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Suturable mesh better resists early laparotomy failure in a cyclic ball-burst model



The small bites surgical technique supported by the STITCH trial has been touted as a strategy for preventing early laparotomy dehiscence through greater force distribution at the suture–tissue interface. However, this hernia prevention strategy requires an alteration in the standard closure technique that has not been widely adopted in the USA. This study seeks to determine whether incorporating a mid-weight polypropylene mesh material into a hollow-bore surgical suture material will effectively increase the force distribution at the suture–tissue interface and potentially help prevent early laparotomy dehiscence in an ex vivo model.


A cyclic stress ball-burst model was used to compare suturable mesh (0 DuraMesh™) to conventional suture. After midline laparotomy, 28 porcine abdominal wall specimens were closed with either 0 DuraMesh™ or #1 polydioxanone double-loop suture. A custom 3D-printed ball-burst test apparatus was used to fatigue the repair on a MTS Bionix Load Frame. The tissue was repetitively stressed at a physiological force of 15–120 N cycled at a rate of 0.25 Hz for a total of 1000 repetitions, followed by a load to failure, and the maximal force was recorded.


The mean maximal force at suture pull-through was significantly higher (p < 0.0095) in the 0 DuraMesh suture group (mean: 850.1 N) compared to the 1 PDS group (mean: 714.7 N).


This ex vivo study suggests that using rational suture design to improve force distribution at the suture–tissue interface may be a viable strategy for preventing the suture pull-through that drives incisional hernia.

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  1. 1.

    Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A, Werner J, Büchler MW, Diener MK (2014) Incisional hernia rate 3 years after midline laparotomy. Br J Surg.

  2. 2.

    Mudge M, Hughes LE (1985) Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg.

  3. 3.

    Nieuwenhuizen J, Eker HH, Timmermans L, Hop WCJ, Kleinrensink G, Jeekel J, Lange JF (2013) A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence. BMC Surg.

  4. 4.

    Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, Franck A, Kieser M, Büchler MW, Knaebel H (2009) Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg.

  5. 5.

    Hope W, Watson L, Menon R, Kotwall C, Clancy T (2010) Abdominal wall closure: resident education and human error. Hernia.

  6. 6.

    Williams Z, Williams S, Easley H, Seita H, Hope W (2017) An evaluation of abdominal wall closure in general surgical and gynecological residents. Hernia.

  7. 7.

    Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FP, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink G-J, Jeekel J, Lange JF (2015) Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet.

  8. 8.

    Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, Joost G, Hop WCJ, Kleinrensink G-J, Jeekel H, Lange JF (2009) Small stitches with small suture distances increase laparotomy closure strength. Am J Surg.

  9. 9.

    Morris ZS, Wooding S, Grant J (2011) The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med.

  10. 10.

    Carlson MA (1997) Acute wound failure. Surg Clin N Am.

  11. 11.

    Xing L, Culbertson EJ, Wen Y, Franz MG (2013) Early laparotomy wound failure as the mechanism for incisional hernia formation. J Surg Res.

  12. 12.

    Souza J, Dumanian Z, Gurjala A, Dumanian G (2015) In vivo evaluation of a novel mesh suture design for abdominal wall closure. Plast Reconstr Surg.

  13. 13.

    Wallace SJ, Mioton LM, Havey RM, Muriuki MG, Ko JH (2019) Biomechanical properties of a novel mesh suture in a cadaveric flexor tendon repair model. J Hand Surg.

  14. 14.

    Hernández-Gascón B, Mena A, Peña E, Pascual G, Bellón J, Calvo B (2013) Understanding the passive mechanical behavior of the human abdominal wall. Ann Biomed Eng.

  15. 15.

    Sahoo S, DeLozier KR, Erdemir A, Derwin KA (2015) Clinically relevant mechanical testing of hernia graft constructs. J Mech Behav Biomed Mater.

  16. 16.

    Cooney GM, Lake SP, Thompson DM, Castile RM, Winter DC, Simms CK (2017) The suture pullout characteristics of human and porcine linea alba. J Mech Behav Biomed Mater.

