Hernia (zooo)4:248-249

Hernia
9 Springer-Verlag2000

Estimation of the inflammatory reaction by CRP-levelsfollowing prosthetic hernia repair

A. Hoeferlin and K.D.Hoehle

ChirurgischeAbteilung,St. Hildegardis-Krankenhaus,D-55131Mainz

Summary: Tissue damage leads to a complex response of the body which is

known as the acute-phase reaction. If the interaction between an implanted
mesh and the immune system led to an additional inflammatory reaction, the
corresponding CRP-levels should show a typical curve. In a prospective clinical study we controlled the CRP-levels before and after Mersilene and Prolene
mesh implantation. Our perioperative measurements of the CRP-levels showed a maximum on the second day with a significant increase for Mersilene
but on the sixth postoperative day the levels for both meshes had fallen
almost to the preoperative value. Postoperative infective complications can
early be noticed by measuring the CRP-level. The results of our study did not
indicate any specific systemic response of the body after mesh implantation.

Correspondence to: A.

Hoeferlin

Key words: Acute-phase reaction - C-reactive protein - Operative trauma ~Healing - I n f l a m m a t i o n

_ _
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Received July 03, 20oo
Accepted in final form October o4, 20oo

A study dated 1992 showed a significant

difference in CRP-concentration between conventional and laparoscopic
cholecystectomy at a4 and 48 hours after
the operation as an expression of less
tissue trauma when the operation is
done laparoscopically [Roumen 19921.
The maximum CRP-level was reached
48 hours postoperatively.
A more recent randomized controlled trial compared postoperative CRPconcentration after laparoscopic and
conventional colorectal resection. Again,
in the laparoscopic group postoperative
increase of CRP-level was less than in

the conventional group [Schwenk zooo].

It can therefore be assumed that the
postoperative CRP-concentration is correlated with the amount of tissue damage.
The implantation of foreign body
material leads to interaction between the
host tissue and the artificial material.
Several aspects of the material like the
chemical composition, surface texture,
porosity and the elastic modules as well
as the location of the implant affect this
process. On the other hand, the host also
influences this interaction. The immune
and nutritional status, deficiencies, dia-

betes mellitus and infection may lead to

destruction, lysis or extrusion of the
foreign material.
When the mesh is accepted, incorporation is closely associated with the process of wound healing. The implanted
prosthesis interferes with the healing
process and in particular the function of
the macrophages is influenced by the
foreign material.
Several authors postulate an inflammatory reaction of the body caused by
mesh implantation [Klinge 1998; Lamb
1983; Schumpelick 1999]. If this interaction between the prosthesis and the

Hoeferlin A. and K.-D. Hoehle: Estimation of the inflammatory reaction by CRP-levels following prosthetic hernia repair

~40

Memi~ene

,,,,'

ooi

//

~ . \.,~

ot /7"
Preoperafiv

"<.i
Day 2

Day 6

Fig. 1

Fig. 2

Postoperative levels of CRP

Postoperative levels of CRP,set out chronologically

i m m u n e system led to an additional

inflammatory reaction or to a prolongation of the acute phase reaction, the corresponding CRP-levels should show a
typical curve. To evaluate such a potentially typical curve was the purpose of
our prospective clinical study.

Material and methods

In a personal series of 39 incisional hernias we measured the CRP-levels preoperatively and on the second and sixth
postoperative days. All meshes were
implanted in a retromuscular position.
The material consisted in z8 cases of
Mersilene and in 11 cases of Polypropylene. The size of the meshes ranged from
z25 to 1 60o cm 2 with an average of
6o5 cm z. All patients received antibiotic
prophylaxis with Cefazolin at the beginning of the operation.

Results

The overall increase for both types of

mesh ranged from 8 to 146 mg/1 on day

249

two and d e c r e a s e d until day six to

55 rag/1. The separate graphs show a statistically significant increase for the
Mersilene mesh compared to Polypropylene (Fig. 1). Because this study was
unrandomized this significance should
be considered critically. A close view on
the individual CRP-levels reveal a wide
mean variation.
If we set out the data chronologically
there appears to be a slight tendency
towards a lesser CRP increase (Fig. z).
This could be explained by a reduction
of the tissue d a m a g e a c o m p a n y i n g
increasing experience with the surgical
technique.

Conclusions

What conclusions can we draw from our

results?
1. The curve of the postoperative
CRP-levels as an expression of the systemic i n f l a m m a t o r y reaction shows a
maximum on the second day and falls
gradually until day six.

z. Inflammatory reaction after Mersilene implantation is greater than after

Polypropylene repair but on the sixth
p o s t o p e r a t i v e day the d i f f e r e n c e
becomes less.
3- If there is an infection, either systemic or - most to be feared - an infection of the mesh, the CRP-level will
not fall but will increase after day two.
The routine measurement postoperatively on the second and sixth days is
therefore an effective and simple guideline to detect infective complications
early.
4. The CRP levels do not differ
essentially from those in operations
without mesh implantation. In a current study we are comparing the CRP
increase after lung resections, coIorectal surgery and mesh implantation. The
preliminary results confirm this statement.
5. Measurement of the postoperative
CRP levels did not indicate any specific
systemic response of the b o d y after
mesh implantation.

References

Klinge U, Klosterhalfen B, M/iller M, et al. (1999)

Foreign body reaction to meshes used for
the repair of abdominal hernias. Eur J Surg
165:665-672
Lamb J, Vitale Th, Kaminski D (1983) Comparative evaluation of synthetic meshes used for
abdominal wall replacement. Surgery 93:
643-648

Roumen R, van Meurs P, Kuypers H, et al. (1992)

Serum interleukin-6 and C reactive protein
responses in patients after laparoscopic or
conventional cholecystectomy. Eur I Surg
z58:541-544
Schumpelick V, Klinge U, Welty G, et al. (1999)
Meshes within the abdominal wall. Chirurg
7o: 876-887

Schwenk W, Jacobi C, Mansmann U, et al. (zooo)

Inflammatory response after laparoscopic
and conventional colorectal resections:
results of a prospective randomized trial.
Langenbeck" s Arch Surg 385:z-9