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Biofilms and effective porosity of hernia mesh: are they silent assassins?



The purpose of this paper is to communicate two new concepts with the potential to cause major morbidity in hernia repair, effective porosity and biofilm. These 2 concepts are interrelated and have the potential to result in mesh-related complications. Effective porosity is a term well described in the textile industry. It is best defined as the changes to pore morphology after implantation of mesh in situ. It is heavily dependent on mesh construct and repair technique and has the potential to impact hernia repair by reducing mesh tissue integration and promoting fibrosis. Bacterial biofilm is a well-described condition affecting prosthesis in breast and join replacement surgery with catastrophic consequences. There is a paucity of information on bacterial biofilm in mesh hernia repair. We speculate that bacterial biofilm has the potential to reduce the effective porosity of mesh, resulting in non-suppurative mesh-related complications as well as the potential for late suppurative infections. We describe the aetiology, pathogenesis, diagnosis, treatment and preventative measures to address bacterial biofilm in mesh hernia surgery. Hernia surgeons should be familiar with these two new concepts which have the potential to cause major morbidity in hernia repair and know how to address them.


Ovid Medline and PubMed were searched for communications on “effective porosity” and “bacterial biofilm”.


There is a paucity of information in the literature of these conditions and their impact on outcomes following mesh hernia repair.


We discuss the two concepts of effective porosity and biofilm and propose potential measures to reduce mesh-related complications. This includes choosing mesh with superior mesh construct and technical nuances in implanting mesh to improve effective porosity. Furthermore, measures to reduce bacterial biofilm and its consequences are suggested.

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  1. 1.

    Engelsman AF, van der Mei HC, Busscher HJ, Ploeg RJ (2008) Morphological aspects of surgical meshes as a risk factor for bacterial colonization. Br J Surg 95(8):1051–1059

  2. 2.

    Aydinuraz K, Agalar C, Agalar F, Ceken S, Duruyurek N, Vural T (2009) In vitro S. epidermidis and S. aureus adherence to composite and lightweight polypropylene grafts. J Surg Res 157(1):e79–86

  3. 3.

    Reslinski A, Mikucka A, Szmytkowski J, Gospodarek E, Dabrowiecki S (2009) In vivo biofilm on the surface of a surgical mesh implant. Pol J Microbiol 58(4):367–369

  4. 4.

    Stoodley P, Sidhu S, Nistico L, Mather M, Boucek A, Hall L et al (2012) Kinetics and morphology of polymicrobial biofilm formation on polypropylene mesh. FEMS Immunol Med Microbiol 65(2):283–290

  5. 5.

    Kathju S, Nistico L, Melton R, Lasko LA, Stoodley P (2015) Direct demonstration of bacterial biofilms on prosthetic mesh after ventral herniorrhaphy. Surg Infect 16(1):45–53

  6. 6.

    Langbach O, Kristoffersen AK, Abesha E, Enersen M, Rokke O, Olsen I (2016) Oral, intestinal, and skin bacteria in ventral hernia mesh implants. J Oral Microbiol 8:31854

  7. 7.

    Jacombs A, Allan J, Hu H, Valente PM, Wessels WL, Deva AK et al (2012) Prevention of biofilm-induced capsular contracture with antibiotic-impregnated mesh in a porcine model. Aesthet Surg J 32(7):886–891

  8. 8.

    Reinbold J, Hierlemann T, Urich L, Uhde AK, Muller I, Weindl T, et al. Biodegradable rifampicin-releasing coating of surgical meshes for the prevention of bacterial infections.

  9. 9.

    Cazalini EM, Miyakawa W, Teodoro GR, Sobrinho ASS, Matieli JE, Massi M et al (2017) Antimicrobial and anti-biofilm properties of polypropylene meshes coated with metal-containing DLC thin films. J Mater Sci Mater Med 28(6):97

  10. 10.

    Bigelow TA, Thomas CL, Wu H, Itani KMF (2019) Impact of high-intensity ultrasound on strength of surgical mesh when treating biofilm infections. IEEE Trans Ultrason Ferroelectr Freq Control 66(1):38–44

  11. 11.

    Perez-Kohler B, Bayon Y, Bellon JM (2016) Mesh infection and hernia repair: a review. Surg Infect 17(2):124–137

  12. 12.

    Guillaume O, Perez Kohler B, Fortelny R, Redl H, Moriarty F, Richards RG et al (2018) A critical review of the in vitro and in vivo models for the evaluation of anti-infective meshes. Hernia 22(6):961–974

  13. 13.

    Guillaume O, Perez R, Fortelny R, Redl H, Moriarty TF, Richards RG et al (2018) Infections associated with mesh repairs of abdominal wall hernias: are antimicrobial biomaterials the longed-for solution? Biomaterials 167:15–31

  14. 14.