  17. 17.

    Lim J, Hong J, Chen WW, Weerasooriya T (2011) Mechanical response of pig skin under dynamic tensile loading. Int J Impact Eng.

  18. 18.

    Freytes DO, Rundell AE, Vande Geest J, Vorp DA, Webster TJ, Badylak SF (2005) Analytically derived material properties of multilaminated extracellular matrix devices using the ball-burst test. Biomaterials.

  19. 19.

    Klinge U, Klosterhalfen B, Conze J, Limberg W, Obolenski B, Ottinger AP, Schumpelick V (1998) Modified mesh for hernia repair that is adapted to the physiology of the abdominal wall. Eur J Surg.

  20. 20.

    Harris HW, Hope WH, Adrales G, Andersen DK, Deerenberg EB, Diener H, Dumanian G, East B, Fischer JP, Ureña MAG, Gibeily GJ, Hansson BM, Hernández- Granados P, Hiles MC, Jeekel J, Levinson H, Lopez-Cano M, Muysoms F, Pereira JA, Prudhomme M, Ramaswamy A, Stabilini C, Torkington J, Valverde S, Young DM (2018) Contemporary concepts in hernia prevention: selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias. Surgery.

  21. 21.

    Muysoms F, Antoniou S, Bury K, Campanelli G, Conze J, Cuccurullo D, de Beaux A, Deerenberg E, East B, Fortelny R, Gillion J-, Henriksen N, Israelsson L, Jairam A, Jänes A, Jeekel J, López-Cano M, Miserez M, Morales-Conde S, Sanders D, Simons M, Śmietański M, Venclauskas L, Berrevoet F (2015) European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia.

  22. 22.

    García-Ureña M, López-Monclús J, Hernando LA, Montes D, Valle de Lersundi A, Pavón C, Ceinos C, Quindós P (2015) Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery. Ann Surg.

  23. 23.

    Bevis PM, Windhaber RAJ, Lear PA, Poskitt KR, Earnshaw JJ, Mitchell DC (2010) Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery. Br J Surg.

  24. 24.

    Bellón JM, Buján J, Contreras L, Hernando A (1995) Integration of biomaterials implanted into abdominal wall: process of scar formation and macrophage response. Biomaterials.

  25. 25.

    Jordan S, Fligor J, Janes L, Dumanian G (2018) Implant porosity and the foreign body response. Plast Reconstr Surg.

  26. 26.

    Dumanian GA, Tulaimat A, Dumanian ZP (2015) Experimental study of the characteristics of a novel mesh suture. Br J Surg.

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The authors would like to acknowledge Ms. Sonja Skeete for her efforts in coordinating execution of this study.


Funding for porcine tissue and materials used in this study was provided through the Uniformed Services University of the Health Sciences and The Geneva Foundation (Transforming Technology for the Warfighters [TTW] HU00011820013). These funding sources had no involvement in the study design, collection/analysis/interpretation of data or in the writing of this report.

Author information

Correspondence to C. J. Scheiber.

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Conflict of interest

The authors received the DuraMesh samples used in this study at no cost from the manufacturer, Mesh Suture Inc. Mesh Suture Inc. did not otherwise influence the study design, study execution, data collection, analysis of the study data, or decision to disseminate the study data. The authors declare that they have no conflict of interest.

Ethical approval

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. All experiments conducted in this study are in the compliance with the current laws of the USA.

Human and animal rights

This article does not contain any studies with human participants performed by any of the authors. All procedures involving animal tissue were performed in accordance with the ethical standards of our institution and the Institutional Animal Care and Use Committee at the Uniformed Services University of the Health Sciences, Bethesda, MD

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This article does not contain studies with human participants performed by any of the authors. Therefore there is no identifiable data that requiresd informed consent.

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Scheiber, C.J., Kurapaty, S.S., Goldman, S.M. et al. Suturable mesh better resists early laparotomy failure in a cyclic ball-burst model. Hernia (2020).

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  • Wound closure techniques
  • Suture
  • Incisional hernia
  • Laparotomy
  • Trauma
  • Mesh