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An in vitro study on the biocompatibility of fibroblasts in sterile and non-sterile low-cost and commercial meshes

  • R. WiessnerEmail author
  • A. Gehring
  • T. Kleber
  • N. Ekwelle
  • R. Lorenz
  • D-U. Richter
Original Article



Despite several successful studies with low-cost meshes (LCM) for the treatment of inguinal hernias in India and Africa, a nationwide application has not been possible for a variety of reasons. One problem is the special preparation and sterilization of these meshes—naturally, they should comply with international standards and demands, which is often difficult to achieve in Africa. Our primary approach was to determine whether there are differences in the biocompatibility of fibroblasts between non-sterile and sterile LCMs and commercial meshes (CM).

Materials and methods

Two polyester CMs with different pore size and a polyester LCM were examined as both sterile and non-sterile. LCM was plasma sterilized at 60 °C and steam sterilized at 134 °C. Sterile and non-sterile meshes were soaked with an antibiotic (penicillin/streptomycin) and antimycotic solution (amphotericin B). Human fibroblasts from healthy subcutaneous tissue were used. Various tests for evaluating the growth behavior and cell morphology of human fibroblasts were conducted. Semiquantitative (light microscopy) and qualitative (scanning electron microscopy) analyses were performed after 1 week and again after 12 weeks. The metabolism of fibroblasts was checked by pH measurements and glucose analyses. Biocompatibility of fibroblasts on sterile and non-sterile meshes was carried out by luminescence methods (cell viability and apoptosis) as well as calorimetric methods for proliferation determination (BrDU assay) and cytotoxicity (LDH assay).


Light and electron microscopy revealed a moderate growth of fibroblasts on all investigated mesh types. The results of glycolysis and the pH value were within the normal range for all sterile and non-sterile meshes. In biocompatibility studies, no elevated level of apoptosis was detected. The viability measurement of mitochondrial activity of fibroblasts showed a 50% inhibition of mitochondria in all nets, with the exception of non-sterile CM, whereas mitochondrial activity was increased in the non-sterile CM. A proliferation measurement (BrdU test) revealed different growth inhibition in the sterile and non-sterile meshes. This growth inhibition was significantly stronger, particularly for non-sterile CM light meshes, than it was for the non-sterile LCM.


Again, our studies show no significant differences in biocompatibility of fibroblasts between expensive and low-cost meshes. In addition, we detected fibroblast growth even in sterile meshes, independent of the mesh group. To our knowledge, the present study is the first of its kind in terms of qualitative equivalence of sterile and non-sterile in vitro mesh samples. We do not wish to create future patient studies with non-sterilized meshes saturated with antibiotics/antimycotics. However, perhaps we can prove in future studies that under semi-sterile conditions with certain LCMs, wound infection rates can be acceptable.


Low-cost meshes Sterilization Fibroblasts Biocompatibility 


Compliance with ethical standards

Conflict of interest

RW, AG, TK, NE and DR declare that they have no conflict of interest. RL declares conflict of interest not directly related to the submitted work. He has given two OP training courses for Company BD/ C.R.BARD and received a Speaker honorarium from Company BD/ C.R.BARD.

Ethical approval

An ethics vote was not necessary for the in-vitro trials.

Human and animal rights

All authors confirm that no experiments with humans or animals have been carried out.

Informed consent

The female patients have given their consent to the provision of fibroblasts.


