Primus FE, Harris HW (2013) A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions. Hernia J Hernias Abdom Wall Surg 17:21–30

    CAS  Article  Google Scholar 

  8. 8.

    Doussot A, Abo-Alhassan F, Derbal S et al (2019) Indications and outcomes of a cross-linked porcine dermal collagen mesh (permacol) for complex abdominal wall reconstruction: a multicenter audit. World J Surg 43:791–797

    Article  Google Scholar 

  9. 9.

    Law-Ki C, Robineau C, Garnier N et al (2018) Cost of complex abdominal wall reconstruction with biological prostheses in a French public hospital. J ViscSurg 155:349–353

    CAS  Google Scholar 

  10. 10.

    Martin DP, Badhwar A, Shah DV et al (2013) Characterization of poly-4-hydroxybutyrate mesh for hernia repair applications. J Surg Res 184:766–773

    CAS  Article  Google Scholar 

  11. 11.

    Scott JR, Deeken CR, Martindale RG et al (2016) Evaluation of a fully absorbable poly-4-hydroxybutyrate/absorbable barrier composite mesh in a porcine model of ventral hernia repair. SurgEndosc 30:3691–3701

    Google Scholar 

  12. 12.

    Plymale MA, Davenport DL, Dugan A et al (2018) Ventral hernia repair with poly-4-hydroxybutyrate mesh. SurgEndosc 32:1689–1694

    Google Scholar 

  13. 13.

    Roth JS, Anthone GJ, Selzer DJ et al (2018) Prospective evaluation of poly-4-hydroxybutyrate mesh in CDC class I/high-risk ventral and incisional hernia repair: 18-month follow-up. SurgEndosc 32:1929–1936

    Google Scholar 

  14. 14.

    Buell JF, Sigmon D, Ducoin C et al (2017) Initial experience with biologic polymer scaffold (poly-4-hydroxybuturate) in complex abdominal wall reconstruction. Ann Surg 266:185–188

    Article  Google Scholar 

  15. 15.

    DeBord J, Novitsky Y, Fitzgibbons R et al (2018) SSI, SSO, SSE, SSOPI: the elusive language of complications in hernia surgery. Hernia J Hernias Abdom Wall Surg 22:737–738

    CAS  Article  Google Scholar 

  16. 16.

    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  17. 17.

    Kanters AE, Krpata DM, Blatnik JA et al (2012) Modified hernia grading scale to stratify surgical site occurrence after open ventral hernia repairs. J Am CollSurg 215:787–793

    Google Scholar 

  18. 18.

    Romain B, Renard Y, Binquet C et al (2020) Recurrence after elective incisional hernia repair is more frequent than you think: an international prospective cohort from the French Society of Surgery. Surgery 168:125–134

    Article  Google Scholar 

  19. 19.

    Messa CA, Kozak G, Broach RB et al (2019) When the mesh goes away: an analysis of poly-4-hydroxybutyrate mesh for complex hernia repair. PlastReconstrSurg Glob Open 7:e2576

    Google Scholar 

  20. 20.

    Levy AS, Bernstein JL, Premaratne ID et al (2020) Poly-4-hydroxybutyrate (PhasixTM) mesh onlay in complex abdominal wall repair. Surg Endosc.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    van Rooijen MM, Jairam AP, Tollens T et al (2020) Outcomes of a new slowly resorbable biosynthetic mesh (PhasixTM) in potentially contaminated incisional hernias: a prospective, multi-center, single-arm trial. Int J SurgLondEngl 83:31–36

    Article  Google Scholar 

  22. 22.

    Huntington CR, Cox TC, Blair LJ et al (2016) Biologic mesh in ventral hernia repair: outcomes, recurrence, and charge analysis. Surgery 160:1517–1527

    Article  Google Scholar 

  23. 23.

    Itani KMF, Rosen M, Vargo D et al (2012) Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH study. Surgery 152:498–505

    Article  Google Scholar 

  24. 24.

    Pessaux P, Lermite E, Blezel E et al (2006) Predictive risk score for infection after inguinal hernia repair. Am J Surg 192:165–171

    Article  Google Scholar 

  25. 25.

    Kaafarani HMA, Kaufman D, Reda D et al (2010) Predictors of surgical site infection in laparoscopic and open ventral incisional herniorrhaphy. J Surg Res 163:229–234

    Article  Google Scholar 

  26. 26.

    Finan KR, Vick CC, Kiefe CI et al (2005) Predictors of wound infection in ventral hernia repair. Am J Surg 190:676–681

    Article  Google Scholar 

  27. 27.

