Introduction
With up to 20 million operations per year, inguinal hernia repair is one of the most frequently performed operations in general surgery worldwide [
1]. Almost one third of all men and about 3% of all women can develop an inguinal hernia during their lifetime [
2]. The prevalence of inguinal hernia is high in low income countries (LICs). Because the health care system in LICs is mostly underdeveloped and elective hernia repair is rare. Most repairs are performed as emergencies; the resulting mortality is as high as 40% [
3,
4]. In addition, there are significantly more scrotal hernias in LICs than in higher-income countries (HICs), as most patients undergo surgery late. In these cases, a pure-tissue technique is often not feasible [
5,
6]. Large hernia defects lead to the necessity of synthetic mesh reinforcement. On the one hand, these are unaffordable for large parts of the population, and on the other hand the implantation techniques often have not been learned by the few surgeons available in LICs [
7‐
10].
The current HerniaSurge Guidline also focuses on the problem of surgery of inguinal hernias in LRSs [
2]. The recommendations of the HerniaSurge Guidline apply to every patient worldwide. For most of the inguinal hernias the Lichtenstein-Technique with use of Low Cost Meshes under local anesthesia was recommended. The chemical and physical properties of the LCMs should be known.
While the studies carried out on patients show equivalent results in comparison to commercial meshes (CMs) [
5,
11‐
13], other studies show inadequate results of the different LCMs after steam sterilization [
14]. The LCMs from Ethiopia, Ghana and India tested by Mitura et al. shrink massively after sterilization at 121 °C and could therefore not be recommended for use in patients [
14].
The aim of this work was to investigate the influence of steam sterilization at different temperatures on the mechanical and chemical properties as well as the biocompatibility of fibroblasts in two LCMs made of polyethylene and polyester.
Discussion
The HerniaSurge Guidline recommends the use of meshes for hernias also for LICs [
2]. In LICs, however, the conventional commercial meshes are unaffordable for the majority of the patients, so that due to the lack of alternatives, cost-effective alternatives were sought [
11]. Tongaonkar, in particular, is considered a pioneer in the use of mosquito meshes and has shown excellent results in more than 700 patients over 10 years with a follow-up of 12–18 months [
17]. Several research groups were also able to demonstrate equivalent results in comparison to CMs [
5,
7,
12,
13,
18], so that the current guideline makes the (weak) recommendation for the use of LCMs in the Lichtenstein technique [
2]. In the guideline, the problem of sterilization of LCMs is only briefly described [
2]. However, the literature used to prepare the recommendation shows slight changes (shrinkage) in polyethylene LCMs after steam sterilization at 121 °C [
19].
The only prospective randomized study does not describe any changes in low density polyethylene LCMs sterilized at 121 °C for 20 min [
12]. The randomized prospective study published by Löfgren et al. with a follow-up of one year showed no differences in the clinical results (recurrence rate, p. o. complications) compared to the commercial polypropylene mesh used in the comparison group [
12]. The polyethylene LCMs were cut into 10 cm × 15 cm pieces and reference was made to the studies by Stephenson and Kingsnorth, who in their publication demonstrated the minimal structural changes described above [
19].
To further substantiate these results, which were obtained directly from the patient, in in-vitro experiments and, if necessary, animal experiments, we have also tried to obtain a low density polyethylene mesh, as these meshes were used most frequently in previous studies [
11,
12,
17,
19]. Our aim was to prove in vitro that LCMs made of polyethylene and polyester are safe to use, as described in the introduction. Thus, our former investigations of cell proliferation, cytotoxicity, oxidative stress, pH and glycolysis including SEM did not show significant differences between the polyester LCM, which is also used currently, and various commercial meshes (inter alia Ultrapro™ (Ethicon, Norderstedt, Germany), Parietex
R (Medtronic GmbH, Meerbusch, Germany)) [
15].
It is well known that different sterilization processes for synthetic materials also lead to very different changes in the individual polymers [
20]. For example, Müller et al. demonstrated in 1999 that only γ radiation should be used to sterilize polyethylene, since sterilization with steam at 121 and 134 °C leads to deformation and destruction of polyethylene. The polyethylene used, which had a crystal melting point of 118 °C, showed pronounced changes in the fibrils even at 121 °C [
20]. Sterilization with 3% formaldehyde for one hour at 60 °C also led to changes in the polyethylene sample [
20]. Our results of the chemical analysis show that the polyethylene LCM examined was high density polyethylene (HDPE) and not low-density polyethylene (LDPE), as described above. HDPE is even more resistant to heat and chemicals than LDPE [
21]. In their 2011 work, Stephenson et al. also investigated a mosquito mesh from India, which consisted of 50% polypropylene and 50% polyethylene [
19]. Steam sterilization of the initial 7 × 5 inch (17.8 × 12.7 cm) mesh at 134 °C led to massive shrinkage, as in our investigations. Sterilization at 121 °C for 20 min resulted in a shrinkage of 30%, which is lower than in our tests (Fig.
