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Purpose: High rates of recurrence and infectious complications are associated with the repair of hernias with synthetic mesh in a contaminated surgical field. Biologic mesh is believed to reduce the rates of these complications. We compared the performance of two widely available biomaterials, Permacol and Alloderm, in a single-stage procedure of infected mesh removal and hernia repair.

Methods: All patients who underwent a single-stage incisional hernia repair with replacement of an infected synthetic mesh by a biologic mesh were identified. Data retrieved included patient demographics, details of current hernia repair with biologic mesh, post-operative complications, and hernia recurrence.

Results: Forty-one incisional hernia repairs met our inclusion criteria. Alloderm was used in 21 (51.2%) cases and Permacol was utilized in 20 (48.8%) cases. Seventeen patients (41.5%) developed a recurrent hernia at a mean interval of 10.4 months from surgery. Hernias repaired with Alloderm recurred in 47.6% (10 of 21) patients, while Permacol repairs recurred in 35% (7 of 20) of cases (p=0.412). Infectious complications necessitating surgical intervention developed in 9 cases (22%). Hernias repaired using the bridging technique revealed an 87.5% recurrence rate (7 of 8), while underlay fixation of the mesh with native fascial reapproximation led to recurrence in only 31.3% of the cases (10 of 32).

Conclusion: Our results demonstrate relatively high rates of recurrence when performing a single stage ventral hernia repair in a contaminated field with biologic mesh. Permacol and Alloderm showed similar results in this series. This rate is significantly higher than typically reported in literature, likely due to longer follow-up and relatively high patient acuity, and calls into question the cost-effectiveness of the use of biologic mesh in a single stage repair for contaminated recurrent hernias vs the older approach of using a lightweight absorbable synthetic with a second-stage definitive repair.
Table 1. Characteristics of patients undergoing hernia repair with biologic mesh in an infected field

	Overall	Alloderm	Permacol	p-value
N	41	21	20	-
Gender, Males	39%	30%	48%	0.248
Age, years	58.7 (11)	56.8 (8)	60.7 (14)	0.094
Mesh positioning (%underlay/inlay/onlay)	78/20/2	62/33/5	95/5/0	0.037
Length of stay, days	6.1 (2)	6.8 (2)	5.4 (2)	0.024
Recurrenc rate	41.5%	47.6%	35%	0.412
Interval to recurrence, months	10.4 (7)	9.0 (7)	12.4 (8)	0.370
Duration of follow-up, months	16.1 (15)	17.0 (15)	15.3 (16)	0.790

Data presented as means (SD), or percentages where indicated

Table 2. Mesh positioning and recurrence rates: Permacol vs. Alloderm

	Overall	Alloderm	Permacol
N	41	21	20
Underlay	32	13	19
Recurrence (%)	10 (31.3)	4 (30.8)	6 (31.6)
Inlay	8	7	1
Recurrence (%)	7 (87.5)	6 (85.7)	1 (100)
Onlay	1	1	0
Recurrence (%)	0 (0)	0 (0)	0 (0)