title: First in-human magnetic resonance visualization of surgical mesh implants for inguinal hernia treatment.
abstract: OBJECTIVE
  Until today, there have been no conventional imaging methods available to visualize surgical mesh implants and related complications. In a new approach, we incorporated iron particles into polymer-based implants and visualized them by magnetic resonance imaging (MRI).After clinical approval of such implants, the purposes of this study were to evaluate the MRI conspicuity of such iron-loaded mesh implants in patients treated for inguinal hernias and to assess the immediate postsurgical mesh configuration.
  
  
  METHODS
  Approved by the ethics committee, in this prospective cohort study, 13 patients (3 patients with bilateral hernia treatment) were surgically treated for inguinal hernia receiving iron-loaded mesh implants between March and October 2012. The implants were applied via laparoscopic technique (transabdominal preperitoneal technique; n = 8, 3 patients with bilateral hernia treatment) or via open surgical procedure (Lichtenstein surgery; n = 5). Magnetic resonance imaging was performed 1 day after the surgery at a 1.5-T scanner (Achieva; Philips, Best, The Netherlands) with a 16-channel receiver coil using 3 different gradient echo sequences (first gradient echo sequence, second gradient echo sequence, and third gradient echo sequence [GRE1-3]) and 1 T2-weighted turbo spin-echo sequence (T2wTSE). Three radiologists independently evaluated mesh conspicuity and diagnostic value with respect to different structures using a semiquantitative scoring system (1, insufficient; 2, sufficient; 3, good; 4, optimal). Mesh deformation and coverage of the hernia were visually assessed and rated using a 5-point semiquantitative scoring system. Statistical analysis was performed using mixed models and linear contrast.
  
  
  RESULTS
  All 16 implants were successfully visualized by MRI. On gradient echo sequences, the mesh is clearly delineated as a thick hypointense line. On T2wTSE, the mesh was depicted as a faint hypointense line, which was difficult to identify. The first gradient echo sequence was rated best for visual conspicuity (mean [SD], 3.8 [0.4]). T2-weighted turbo spin-echo sequence was preferred for evaluation of the surrounding anatomy (mean [SD], 3.7 [0.3]). For the combined assessment of both mesh and anatomy, GRE3 was rated best (mean [SD], 2.9 [0.7]). Local air slightly reduced mesh delineation (lowest mean [SD] rating, 2.9 [0.7] for GRE3). Overall, in both implantation techniques, the meshes exhibited mild to moderate deformations (mean [SD], 3.3 [0.4], 3.1 [0.3], and 2.8 [0.3] on average with open technique, 2.7 [0.3], 2.7 [0.2], and 2.3 [0.3] with laparoscopic technique). Coverage of the hernia was achieved in 15 of the 16 implants.
  
  
  CONCLUSIONS
  Combining iron-loaded implants and MRI, we achieved mesh visualization for the first time in patients. For MRI protocol, we propose a combination of different gradient echo sequences and T2-weighted turbo spin-echo sequences: first gradient echo sequence for mesh configuration, T2wTSE for anatomy assessment, and GRE3 for evaluation of hernia coverage and mesh localization. Using our approach, MRI could become a noninvasive alternative to open surgical exploration if mesh-related complications were suspected.
authors.affiliation: From the Departments of *Diagnostic and Interventional Radiology and †Surgery, and ‡Institute of Medical Statistics, RWTH Aachen University Hospital, Aachen, Germany.
authors.forename: Nienke Lynn
authors.initials: NL
authors.lastname: Hansen
authors.forename: Alexandra
authors.initials: A
authors.lastname: Barabasch
authors.forename: Martina
authors.initials: M
authors.lastname: Distelmaier
authors.forename: Alexander
authors.initials: A
authors.lastname: Ciritsis
authors.forename: Nicolas
authors.initials: N
authors.lastname: Kuehnert
authors.forename: Jens
authors.initials: J
authors.lastname: Otto
authors.forename: Joachim
authors.initials: J
authors.lastname: Conze
authors.forename: Uwe
authors.initials: U
authors.lastname: Klinge
authors.forename: Ralf-Dieter
authors.initials: RD
authors.lastname: Hilgers
authors.forename: Christiane K
authors.initials: CK
authors.lastname: Kuhl
authors.forename: Nils Andreas
authors.initials: NA
authors.lastname: Kraemer
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007501:Iron; D010535:Laparoscopy; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011108:Polymers; D011183:Postoperative Complications / Q000175:diagnosis*; D011446:Prospective Studies; D013526:Surgical Mesh; D016896:Treatment Outcome
chemical_list: D011108:Polymers; D007501:Iron