1c,
2c) [
19]. These (shrunken) meshes were then implanted in 51 patients (54 hernias) in a size of 10 × 12 cm [
19]. The 6-month follow-up showed no complications [
19]. A shrinkage of 30% naturally leads to a change in mesh size and thus in effective porosity. In their prospective randomized study Löfgren et al. also implanted these (shrunken) meshes in 150 patients, whereby the initial size of the meshes before sterilization at 121 °C was approx. 10 × 15 cm (with approx. 30% shrinkage after sterilization then approx. 7 × 11.5 cm; assuming the same chemical composition of the Amsa Plastic mesh used as that of Stephenson et al. 2011) [
12]. For a hernia repair using the Lichtenstein technique, this mesh size is just barely acceptable. However, the mesh size is only one parameter that can change due to sterilization of synthetic materials.
Thus, the aim of our mechanical investigations was to identify the influence of different sterilization methods on the mechanical properties of two different meshes. Since the focus was on the comparison of the unsterile conditions to different sterilized specimen, the test setup was chosen to be intriguingly simple rather than to mimic a complex condition after implantation in a human body. The investigations served this purpose very well. It was found that the difference of the mechanical properties in unsterile and sterile conditions was relatively small for most of the investigated specimens. In general, the maximum loads are higher for the unsterile meshes compared to the sterilized specimens. The most significant effect was observed for polyester sterilized at 100 °C (Table
1). The polyethylene specimen could not be tested at 121 and 134 °C due to significant shrinkage effects. However, a sterilization at 100 °C led to a small reduction of the maximum load (approximately 2.5% for the arithmetic mean value, Table
2).
It seems that 100 °C sterilization has a deeper impact on lactate production, LDH cytotoxicity test, and moreover, there is a decrease of the maximum tensile force. We neither have an explanation for our results nor have we found an association for this effect at 100 °C in our literature research.
The biocompatibility of the fibroblasts also changed during our investigations due to sterilization, both for the polyethylene LCMs and the polyester LCMs. Thus, all sterilized LCMs showed the lowest mitochondrial activity as a sign of cell death compared to the unsterilized meshes. The cytotoxicity (LDH measurement) was also lowest in the unsterilized meshes, while it increased significantly after steam sterilization, particularly in the case of polyester LCMs. Similarly, cell metabolism showed a greater drop in pH and an increase in lactate in the sterilized meshes. This corresponds to the results already published by Broll et al. in 2002 [
22]. They showed in vitro experiments with human fibroblasts that resterilized polypropylene meshes after steam sterilization at 121 °C showed both a significant decrease in the proliferation index and a significant increase in the apoptosis rate of the fibroblasts compared to the control and the unsterilized meshes [
22]. As in our experiments, the sterilization process changes the growth behavior of the cells. The authors assume that the thermal treatment of the meshes damages the DNA and conclude that a malignant transformation of the tissue surrounding the sterilized meshes is possible over years or decades and could lead to the induction of sarcomas [
22].
Mitura et al. also showed that massive shrinkage of mosquito meshes can occur [
14]. The authors also carried out chemical and mechanical tests on the various LCMs and found massive changes (shrinkage, deformation) in meshes from Ethiopia, Ghana and India after sterilization at 121 and 134 °C [
14]. Mitura et al. clearly stated that the chemical composition of the locally acquired meshes is not known, so that a certain risk is present and therefore the unrestricted use of LCMs cannot be recommended [
14]. For the local producers of mosquito meshes, the suppliers of the raw materials can change every year, e.g. for cost reasons, so that an externally identical mesh can now change significantly during steam sterilization due to the change in composition. This is no problem for the producers of LCMs—they do not produce their nets for use as medical devices in humans! Löfgren et al. have also recommended that the mesh used in a randomized prospective study should no longer be used in its current form [
23]. A general use of LCMs, as recommended in the current HerniaSurge Guideline, is, despite all the known economic problems in LICs, only recommended with very severe limitations and should be critically reviewed.
In our view, two approaches should be pursued.
On the one hand, the training of local surgeons, especially for suture-based procedures, should be intensively promoted. For example, Mitura et al. showed that there are anatomical differences in the inguinal region between Africans and Caucasians and that therefore pure tissue repairs could be promising, especially for African patients [
24]. A recent Cochrane analysis also recommends mesh-free methods for LICs [
25].
Since only suture-based procedures are not always feasible for the very large inguinal hernia gaps, which are often very common, and thus meshes are urgently required, we also see, like Löfgren et. al., a possibility to solve the problem by establishing a manufacturing facility in Central Africa [
23].
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