Comparative outcomes of bioabsorbable poly-4-hydroxybutyrate versus synthetic mesh in ventral hernia repair: A propensity-matched cohort study

Abstract Purpose Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh offers a bioabsorbable alternative to permanent synthetic mesh in ventral hernia repair, but comparative outcome data are limited by selection bias, as P4HB is preferentially used in complex and contaminated cases. Methods We performed a retrospective cohort study of adults undergoing ventral hernia repair with P4HB, biologic, or permanent synthetic mesh at a single tertiary center from January 2014 to January 2025. The primary outcome was hernia recurrence. Secondary outcomes included 30-day postoperative complications, mesh infection, and time to recurrence. Of 506 patients, 32 with non-ventral hernias and 71 with missing mesh type data were excluded, leaving 403 ventral hernia repairs for analysis (45 P4HB, 22 biologic, and 336 permanent synthetic). Patients receiving P4HB were matched 1:1 to patients receiving permanent synthetic mesh using propensity scores derived from age, sex, body mass index, diabetes, CDC wound class, Ventral Hernia Working Group grade, and hernia size. Results In the unmatched cohort, P4HB patients had larger hernia defects, higher VHWG grades, more contaminated CDC wound classes, and longer operative times than patients receiving permanent synthetic mesh. Mesh infection and hernia recurrence were low and did not differ significantly between groups, but P4HB patients had higher rates of 30-day reoperation, ileus, and small bowel obstruction. After propensity score matching (25 P4HB vs 25 permanent synthetic), operative time was similar between groups. Hernia recurrence remained uncommon and was not significantly different (4.0% vs 8.0%, p =0.55), and mesh infection rates were also low (0% vs 8.0%, p =0.15). P4HB was associated with lower 30-day surgical site infection (0% vs 16.7%, p =0.04) and surgical site occurrence (4.2% vs 33.3%, p =0.01), while other 30-day outcomes were not significantly different. Conclusions In this retrospective, single-center propensity-matched cohort, long-acting resorbable poly-4-hydroxybutyrate mesh demonstrates comparable recurrence and mesh infection rates with lower short-term wound morbidity after balancing key risk factors, suggesting bioabsorbable mesh to be a reasonable alternative to synthetic mesh in selected complex or contaminated ventral hernia repairs. However, the modest matched sample size, exclusions due to missing data, and follow-up shorter than the expected P4HB resorption period warrant cautious interpretation and emphasize the need for larger studies with longer-term follow-up.