Prosthetic mesh can create the unique problems of infection, extrusion, adhesions, and fistula formation. Is it acceptable to place mesh directly on bowel? Review of the current literature and my clinical experience implies that it is, although it is difficult to know the exact frequency of these complications. Considering some of the unique disintegration problems and occasional poor integration of bioprosthetics,14 the far greater cost, and the higher hernia recurrence rates,15 tradeoffs will need to be presented by the surgeon to the patient. In my practice, I avoid using prosthetic meshes in inflamed fields and in cases with tenuous soft tissues for cover. I do not use permanent mesh when there are intraabdominal suture lines or significant serosal tears. I limit the mesh size using components separation techniques and place the mesh under tension to avoid wrinkles. I recognize that reoperative abdominal surgery may be complicated by the presence of prosthetic mesh, but it has not required bowel excisions in my hands.16 In the end, human outcomes studies may demonstrate that it is the skill of the archer that is important, rather than the arrow.
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