Original article

Biomechanical abdominal wall model applied to hernia repair

M. Lyons1 , H. Mohan2 , D. C. Winter2,3 and C. K. Simms1
1
Trinity Centre for Bioengineering, Department of Mechanical and Manufacturing Engineering, Parsons Building, Trinity College, 2 Department of
Surgery, St Vincent’s University Hospital, and 3 School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
Correspondence to: Dr M. Lyons, Trinity Centre for Bioengineering, Department of Mechanical and Manufacturing Engineering, Parsons Building, Trinity
College, Dublin 2, Ireland (e-mail: lyonsm2@tcd.ie)

Background: Most surgical innovations require extensive preclinical testing before employment in the
operative environment. There is currently no way to develop and test innovations for abdominal wall
surgery that is cheap, repeatable and easy to use. In hernia repair, the required mesh overlap relative
to defect size is not established. The aims of this study were to develop a biomechanical model of the
abdominal wall based on in vivo pressure measurements, and to apply this to study mesh overlap in hernia
repair.
Methods: An observational study of intra-abdominal pressure (IAP) levels throughout abdominal surgery
was conducted to identify the peak perioperative IAP in vivo. This was then applied in the development
of a surrogate abdominal wall model. An in vitro study of mesh overlap for various defect sizes was then
conducted using this clinically relevant surrogate abdomen model.
Results: The mean peak perioperative IAP recorded in the clinical study was 1740 Pa, and occurred
during awakening from anaesthesia. This was reproduced in the surrogate abdomen model, which was
also able to replicate incisional hernia formation. Using this model, the mesh overlap necessary to
prevent hernia formation up to 20 kPa was found, independent of anatomical variations, to be 2 × (defect
diameter) + 25 mm.
Conclusion: This study demonstrated that a surgically relevant surrogate abdominal wall model is a
useful translational tool in the study of hernia repair.

Surgical relevance
This study examined the mesh overlap requirements for hernia
repair, evaluated in a biomechanical model of the abdomen. Cur-
rently, mesh size is selected based on empirical evidence and may
underpredict the requirement for large meshes.
The study proposes a relationship between the defect size and
mesh size to select the appropriate mesh size. Following further
trials and investigations, this could be used in clinical practice to
reduce the incidence of hernia recurrence.

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Paper accepted 29 September 2014

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9687

Introduction Much of this testing is currently conducted in animal mod-

No biomechanically accurate abdominal wall model cur-
rently exists to study abdominal wall surgery, especially
hernia repair and wound closure. Data from an in vitro
abdominal wall model would also be useful in the study of
innovative techniques in abdominal closure before ethical
approval and investment in costly and time-consuming
animal experiments and clinical trials. The majority of
surgical innovations require extensive preclinical testing
before being employed in the operating environment.
els, which are subject to ethical and cost constraints. It is
likely that many new concepts are not developed owing to
these constraints, rather than the viability of the innovation
itself. A reliable testing environment is therefore a valu-
able tool for trial-and-error developments before costly
animal trials.
Abdominal wall hernia is a common problem, and mesh
repair has been shown to reduce recurrence compared
with primary suture repair1 . However, there are limited
data on the optimal mesh overlap ratio for repairing

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Published by John Wiley & Sons Ltd
e134 M. Lyons, H. Mohan, D. C. Winter and C. K. Simms

