The concern about placing permanent mesh in a contaminated wound is understandable: infection may persist around the implant. Yet loss of mechanical support can leave the abdominal wall vulnerable to recurrence. Biologic scaffolds were introduced into this difficult setting, and their use grew after the Ventral Hernia Working Group (VHWG) related patient and wound characteristics to choices in reconstruction [1]. At that stage, comparative trials had not established the clinical benefit attributed to biologic mesh [2].

The PRICE trial and a separate multicenter trial in clean-contaminated and contaminated repairs subsequently reported fewer recurrences with permanent synthetic mesh than with the biologic comparator [3][4]. Follow-up of the latter trial, published in 2026, extended the observations on recurrence and late mesh complications [5]. These findings have a direct bearing on material choice for the operations studied. Their relevance to a different operation depends on its wound conditions and technique.

The term “contaminated hernia” alone gives too little information for that judgment. A surgeon planning reconstruction alongside controlled bowel surgery faces different conditions from one treating an emergency perforation. A previous wound infection adds another, distinct consideration. Physiological stability and the feasibility of repair are central to the 2026 European Hernia Society (EHS) emergency guidelines [6]. For absorbable implants, longer follow-up and recent comparative cohorts also allow a closer assessment of individual products than the broad label “biosynthetic mesh”.

We examine the choice among permanent synthetic mesh, principally polypropylene, biologic mesh, and absorbable biosynthetic mesh for adults with ventral or incisional hernias in Centers for Disease Control and Prevention (CDC) class II-IV fields. The main comparisons concern recurrence and infection or removal of the implant. We also consider wound complications, further surgery, patient-reported outcomes, and cost. For elective cases, the question is which material to use in planned single-stage reconstruction, particularly when the fascia can be closed and reinforced retromuscularly. Emergency evidence addresses a separate decision: whether mesh repair is appropriate after stabilization and source control, or whether definitive reconstruction should be postponed.

For this narrative review, we combined search terms for ventral or incisional hernia with contamination, biologic, synthetic, biosynthetic, absorbable, polypropylene, and poly-4-hydroxybutyrate. PubMed-indexed records, Europe PMC, publisher pages, and reference lists of key papers were examined, with targeted searches for recent studies through September 9, 2026. Priority was given to randomized comparisons, subsequent reports from those trials, comparative cohorts, prospective studies of absorbable meshes, and guidelines relevant to contaminated repair. Foundational publications were retained to explain earlier practice.

For each key study, interpretation considered the enrolled population, contamination definition, mesh material and plane, fascial closure, outcome ascertainment, and duration and completeness of follow-up. Clean-wound studies were used only to identify limits of extrapolation. Primary inguinal and hiatal hernia studies, prophylactic mesh placement without an existing ventral defect, and preclinical studies without a direct clinical contribution were outside the review’s scope. We did not attempt an exhaustive search, register a protocol, formally grade the risk of bias, or pool the results. When a trial produced several publications, we identified the later reports as follow-up or secondary analyses to avoid counting the trial more than once.

Permanent synthetic meshes vary in polymer, filament structure, pore size, and density. These characteristics are not interchangeable, and mesh weight alone is an incomplete description. Mechanical behavior also depends on the interaction between implant and abdominal wall, rather than tensile strength in isolation [11]. The strongest randomized evidence discussed below applies specifically to polypropylene and to the tested implantation technique. It does not establish equivalent performance for every permanent polymer or intraperitoneal composite.

Biologic meshes are tissue-derived extracellular matrix scaffolds. Processing, tissue source, and cross-linking alter their behavior. The prospect of tissue incorporation helped motivate their use. Whether that remodeling translates into fewer infections must be established clinically. Early critical appraisal found that recommendations favoring biologic mesh in contaminated fields relied predominantly on case reports and case series [2]. Their performance needs to be judged against a contemporary comparator and with adequate follow-up.

Biosynthetic absorbable meshes provide temporary reinforcement. The term covers different materials, including polyglycolic acid-trimethylene carbonate (PGA-TMC) and poly-4-hydroxybutyrate (P4HB), with different resorption profiles. PGA-TMC is generally absorbed within approximately 6 - 7 months, whereas P4HB resorption takes approximately 12 - 18 months [12][13]. Neither the absence of a permanent polymer nor the duration of resorption establishes that a product will resist infection or prevent late recurrence better than polypropylene.

The work required of a mesh depends on whether it reinforces a fascial closure or spans a defect that remains open. A multicenter comparison and meta-analysis by Holihan and colleagues associated primary fascial closure with fewer recurrences than bridging, while acknowledging substantial heterogeneity and limitations in the underlying studies [14]. Comparisons between mesh products therefore need to record whether the fascia was closed.

