Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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D.S. Edelman
pericardium, stomach, bladder, and intestinal submucosa, are also available.
There is not enough literature to compare differences in clinical
outcomes across different tissues of origin. All tissue sources contain
significant amounts of collagen and other ECM proteins. However,
some tissues such as the pericardium and intestinal submucosa lack the
protein elastin, a significant component of the dermis that gives skin its
elasticity. Elastin has been theorized to cause in vivo stretching of the
allograft, resulting in diastasis after bridged repair of ventral hernia [ 11 ,
12 ]. At the same time, the elasticity of dermis-based grafts is favorable
when implanted in areas where tissue pliability is necessary, such as in
breast reconstruction following mastectomy. Thus, the tissue of origin
may be a significant factor to consider when choosing the best BPM for
the procedure of interest.
Lastly, BPMs are either purposely cross-linked or non-cross- linked at
the time of their processing. Cross-linking is a way of stabilizing the
graft and making it more resistant to tissue-degrading enzymes and bacteria
that break down collagen. While this process may increase the
durability of the graft [ 13 ], clinical studies have shown that the majority
of adverse events associated with hernia repair grafts have occurred with
cross-linked products [ 14 ]. These complications included acute mechanical
failure of the mesh, degradation of the mesh, and poor integration of
the mesh. Poor mesh integration is a result of poor angiogenesis into the
material, which can lead to encapsulation or prolonged inflammatory
response characterized by foreign body giant cell reaction. Recent findings
suggest that cross-linking does not necessarily translate to durability,
and, while there may yet be a place for cross-linked materials in
hernia repair, cross-linked materials need to be used with caution until
the optimal degree of cross-linking to overcome these complications can
be understood [ 15 ].
BPM and Inguinal Hernia Repair
One of the first studies reporting the use of BPM in humans was
reported in 2002 [ 16 ]. This was a preliminary study on 15 inguinal hernias
in 12 patients. The preliminary results were good with no recurrences
at 1 year and no chronic pain. Since then, there have been
multiple studies demonstrating positive results after inguinal hernia
repair with biologic tissue. Fine repaired 51 hernias in 38 patients with
BPM mesh and fibrin sealant [ 17 ]. He showed no major complications,
one recurrence at 13 months, and chronic pain in three patients (7.9 %).