Plastic Surgery Research Council

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Mesh Suture Better Resists Pull Through in a Repetitive Stress Ball Burst Model
Christopher Scheiber, MD, Jason Souza, MD, Christopher Dearth, PhD, Stephen Goldman, PhD, Peter Liacouras, PhD.
Walter Reed National Military Medical Center, Bethesda, MD, USA.

PURPOSE: At its core, incisional hernia is the result of suture pull-through, which results in early fascial dehiscence and failed healing of the abdominal wall tissues. The small bites surgical technique supported by the STITCH trial aims to better distribute forces at the suture-tissue interface, as demonstrated in a previously reported porcine tensile force model. Despite the benefits attributed to the small bites surgical technique, may surgeons have been reluctant to adopt it as standard practice and the incidence of incisional hernia remains high. By incorporating mid-weight polypropylene mesh material into a hollow-bore surgical suture, increased force distribution at the suture-tissue interface can be achieved through an alteration in suture design rather than surgical technique. A ball burst fatigue model was used to assess the efficacy of this approach to hernia prevention.
METHODS: A midline laparotomy was made in 26 abdominal wall specimens. Samples were then randomized into the experimental (2.0 mm DuraMesh ) or control (1 PDS polydioxanone double loop suture) groups using a random number generator. A 7 cm long incision was then repaired using a running continuous technique with 1 cm bites and 1 cm travel between sutures. A 3D-printed ball burst test apparatus was developed and used to secure the porcine tissue on a MTS Bionix Load Frame. Within the MTS Load Frame the tissue was repetitively stressed at a physiological force of 15 to 120 N cycled at a rate of 0.25 Hz for a total of 1000 repetitions (Klinge et al.). Following this stress, the tissue was then subjected to a compression to failure and maximum force was recorded. Compression was visually recorded to ensure that tissue failure occurred at the suture line and correlated with the maximum force.
RESULTS: The mean maximal force before suture pull through was significantly higher in the 2 mm DuraMesh suture group (850.1 N) compared to the 1 PDS (polydioxanone) double loop group (714.7). This difference between the means of 135.4 N was determined to be statistically significant with a p value of 0.0095.
CONCLUSION: This study suggests that using rational suture design to improve force distribution at the suture-tissue interface may be a viable strategy for preventing the suture pull-through that drives incisional hernia formation. The model described builds on prior linear tensile testing to incorporate cyclic loading and a more physiologically relevant force vector.
Works Cited: U. Klinge, B. Klosterhalfen, J. Conze, W. Limberg, B. Obolenski, A. P. Ottinger and V. Schumpelick. Modified Mesh for Hernia Repair that is Adapted to the Physiology of the Abdominal Wall. Eur J Surg 1998; 164: 951-960


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