defects2 – 5 , and current recommendations are to use a closed; and at awakening – maximum pressure during
mesh with a 50-mm overlap, regardless of defect size6 – 11 . awakening from anaesthesia.
The risk of recurrence is likely to be higher if mesh size Exclusion criteria included patients with a short bowel
is underestimated7,10,11 , whereas excess mesh may lead to due to previous resections, extensive abdominal scarring,
adhesions12,13 . No study has examined the mesh overlap chronic lung disease, body mass index less than 19 kg/m2 ,
required relative to defect size based on a biomechanically age less than 18 years, and patients whom the anaesthetist
informed model. deemed unsuitable for Valsalva.
The aim of this study was to examine peak intra-
abdominal pressures (IAPs) in vivo in the perioperative
Design
setting and use these to develop a biomechanically relevant
in vitro surrogate abdominal model. This model was then A rectangular box-shaped rig was designed to represent
applied to study mesh overlap requirements for abdominal the abdominal cavity (Fig. 1). The top of the rig is the
wall hernia repair. surrogate abdominal wall. The box contains an oversized
balloon and surrogate small intestine. Inflating the balloon
with compressed air applies pressure to the surrogate intes-
Methods tine, which can herniate through a defect in the surrogate
A small observational study was conducted in patients abdominal wall. As the balloon is oversized, the pressure
undergoing abdominal laparoscopic surgery to under- in the balloon is substantially equal to the pressure in the
stand the baseline IAPs in surgery. A surrogate rig for the surrogate intestine.
abdomen was then designed, constructed and used for a To represent the circumferential curvature of the
proof-of-concept study on mesh overlap requirements for abdomen, the top of the rig was given a radius of curvature
defect closure. of 200 mm15 . Longitudinal curvature of the abdomen was
assumed to be infinite, thus no longitudinal curvature
was applied. The lid of the rig was designed to have
Observational study the same curvature as the base and to contain a large
rectangular hole in the middle, almost the same size as
The observational study evaluated the IAPs generated
the rectangular box. This lid holds the abdominal wall
at various stages of laparoscopic surgery, and allowed
in place on top of the box containing the intestines and
partial validation of the surrogate abdomen rig. It was
conducted on patients at St Vincent’s Hospital, Dublin,
between January and July 2013. The study was approved
by the St Vincent’s Healthcare Group Ethics and Medical
Research Committee. This study measured bladder pres-
sure via the urinary catheter connected to an abdom-
inal pressure manometer14 (UnoMeterTM ; UnoMedical,
Lejre, Denmark). The manometer was attached to the uri-
nary catheter at the start of the procedure before drap-
ing. The 0-cm point (mid-axillary line, in line with the
anterior superior iliac spine) was marked using a skin
marker, to avoid intraoperative discrepancies. All record-
ings were conducted with the table flat, with the patient
either supine or in the lithotomy position. A Valsalva
manoeuvre was performed by the anaesthetist before clo-
sure of the wound to a maximum airway pressure of
4 kPa.
Intra-abdominal pressure (IAP) was measured at five
stages: preoperative baseline, after induction of anaes-
thesia at the start of the procedure immediately before
draping; intraoperative baseline, at the end of the proce- Fig. 1The surrogate abdomen rig in operation with a Perspex®
dure before the Valsalva manoeuvre; abdominal straining (Lucite International, Darwen, UK) box to hold the balloon and
manoeuvre, at the end of the procedure during Valsalva; intestines, and a curved lid to replicate the curvature of the
wound closure – the patient anaesthetized with all wounds abdominal wall

