Clinical application of porcine small intestinal submucosa in the management of infected or potentially contaminated abdominal defects

The repair of abdominal wall defects in potentially contaminated or grossly infected fields presents a difficult clinical problem. Polypropylene mesh is relatively contraindicated in these settings because of the potential for chronic infection. The alternatives to polypropylene include polyglactin mesh, which is not associated with chronic infection but is associated with a 100% recurrence of hernia. The ideal prosthetic for this patient group should be resistant to infection and ensure a low rate of hernia recurrence. We studied the use of small intestinal submucosa, which has been reported to be resistant to infection and incorporates into the fascia over 3 to 6 months, in 20 patients with ventral or inguinal hernias (18 ventral, 2 inguinal hernia) in the setting of bacterial contamination. The early postoperative complication rate was 50%. One patient with fasciitis had degradation of the small intestinal submucosa and loss of the bioprosthesis within 7 days. Other early complications included seroma (n = 2), ileus (n = 1), and wound infection (n = 8). No patient experienced chronic infection. Mean follow up was 15.7 months and the rate of recurrence documented by CT or physical examination was 30%. We concluded the following: (1) small intestinal submucosa is an effective alternative bioprosthesis in the management of ventral/inguinal hernia when there is associated bacterial contamination; (2) human vs. pig immune response has not been seen in this patient population; (3) early graft failure due to overwhelming fascial infection was noted in one patient and may be a limitation of this technology in a minority of patients; and (4) early hernia recurrence is relatively low but long-term follow-up has not been completed.