The RICH study established that single-stage reconstruction using non-cross-linked porcine dermis was feasible in selected contaminated cases. Among 80 patients, 28% developed recurrence and 66% experienced at least one wound event by two years, although no matrix required complete excision. Sixteen defects were bridged, and only two patients had CDC class IV wounds [23]. These details matter: graft retention is a different outcome from durable repair, and the cohort provides little direct evidence for heavily infected class IV defects.

The randomized comparisons carry more weight in routine material selection than this uncontrolled experience. Contamination alone is not a supported indication for choosing the biologic products evaluated in those trials [3][4]. Conversely, unfavorable findings for a particular porcine dermal matrix cannot prove that every biologic product behaves identically. Current comparisons have not identified a benefit that would justify routine use. When a biologic implant is considered for an exceptional case, including salvage, the reason should be explicit and weighed against recurrence risk and cost.

The preference for polypropylene in elective reconstruction rests mainly on the randomized comparisons with the biologic products tested [3][4]. The completeness of follow-up needs careful reading. Rosen and colleagues reported two-year follow-up for 233 of 241 surviving participants (97%). The later report assessed 203 of the original 253 randomized patients (80.2%) [4][5]. One percentage uses survivors as its denominator and the other uses everyone randomized, so the figures cannot be compared directly as retention rates. Missing outcomes may change the estimated recurrence rate and matter particularly when few late infections occur. Confidence is consequently greater in the recurrence benefit within this elective setting than in estimates of rare late harms.

In observational studies, surgeons choose the material with knowledge of the contamination, previous failures, and planned operation. Those same factors, along with surgeon expertise, may affect the result. Propensity matching can balance measured characteristics but leaves unmeasured selection factors unresolved [19]-[22]. Cohorts without a comparator show what was achievable with a biologic or biosynthetic implant in selected patients. Attrition and differences in the device or fascial closure further restrict comparisons across these studies [12][13][23][24][28]. They support consideration of alternatives in selected cases, while leaving comparative superiority or equivalence to polypropylene unproven. Emergency recommendations are conditional because their supporting evidence has low or very low certainty [6]. This appraisal is qualitative; we did not conduct a formal risk-of-bias assessment or apply GRADE.

Here, adequate source control means treating the anatomical focus that sustains infection. Depending on the findings, this may require draining a collection, debriding infected nonviable tissue, or stopping an enteric leak. Giving antibiotics alone does not establish that the source has been controlled. This operational interpretation follows sepsis guidance and the EHS requirement for source control before emergency mesh repair [6][29].

Uncontrolled sepsis is used here to describe unresolved infection accompanied by persistent or worsening organ dysfunction or hemodynamic instability despite initial treatment. It is a clinical boundary for applying elective reconstruction evidence, not a separate diagnostic category or a single laboratory cutoff. Resuscitation and infection management take priority in these patients, particularly in septic shock [6][10][29].

Feasible fascial closure means that the native fascial edges can be approximated without bridging, excessive tension, or physiological compromise [6][10]. The emergency EHS pathway requires direct closure without a myofascial release [6]. In elective specialist reconstruction, a planned release can still produce the fascial closure used in the randomized trial [4]. Preoperative CT helps anticipate the need for advanced closure techniques, but does not provide a universal threshold for safe closure [9].

The elective use best supported by direct comparison is retromuscular reinforcement with macroporous polypropylene in a class II-III field, once the infectious source is controlled and fascial closure is feasible [4]. Technical planning should establish how the defect will be closed and how the mesh will be separated from the viscera. A different closure or mesh position changes how closely the repair resembles the trial operation and therefore how confidently its results can guide the decision.

For emergency repair, the 2026 EHS recommendation is conditional: mesh may be used in a patient who is stable, has adequate source control, and has a wound of CDC class II or higher that permits direct closure. For mesh repair, the guidelines favor permanent macroporous synthetic mesh. However, they suggest onlay placement for open emergency repair and defer definitive reconstruction when direct closure is not feasible; certainty is low or very low for these recommendations [6]. This differs from specialist elective reconstruction in both patient selection and technical priorities. The guideline could not provide separate estimates for class II-III versus class IV wounds, so its broad recommendation does not eliminate uncertainty in dirty cases.

Class IV wounds should therefore prompt a decision about source control and reconstructive timing, rather than an automatic switch to a biologic or biosynthetic implant. In a prospective nonrandomized study, Birolini and colleagues reported feasible single-stage onlay polypropylene repair in 40 selected dirty-infected cases compared with 40 clean controls [30]. That experience suggests that infection is not an absolute barrier in every carefully selected reconstruction, but it does not justify definitive mesh repair during uncontrolled sepsis.

Management after removal of an infected mesh is another distinct problem. A 2025 two-center series used P4HB after explantation in 29 patients and reported substantial early morbidity, a short mean follow-up of 17 months, and one subsequent mesh explantation [31]. This experience is relevant to specialist salvage decisions, although it cannot determine which replacement material is best across such cases. Temporary closure or staged reconstruction remains relevant when patient physiology, tissue viability, or ongoing contamination prevents a durable immediate repair. Table 2 summarizes the questions that should be resolved before choosing an implant; it is a clinical synthesis, not a validated decision rule.