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Biomechanical abdominal wall model applied to hernia repair
the balloon. The lid was affixed tightly to the base using
cables and pulleys to prevent slippage of the abdominal
wall layer on application of pressure. Additionally, the
surfaces in contact with the abdominal wall were lined
with steel grater sheet to further reduce slippage. A com-
pressed air network was designed to allow control of air
pressure up to 20 kPa (150 mmHg), greater than the max-
imum pressure observed by Cobb and colleagues16 during
coughing.
A separate study was undertaken to develop a surro-
gate material for the intestines for use in applications on
trocar-site closure and mesh repair of hernias. It was found
that reconstituted powdered potato (RPP) was the most
suitable surrogate for intestines for this application17 .
Surrogate abdomen model validation
Initial validation was conducted using porcine intestines
and a porcine abdominal wall. A pressure of 10 kPa was
applied to ensure appropriate rig set-up. Subsequently,
with the pressure released, a 10-mm defect was created in
the abdominal wall, through the umbilicus with a trocar
port (Bluntport™; Covidien, Dublin, Ireland).
With the defect left open, pressure was increased slowly
until some of the intestine extruded through the defect in a
similar manner to a hernia. This pressure was recorded and
the experiment was repeated twice for statistical reasons.
The diameter of the defect was subsequently increased
by 10 mm and the pressure increased again until a her-
nia developed. Defect sizes from 10 to 50 mm were inves-
tigated in this manner. The tests described above were
repeated using RPP. Again, five tests (defect size from 10 to
50 mm) were conducted and each extrusion was conducted
three times for statistical purposes.
Mesh overlap study
Tests using the surrogate abdomen model were conducted
to assess the mesh diameter required to prevent hernia
onset in the event of a defect. Four porcine abdominal walls
were sourced from a local pig abattoir. All pigs were aged
26–28 weeks, and all females were nulligravid. Animals
were killed and dissected in the abattoir using their stan-
dard procedures, where the abdominal walls were harvested
and frozen pending collection. They were subsequently
kept frozen at −20 ∘ C until testing in the laboratory.
Before testing, abdominal walls were defrosted at 5 ± 1 ∘ C
for 40 h.
Pieces of mesh (PhysioMesh™; Ethicon, Cincinnati,
Ohio, USA) of diameter 20–100 mm in 10-mm steps were
prepared by cutting large pieces of mesh with a stencil.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
e135
a
d b
c
Abdominal wall containing a defect closed with a tacked
Fig. 2
mesh. a Defect size template; b Mesh size template; c Posterior
porcine abdominal wall; d Defect
Using plastic stencils and a scalpel, a 10-mm diameter
hole was created in the centre of the abdominal specimen
(Fig. 2). This defect was then closed using a 20-mm mesh
tacked in place using a laparoscopic tacker (Tacker™;
Covidien) with tacks spaced every 10 mm around the
circumference (Fig. 2). The mesh was placed inside the
abdominal wall in direct contact with the surrogate
viscera.
The rig was set up with RPP to represent the small
intestines, as it has been found to extrude at a slightly
lower pressure than real intestines, thus incorporating
safety, as well as being cheap, repeatable, clean and easy
to use17 . Pressure was applied, beginning at 2 kPa and
increasing in 1 kPa steps until the RPP began to extrude
through the defect, signifying mesh failure. This pressure
was recorded, the mesh removed, and mesh with a diam-
eter 10 mm larger tacked in place. When a mesh size was
found that did not show signs of failure at 20 kPa, the defect
diameter was increased by 10 mm and the process started
again.
This method was repeated for defect diameters of 10, 20,
30, 40 and 50 mm on each belly, resulting in a range of mesh
sizes and failure pressures for a variety of defect diameters
in a number of porcine abdominal walls. To ensure that
there was no effect of continually testing the same abdom-
inal wall with increasing defect sizes, spot checks were car-
ried out using additional abdominal walls. In these cases,
one of the 20-, 30-, 40- or 50-mm defect diameters and
the corresponding mesh diameter was chosen and tested in
isolation to ensure the result obtained was within the range
observed in the sequential tests.
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e136 M. Lyons, H. Mohan, D. C. Winter and C. K. Simms

