Are Biologic Grafts Effective for Hernia Repair? A Systematic Review of the Literature

Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically crosslinked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.