It is highly unlikely that biologic meshes will play a relevant role in inguinal hernia repair in the future. In consequence, it should be sufficient to point out that there is no clinical evidence for superiority over synthetic meshes in inguinal hernia repair or any other indication. A recent publication in the ANZ Journal of Surgery demonstrated that biologic inguinal hernia repair was associated with longer operation times and more seroma formation compared to standard mesh repair [1].

A new class of synthetic mesh was introduced to the market in the recent past, namely bioabsorbable implants, such as BioA (polyglycolic acid/trimethylene carbonate), TIGR (polylactic and polyglycolic acid) and Phasix (poly-4-hydroxybutyrate). Potential advantages include rapid integration and a mild foreign body reaction compared to biologic meshes. Compared to the other above mentioned meshes, the BioA represents a 3D matrix rather than a 2D mesh layer. TIGR and Phasix are more conventional in design, but all three share the feature of being resorbed in 9 to 24 months after implantation. Our study group could demonstrate that the BioA actually reinforces the abdominal wall by eliciting a robust scar formation, yielding reticular collagen formation. If this is also achieved by the other competitors has, to the best of our knowledge, not been investigated in detail yet. Considering the ongoing debate about genetic and epigenetic factors influencing hernia formation, it is totally unclear if resorbable meshes could lead to an increased rate of recurrences.

This issue will become even more important as a variety of synthetic, resorbable meshes will enter the market in the near future. Furthermore, it must be emphasized that the resorption process of these implants (most of them polyglycolic/polylactic acid derivatives) could lead to seroma formation or prolonged local inflammation. Because bioabsorbable, synthetic meshes have been presented as direct competitors of collagen matrices, many surgeons are eager to use them in contaminated wound fields. The first study using BioA in contaminated fields (CDC class 2 and 3 [2]) with promising results was published recently [3]. The future will show how these new meshes will perform in other than clean wounds (e.g., after resection of incarcerated bowel).

Although polypropylene and polyester meshes are the most commonly used implants in hernia repair and are usually well tolerated, it is currently unclear how these polymers behave in terms of aging and mechanical breakdown. If implanted in young adults, meshes will have to perform for up to seven decades considering the life expectancy in developed countries. There is at least some evidence that differences between polypropylene and polyester can be found [4]. However, this question must be elucidated in more detail in the future.