To provide a comparison with current mesh overlap Table 1 Summary of demographics for the seven patients in the
practice6 – 9,11 , several mathematical models were also clinical study
considered; Hollinsky and Hollinsky4 assessed the mesh No. of patients*
requirement and recommended a mesh three times the size
Age (years)† 51 (29–70)
of the defect. Additionally, a more representative mathe- Sex ratio (M : F) 2:5
matical model was generated in this study (Appendix S1, Weight (kg)† 77 (63–98)
supporting information18 – 20 ), which incorporated tack fix- Body mass index (kg/m2 )† 26 (25–30)
ation of the mesh. Finally, a simple empirical mathematical Waist circumference (cm)† 120 (93–130)
Steroids
model was also assessed:
Yes 1
No 6
Mesh diameter (mm) = Factor × Defect diameter (mm)
Disease
+ Extra mesh (1) Inflammatory bowel disease 4
Colorectal cancer 3
Type of surgery
Laparoscopic 5
Results
Laparoscopic converted 1
Laparotomy 1
Seven patients were included in the clinical study after
No. of port sites
providing written, informed consent. Their demographic 3 3
data, along with their clinical details, are presented in 4 3
Table 1. Previous abdominal surgery
Yes 4
Abdominal pressure recordings at the five intervals are
No 3
summarized in Fig. 3. There was considerable variation Previous incisional hernia
in absolute values between patients, but the overall trend Yes 1
was similar, with highest pressures recorded at the end No 5
Unknown 1
of the operation when the wound was closed, and during
awakening. *Unless indicated otherwise; †values are mean (range).

Surrogate abdomen model validation

2500
Fig. 4 shows the actual pressure at which a hernia devel-
oped for various defect sizes, with cleaned intestines or 2000
RPP. The data reflect the IAP at which hernia would
be expected to occur through an open defect. The pres-
IAP (Pa)

1500
sures with which a hernia developed with porcine intes-
tine and RPP were similar, and decreased with increasing 1000
defect size.
500
Mesh overlap
Fig. 5 shows the three-dimensional relationship between 0
e e
tiv tiv va ur
e
in
g
pressure, mesh diameter and defect diameter. Each data ra ra al os en
ls l
op
e
op
e
Va rc ak
point represents the failure pressure of a particular mesh e tra te aw
pr in Af n
diameter covering a specific defect diameter. A quadratic e O
lin li ne
se se
surface fit (R2 = 0⋅96) to these data shows an increase in Ba Ba
hernia-onset pressure (P in pascals) with increasing mesh
size (M in millimetres) for a given defect diameter (H in Fig. 3Perioperative mean(s.d.) intra-abdominal pressure (IAP) in
millimetres). This surface separates regions correspond- the seven patients
ing to hernia formation (above the surface) and no her-
nia formation (below the surface), and is given by the In all cases, failure of the mesh repair occurred by the
equation: tacks pulling out of the tissue and intestine material extrud-
P = 7.8 − 0.15H + 0.25M + 0.001H 2 ing out through the gap created. The location of the fail-
ure was variable throughout the tests, but the method was
− 0.008HM + 0.003M 2 (2) always the same.

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Biomechanical abdominal wall model applied to hernia repair e137

Small intestine
7 RPP
Small intestine quadratic fit
Pressure at onset of hernia (kPa) 6 RPP quadratic fit

0
10 20 30 40 50
Defect size (mm)

Fig. 4Recorded hernia-onset pressures for reconstituted powdered potato (RPP) and porcine intestines at a range of defect sizes with
error bars (± 1 s.d.) and quadratic fits

25
Pressure at onset of hernia (kPa)

20

15

10

0
10
Defe 20 30
ct d 40 50 60 70 80 90 100
iam 50 0 20 30 40
eter 10
(mm
) Mesh diameter (mm)

Fig. 5Three-dimensional relationship between defect diameter, mesh diameter and pressure at hernia onset. Each data point represents
the failure pressure of a particular mesh diameter covering a specific defect diameter

Discussion pressures available from the perioperative tests were all

for patients without hernia. This provides unique thresh-
This observational study investigated how IAP changes old data for the onset pressure of hernia formation, and
throughout the course of a surgical procedure and provides provides partial validation of the surrogate abdomen
clinical data to evaluate the surrogate abdomen model. The model.
mean resting pressure observed before the beginning of Although it is not possible to say with certainty what
the procedure compares well with previous findings21 – 24 . pressure will create a hernia in an open 10-mm defect,
Straining for bowel movements, doing abdominal crunches combining the observational data with the surrogate model
(sitting up) and even climbing stairs can result in a sub- yields a prediction that hernia-onset pressure lies between
stantial increase in IAP, up to 11 kPa16 , which is much 2⋅1 and 5 kPa. Considering the IAPs recorded by Cobb
higher than the pressures in the observational study. The and co-workers16 , the risk activities for developing a hernia