    Vert M, Hellwich KH, Hess M et al (2012) Terminology for biorelated polymers and applications (IUPAC recommendations 2012). Pure Appl Chem 84:377–410

  15. 15.

    Costerton JW, Stewart PS, Greenberg EP (1999) Bacterial biofilm: a common cause of persistent infections. Science 284:1318–1322

  16. 16.

    Srivastava S, Bhargava A (2015) Biofilms and human health. Biotechnol Lett 38:1–22

  17. 17.

    Arciola CR, Campoccia D, Montanaro L (2018) Implant infections: adhesion, biofilm formation and immune evasion. Nat Rev Microbiol 16:397–409

  18. 18.

    Del Pozo JL, Patel R (2007) The challenge of treating biofilm-associated bacterial infections. Clin Pharmacol Ther 82:204–209

  19. 19.

    Arciola CR, Campoccia D, Ehrlich GD et al (2015) Biofilm-based implant infections in orthopaedics. Adv Exp Med Biol 830:29–46

  20. 20.

    Stoodley P, Ehrlich GD, Sedghizadeh PP et al (2011) Orthopaedic biofilm infections. Curr Orthop Pract 22:558–563

  21. 21.

    Jacombs A, Tahir S, Hu H et al (2014) In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants. Plast Reconstr Surg 133:471e–e480

  22. 22.

    Chong SJ, Deva AK (2015) Understanding the etiology and prevention of capsular contracture: translating science into practice. Clin Plast Surg 42:427–436

  23. 23.

    Kirmusaoglu S, Yurdugul S, Metin A et al (2017) The effect of urinary catheters on microbial biofilms and catheter associated urinary tract infections. Urol J 14:3028–3034

  24. 24.

    Laohapensang K, Arworn S, Orrapin S et al (2017) Management of the infected aortic endograft. Semin Vasc Surg 30:91–94

  25. 25.

    Rupp ME, Karnatak R (2018) Intravascular catheter-related bloodstream infections. Infect Dis Clin N Am 32:765–787

  26. 26.

    Romano CL, Romano D, Morelli I, et al. The concept of biofilm-related implant malfunction and "low-grade infection". In: Drago J (eds) A modern approach to biofilm-related orthopaedic implant infections. advances in experimental medicine and biology. Switzerland: Springer International; 2017. p. 1–13.

  27. 27.

    Richter K, Thomas N, Claeys J et al (2017) A topical hydrogel with deferiprone and gallium-protoporphyrin targets bacterial iron metabolism and has antibiofilm activity. Antimicrob Agents Chemother 61:e00481–e517

  28. 28.

    Kathju S, Nistico L, Melton R et al (2016) Direct demonstration of bacterial biofilms on prosthetic mesh after ventral herniorrhaphy. Surg Infect (Larchmt) 16:45–53

  29. 29.

    Jianfeng J, Dongdong F, Yumei Z, Qintao W (2019) Functionalized titanium implant in regulating bacteria and cell response. Int J Nanomed 14:1433–1450

  30. 30.

    Miao L, Wang F, Wang L et al (2015) Physical characteristics of medical textile prostheses designed for hernia repair: a comprehensive analysis of select commercial devices. Materials 8:8148–8168

  31. 31.

    Klinge U, Klosterhalfen B (2018) Mesh implants for hernia repair: an update. Expert Rev Med Dev 15:735–746

  32. 32.

    Klosterhalfen B, Klinge U (2013) Retrieval study at 623 human mesh explants made of polypropylene—impact of mesh class and indication for mesh removal on tissue reaction. J Biomed Mater Res B Appl Biomater 19:19

  33. 33.

    Belyanski I, Tsirline VB, Montero PN, Sathishkumar R, Martin TR, Lincourt AE, Shipp J, Vertegel A, Heniford BT (2011) Lysostpahin-coated mesh prevents staphylococcal infection and significanty improves survival in a contaminated surgical field. Am Surg 77:1025–1031

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The Microscopy Department, School of Biological Sciences, Macquarie University is kindly acknowledged for providing expertise in electron microscopy. KR is recipient of a CJ Martin Biomedical Early Career Fellowship (#1163634) by the National Health and Medical Research Council, Australia. Chris Hensman is a consultant for Medtronic. Bernd Klosterhalfen is a consultant to FEG Textiltechnik and also an expert witness in the US and Australia in mesh litigation cases.

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Correspondence to C. Hensman.

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Jacombs, A.S.W., Karatassas, A., Klosterhalfen, B. et al. Biofilms and effective porosity of hernia mesh: are they silent assassins?. Hernia 24, 197–204 (2020).

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  • Hernia
  • Mesh
  • Effective porosity
  • Biofilm
  • Mesh infection
  • Mesh pore size