Table 2. Clinical questions that determine the relevance of mesh evidence.

This table is an interpretive clinical synthesis, not a validated treatment algorithm. Wound class, physiological stability, defect closure, operative plane, and the specific device all affect applicability. Elective trial results should not be transferred uncritically to emergency surgery.

Enteric fistula, anastomotic leak, planned stoma surgery, and active mesh infection should not be treated as interchangeable forms of contamination. The elective class II-III trial included selected fistula repairs and stoma creation or reversal; their presence alone does not exclude applicability, although these small subgroups cannot establish separate material effects [4]. A persistent fistula or anastomotic leak with ongoing contamination requires source control before the elective evidence can guide reconstruction [18][29]. Planned stoma surgery should be classified by the actual operative contamination, rather than assumed to be a dirty wound [7]. Active mesh infection differs from a history of infection and requires a separate assessment of explantation, residual contamination, and timing; salvage series do not establish the best replacement material [31].

A repair may remain intact while leaving a patient with pain, impaired abdominal wall function, or the burden of further procedures. These outcomes deserve attention alongside recurrence and mesh removal. The quality-of-life analysis of PRICE found no significant between-group differences using mixed models, including in analyses by contamination. Some analyses of change in the Short Form 36 favored synthetic mesh, and overall costs were higher with biologic mesh [32]. Across these measures, patients did not report a consistent advantage from the biologic material.

An ACHQC study examined patient-reported outcomes after elective contaminated reconstruction. After propensity matching, changes in pain and quality-of-life scores did not differ significantly among nonabsorbable mesh, absorbable synthetic mesh, and biologic mesh at the follow-up intervals reported [33]. The matched groups were small and longer-term observation was incomplete, so modest differences may remain uncertain. Taken with the recurrence findings from randomized trials, these results offer no established patient-reported benefit that would routinely favor biologic mesh.

Patients should be asked which outcomes matter to them and how they view a permanent implant. A 2025 study using a video decision aid and probability trade-off questions in 100 patients found that most prioritized recurrence risk over mesh category [34]. Because the study included hernias beyond contaminated cases, its findings should guide the discussion rather than determine an individual choice. Recurrence and further surgery can be discussed in concrete terms alongside the permanence or eventual absorption of the implant.

In the principal randomized trial, the median prosthetic cost was US$105 for synthetic mesh and US$21,539 for biologic mesh. Direct hospital expenditure over 30 days was also lower in the synthetic arm [4]. These are study-specific US costs, not current prices applicable to every hospital. A separate cost-utility model favored synthetic mesh for elective retromuscular repair, while showing that different assumptions about late complications could change the preferred strategy [35]. An earlier analysis confined to clean-contaminated repair reached a similar economic conclusion [36]. The value of these models depends on the clinical estimates entered into them, which makes observed long-term outcomes essential. A more costly scaffold needs to offer additional patient benefit if it is to replace polypropylene in routine practice.

Much of the uncertainty arises when results from a narrowly selected population are applied to the wider range of cases described as contaminated hernias. Elective specialist reconstruction, emergency bowel surgery, previously infected wounds, and active mesh infection should not be pooled conceptually as a single indication. Technical differences further complicate interpretation, particularly when bridging, fascial closure, or mesh plane varies between treatment groups.

How and when recurrence is sought affects the result. Examination, imaging, patient reports, and records of reoperation will not identify exactly the same recurrences. Attrition can obscure both late recurrence and uncommon infection, especially in registries. Future comparative studies should report denominators at each interval and distinguish asymptomatic imaging findings from symptomatic recurrence and repeat repair. Reports from the same trial should remain identifiable to avoid counting the same participants repeatedly.

A useful next comparison would test a specified biosynthetic device against contemporary polypropylene in patients with a clearly defined degree of contamination, using a consistent technique and follow-up that continues after resorption. Dirty wounds and infected-mesh replacement require separate evaluation. Patient-reported outcomes and the total burden of subsequent procedures should accompany recurrence and mesh retention. Our own review selected studies narratively and did not formally grade their risk of bias. The resulting clinical interpretation retains those limitations.

For elective single-stage reconstruction of class II-III ventral hernias, permanent macroporous polypropylene is the best-supported choice when the fascia can be closed and reinforced in the retromuscular plane. Its recurrence advantage over the biologic comparator persisted at longer follow-up, without a detected increase in late mesh infection or excision. Absorbable biosynthetic devices remain an option, but a consistent benefit over polypropylene in contaminated wounds has yet to be demonstrated. Emergency presentations and active infection require their own assessment of source control, closure, and timing. Material selection should follow that assessment and remain within the limits of the populations and operations studied.

This work received no specific funding.

The first author drafted the manuscript. The corresponding author conceived the review.

This narrative review was not prospectively registered.