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e138
in an unclosed 10-mm defect therefore include bending
at the waist and sitting up in bed, both of which are
frequently done by patients after surgery. The data pertain
to hernia formation for unclosed 10-mm defects and thus
incorporate a large factor of safety over a patient who has
undergone fascial closure. As a result, surgical closure of all
10-mm trocar defects should be recommended, given that
almost all patients will either bend at the waist or sit up in
bed, creating IAPs in the at-risk range.
The mesh overlap experiments generated predictions
on the relationship between mesh size and failure pres-
sure for various defect diameters. The current standard
of a 50-mm overlap6,8 – 11,25,26 is shown alongside the
Hollinsky model4 of a mesh three times the diameter of
the defect and the mathematical and experimental results
from the present study (Fig. S1, supporting information).
The experimental data here show the maximum mesh size
required in each case, with error bars indicating the range
(maximum–minimum) of mesh sizes that were successful
in preventing hernia formation.
There is good concordance between the complex math-
ematical model derived from first principles (Appendix S1,
supporting information) and the physical surrogate
abdomen model, providing mutual validation for both
approaches as both predictions were developed indepen-
dently. The empirical mathematical model (Equation 1
and Fig. S1, supporting information) was designed to fit
to the experimental data, but allowing for some safety as
well as simplicity when calculating the required mesh size.
Experimental data were not available to corroborate the
extrapolation of the empirical mathematical model, but,
given the linear relationship between pressure and area, it
is reasonable to assume that the relationship will hold for
large defect sizes. The resulting linear fit parameters are as
follows:
Mesh diameter (mm) = 2 × Defect diameter (mm)
+ 25 mm (3)
This is a simple calculation to perform in the operating
theatre and provides a mesh that is slightly bigger than
was required in the experimental study. It is suggested that
surgeons might use a mesh that is twice the diameter of
the defect plus an additional 25 mm, and tack it around its
circumference with tacks 10 mm apart.
The current practice of using a 50-mm overlap in all cases
leads to low recurrence rates6 – 11 , but it is based on empir-
ical evidence with no biomechanical basis. For very small
defects, it is clear that there is a large difference between
the mesh size required versus that used in current practice.
For defects greater than 75 mm, the empirical mathemat-
ical model suggests mesh sizes with overlaps larger than
© 2015 BJS Society Ltd
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M. Lyons, H. Mohan, D. C. Winter and C. K. Simms
50 mm. Current practice may be underestimating the mesh
size required for large hernias. Compared with the model
of Hollinsky and Hollinsky4 , who recommend using a mesh
three times the diameter of the defect, there is less overpre-
diction of the experimental results by the present empirical
mathematical model, particularly at large defect diameters.
Most rule-based methods are likely to suggest unrealis-
tically large mesh sizes for very large defects. Naturally,
homogeneous overlap around the defect would be required
for this ideal case to be realized. This may not always be
practical, particularly with non-circular defects where the
largest diameter of the defect should be used for the calcu-
lations, to minimize the chance of recurrence.
A weakness of the observational study is the small sam-
ple size, which limits the statistical power of the findings.
Other potential weaknesses are that the study did not exam-
ine tack spacing, or the value of other fixation solutions.
Furthermore, underlying structures including bone promi-
nences or tendons may affect fixation or overlap amount.
Acknowledgements
This work was funded by the Irish Research Council.
Disclosure: The authors declare no conflict of interest.
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Supporting information
Additional supporting information may be found in the online version of this article:
Appendix S1 Details of the mathematical model (Word document)
Fig. S1 Comparison of required mesh sizes as a function of defect diameter, including the simple and complex
mathematical models derived in this study, the Hollinsky model and current practice (Word document)
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