  1. 1.
    Yang J, Papandria D, Rhee D, Perry H, Abdullah F (2011) Low-cost mesh for inguinal hernia repair in resource-limited settings. Hernia 15(5):485–489. (Epub 2011 May 24. Review) CrossRefGoogle Scholar
  2. 2.
    Primatesta P, Goldacre MJ (1996) Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 25(4):835–839CrossRefGoogle Scholar
  3. 3.
    Rutkow IM (2003) Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin N Am 83(5):1045–1051CrossRefGoogle Scholar
  4. 4.
    Lavy C, Tindall A, Steinlechner C, Mkandawire N, Chimangeni S (2007) Surgery in Malawi—a national survey of activity in rural and urban hospitals. Ann R Coll Surg Engl 89(7):722–724CrossRefGoogle Scholar
  5. 5.
    Wilhelm TJ, Anemana S, Kyamanywa P, Rennie J, Post S, Freudenberg S (2006) Anaesthesia for elective inguinal hernia repair in rural Ghana—appeal for local anaesthesia in resource-poor countries. Trop Doct 36(3):147–149CrossRefGoogle Scholar
  6. 6.
    Yenli EMT, Abanga J, Tabiri S, Kpangkpari S, Tigwii A, Nsor A, Amesiya R, Ekremet K, Abantanga FA (2017) Our experience with the use of low cost mesh in tension-free inguinal hernioplasty in Northern Ghana. Ghana Med J 51(2):78–82Google Scholar
  7. 7.
    Ohene-Yeboah M, Abantanga FA (2011) Inguinal hernia disease in Africa: a common but neglected surgical condition. West Afr J Med 30(2):77–83 (Review) Google Scholar
  8. 8.
    Moser KH, Heiss M, Meyer J (2011) “Operation” Afrika. Hilfe von Bürger zu Bürger. Deutsches Ärzteblatt 108(40):2090–2092Google Scholar
  9. 9.
    HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22(1):1–165. (Epub 2018 Jan 12) CrossRefGoogle Scholar
  10. 10.
    Freudenberg S, Sano D, Ouangré E, Weiss C, Wilhelm TJ (2006) Commercial mesh versus Nylon mosquito net for hernia repair. A randomized double-blind study in Burkina Faso. World J Surg 30(10):1784–1789CrossRefGoogle Scholar
  11. 11.
    Tongaonkar R, Reddy B, Mehta V, Singh N, Shivade S (2003) Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg 65:89–95Google Scholar
  12. 12.
    Löfgren J, Nordin P, Ibingira C, Matovu A, Galiwango E, Wladis A (2016) A randomized trial of low-cost mesh in groin hernia repair. N Engl J Med 374(2):146–153CrossRefGoogle Scholar
  13. 13.
    Stephenson BM, Kingsnorth AN (2011) Safety and sterilization of mosquito net mesh for humanitarian inguinal hernioplasty. World J Surg 35(9):1957–1960CrossRefGoogle Scholar
  14. 14.
    Mitura K, Kozieł S (2018 Jun) The influence of different sterilization types on mosquito net mesh characteristics in groin hernia repair. Hernia 22(3):483–490CrossRefGoogle Scholar
  15. 15.
    Wiessner R, Kleber T, Ekwelle N, Ludwig K, Richter DU (2017) In-vitro examination of the biocompatibility of fibroblast cell lines on alloplastic meshes and sterilized polyester mosquito mesh. Hernia 21(3):407–416CrossRefGoogle Scholar
  16. 16.
    Riss TL, Moravec RA, Niles AL, Duellman S, Benink HA, Worzella TJ, Minor L (2013) In: Sittampalam GS, Coussens NP, Brimacombe K, Grossman A, Arkin M, Auld D, Austin C, Baell J, Bejcek B, Caaveiro JMM, Chung TDY, Dahlin JL, Devanaryan V, Foley TL, Glicksman M, Hall MD, Haas JV, Inglese J, Iversen PW, Kahl SD, Kales SC, Lal-Nag M, Li Z, McGee J, McManus O, Riss T, Trask OJ Jr, Weidner JR, Wildey MJ, Xia M, Xu X (eds) Cell viability assays. Assay guidance manual [Internet]. Eli Lilly & Company and the National Center for Advancing Translational Sciences, Bethesda [2004–2013 May 1 (updated 2016 Jul 1)] Google Scholar
  17. 17.
    O`Brian M (2004) Technically speaking: cell-based caspase assays analyzing the data. Promega Notes 87:33–36Google Scholar
  18. 18.
    Keilin D, Hartree EF (1952) Specificity of glucose oxidase (notatin). Biochem J 50(3):331–341CrossRefGoogle Scholar
  19. 19.
    Bozorgmehr K (2010) Rethinking the ‘global’ in global health: a dialectic approach. Global Health 6:19CrossRefGoogle Scholar
  20. 20.
    Shrime MG, Bickler SW, Alkire BC, Mock C (2015) Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health 3 Suppl 2:S8–S9CrossRefGoogle Scholar
  21. 21.
    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386(9993):569–624CrossRefGoogle Scholar
  22. 22.
    Shillcutt SD, Clarke MG, Kingsnorth AN (2010) Cost-effectiveness of groin hernia surgery in the Western Region of Ghana. Arch Surg 145(10):954–961CrossRefGoogle Scholar
  23. 23.
    Lubbe DE, Fagan JJ (2003) South African survey on disinfection techniques for the flexible nasopharyngoscope. J Laryngol Otol 117(10):811–814CrossRefGoogle Scholar
  24. 24.
    Cissé CT, Faye O, Ndiaye G, Sakho A, Faye EO, Maiga A, Wade F, Sy-Ngom K, Gueye M, Zino JM, Diadhiou F (2000) Prevention of infection in a surgical environment in the regional hospitals of Senegal. Sante 10(3):189–194Google Scholar
  25. 25.
    Patterson T, Currie P, Patterson S, Patterson P, Meek C, McMaster R (2017) A systematic review and meta-analysis of the post-operative adverse effects associated with mosquito net mesh in comparison to commercial hernia mesh for inguinal hernia repair in low income countries. Hernia 21(3):397–405CrossRefGoogle Scholar
  26. 26.
    Wiegering A, Sinha B, Spor L, Klinge U, Steger U, Germer CT, Dietz UA (2014) Gentamicin for prevention of intraoperative mesh contamination: demonstration of high bactericide effect (in vitro) and low systemic bioavailability (in vivo). Hernia 18(5):691–700CrossRefGoogle Scholar
  27. 27.
    Löfgren J, Beard J, Ashley T (2018) Groin hernia surgery in low-resource settings—a problem still unsolved. N Engl J Med 378(14):1357–1358CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of General an Visceral SurgeryBodden-Kliniken Ribnitz-DamgartenRibnitz-DamgartenGermany
  2. 2.Heart und Vascular CenterAlbertinen HospitalHamburgGermany
  3. 3.Department of General and Visceral SurgeryHospital Märkisch OberlandWriezenGermany
  4. 4.3+ ChirurgenBerlin-SpandauGermany
  5. 5.Department of Obstetrics and GynecologyUniversity of RostockRostockGermany

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