    Rosen MJ, Bauer JJ, Harmaty M et al (2017) Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the COBRA study. Ann Surg 265:205–211

    Article  Google Scholar 

  28. 28.

    Bloemen A, van Dooren P, Huizinga BF et al (2012) Comparison of ultrasonography and physical examination in the diagnosis of incisional hernia in a prospective study. Hernia J Hernias Abdom Wall Surg 16:53–57

    CAS  Article  Google Scholar 

  29. 29.

    Köckerling F, Koch A, Lorenz R et al (2015) How long do we need to follow-up our hernia patients to find the real recurrence rate? Front Surg 2:24

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Kroese LF, Sneiders D, Kleinrensink GJ et al (2018) Comparing different modalities for the diagnosis of incisional hernia: a systematic review. Hernia J Hernias Abdom Wall Surg 22:229–242

    CAS  Article  Google Scholar 

  31. 31.

    Romain B, Renard Y, Binquet C, Poghosyan T, Moszkowicz D, Gillion JF, Ortega-Deballon P (2019) Rapport de l’Association Française de Chirurgie des éventrations postopératoires

  32. 32.

    Pereira JA, López-Cano M, Hernández-Granados P et al (2016) Initial results of the National Registry of Incisional Hernia. CirugEsp 94:595–602

    Google Scholar 

  33. 33.

    Atema JJ, de Vries FEE, Boermeester MA (2016) Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects. Am J Surg 212:982-995.e1

    Article  Google Scholar 

  34. 34.

    Praveen Raj P, Senthilnathan P, Kumaravel R et al (2012) Concomitant laparoscopic ventral hernia mesh repair and bariatric surgery: a retrospective study from a tertiary care center. ObesSurg 22:685–689

    CAS  Google Scholar 

  35. 35.

    Ion D, Stoian RV, Bolocan A et al (1990) Is prosthetic repair of the abdominal wall in clean-contaminated surgical interventions possible? ChirBuchar Rom 2013(108):855–858

    Google Scholar 

  36. 36.

    El-Gazzaz GH, Farag SH, El-Sayd MA et al (2012) The use of synthetic mesh in patients undergoing ventral hernia repair during colorectal resection: risk of infection and recurrence. Asian J Surg 35:149–153

    Article  Google Scholar 

  37. 37.

    Chan DL, Talbot ML, Chen Z et al (2014) Simultaneous ventral hernia repair in bariatric surgery. ANZ J Surg 84:581–583

    Article  Google Scholar 

  38. 38.

    Brahmbhatt R, Carter SA, Hicks SC et al (2014) Identifying risk factors for surgical site complications after laparoscopic ventral hernia repair: evaluation of the Ventral Hernia Working Group grading system. Surg Infect 15:187–193

    Article  Google Scholar 

  39. 39.

    Helton WS, Fisichella PM, Berger R et al (2005) Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg Chic Ill 140:549–560; discussion 560–562

  40. 40.

    Iacco A, Adeyemo A, Riggs T et al (2014) Single institutional experience using biological mesh for abdominal wall reconstruction. Am J Surg 208:480–484; discussion 483–484

  41. 41.

    Krpata DM, Stein SL, Eston M et al (2013) Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. Am J Surg 205:354–358; discussion 358–359

  42. 42.

    Schachtrupp A, Wetter O, Höer J (2016) An implantable sensor device measuring suture tension dynamics: results of developmental and experimental work. Hernia J Hernias Abdom Wall Surg 20:601–606

    CAS  Article  Google Scholar 

  43. 43.

    Ireton JE, Unger JG, Rohrich RJ (2013) The role of wound healing and its everyday application in plastic surgery: a practical perspective and systematic review. PlastReconstrSurg Glob Open. 1(1):e10–e19

    Google Scholar 

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Correspondence to D. Charleux-Muller.

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Conflict of interest

Ortega Deballon P., received grants from Bard/Beckton-Dickinson within the past 5 years. Dubuisson V., received grants from Bard/Beckton-Dickinson within the past 5 years. Renard Y., received grants from Bard/Beckton-Dickinson within the past 5 year. Bard/Beckton-Disckinson didn’t influence analysis and writing process of the study. D. Charleux-Muller, R. Hurel, T. Fabacher, C. Brigand, S. Rohr, S. Manfredelli, G. Passot, B. Romain authors declare that they have no conflict of interest.

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Charleux-Muller, D., Hurel, R., Fabacher, T. et al. Slowly absorbable mesh in contaminated incisional hernia repair: results of a French multicenter study. Hernia (2021).

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  • Biosynthetic mesh
  • Contaminated surgery
  • Incisional hernia repair