ABDOMINAL WALL HERNIAPROSTHETIC MATERIALS AND FIXATION DEVICES

CHOICE & CHALLENGES

Dr.S.EaswaramoorthyMS, FRCS(Edin) ,FRCS (Eng) ,FRCS (Glas), FAES,

FIAGES, FMASConsultant Surgeon, Lotus Hospital, Erode

EC member, IAGES (South Zone) Treasurer ASI TN & P Chapter

ICS Hernia Meet Chennai 2015

Billroth’s Vision

‘‘If we could artificially produce tissues of the density and toughness of fascia and tendon the secret of the radical cure of hernia wouldbe discovered’’.

- Beitrage zur Chirurgie (1878)

ConceiveBelieve &Achieve

Inventor of Prosthetic Mesh repair: Dr. Francis Usher (1908-1980)

• Inventor of Polyehylene(Marlex) and Polypropylene mesh• Several Animal studies about their inertness• 20 papers• Innovative ways of placing the meshes: Inlay, Overlay, Sandwich tech etc

ConceiveBelieve &Achieve

Lichtenstein’s Mesh Repair

Tension Free repair• Under LA• Day care• Low recurrence rate!

ConceiveBelieve &Achieve

Mesh is a must!

Why Mesh?

Low recurrence rate Tension free & Pain free Quick recovery Quick to learn and easy

to do!

History of Inguinal Hernia Repair

We are in Era of Tension Free Mesh Repair!

10% 1% 0.1%100%Recurrence rate

Bassini Shouldice LichtensteinAncient Era

Why Mesh?Pathogenesis of Hernia Defective Collagen

Reduced ratio of type I and type III collagen Type I: Mature Collagen, strong and normal tissue Type III: Immature Collagen, weak, in healing wounds Type I : Type III ratio normally is 4:1

?Genetic defect

Connective tissue pathology is not only a cause of primary herniation but its presence can prevent cure!

A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia?Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and Volker Schumpelick, BMC Med Genet. 2002; 3: 2.

Why Mesh? What type of Mesh? Where to place the Mesh? How to place the place?

Types of Mesh Synthetic Mesh

Non absorbable Polyprophylene(Prolene) Polyethylene(Marlex) Polyester(Dacron) PTFE (Teflon/Gordex)

Absorbable Vicryl

Combined Vypro, Ultrapro

Synthetic with Absorbable Barrier( Dual mesh) Parietex Proceed Etc

Biological Mesh Surgisis ( Porcine submucosa) Alloderm (Cadaveric human dermis)

What Type of Mesh?Light weight Vs Heavy weight?

Light weight Mesh

Heavy weight Mesh

Definition Thin fibres, macro pores (>1.5mm)

Thick fibres, micro pores (< 1.5mm)

Qualities FlexibleLess FB reaction and pain

StifferMore FB reaction and pain(Problem of adhesion, fistula)Shrinks moreStronger! - so what

Examples Ultrapro, Vipro Marlex, Dacron, PTEFThe lightweight and large porous mesh concept for hernia repair.Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.

3 D Mesh

Composite Mesh

Visceral side: averts adhesion of bowel

Parietex Mesh

Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience. 2001 Surg Laparoc Endosc Percutan Tech Apr;11(2):103-6

Proceed Mesh

Laparoscopic Ventral Hernia RepairChoice of Composite Mesh

Name Parietal side Visceral Side Longevity

Remarks By

Parietex Polyester Atelocollagen, PEG, Glycerol

20 days

expensive Covidien

Proceed Polypropylene

Oxidised (ORC) regenerated cellulose/PDS

30 days

Ethicon

Sepramesh

PP PGA/Hydrogel

30 days

Davol

C QUR PP Omega 3 FA AtriumPro VISC 160

Polyester Polyurethane Life Cost effective

Lotus

Dual Mesh e PTFE (rough)

e PTFE(smooth)

Life Gore

Kugel/Composix

PP(HW) e PTFE Life Can't trim Bard

Proceed Mesh (Ethicon)Time line

1 week

2 weeks

Day 1

3 months

Pro VISC 160

Polyester White Parietal side

Polyurethane Blue smooth visceral

side With Sutures Pre cut in various

sizes

Parietal side: ProleneVisceral side: e PTFE

Bard (Composix) Gore Dual Mesh

Parietal side: Rough PTFEVisceral side: smooth PTFE

Frequently Asked Questions! Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh?

Myopectineal Orifice of Fruchaud

15/10cm to 15/15cmSize do matter…

Where to place the Mesh?On Lay In Lay

Under Lay IPOM

Pascal’s Hydrostatic Principle

Onlay Vs Inlay

Effect of Intra abdominal Pressure

Choose a mesh at least 5cm larger than the defect all

round.

Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh?

Mesh Fixation Methods…AbsorbaTack (Covidien)

Permasorb (Davol / Bard )

Fibrin sealant

Spiral Tackers

Staples

Fibrin Glue

Suture

Ideal Fixation Method

No Type of Fixation

Features

1 Trans Fascial suture fixation

Chronic pain

2 Suturing 2cm apart3 Spiral

Titatinum Tackers

2cm apartDouble crown techniqueNerve entrapment, adhesion, rarely tacker hernia

4 Absorbable tackers

For initial 1 year

5 Fibrin Glue Suitable for inguinal hernia? Ventral Hernia: Alternative or Adjunct: needs trial.Closure of Hernia defect to avoid mesh protrusion or displacement

To withstand the intra abdominal tangential force and also shearing Force due to abdominal muscle contraction

Conclusion

Mesh repair is the Standard of Care. Use Composite mesh for ventral hernia Secure the mesh to prevent recurrence

Forthcoming Courses /Erode ASIContact Us: 9843328928/9790028328 3rd ASI Endoscopic course

On 5 days/all Sundays from 8am to 5pm 8th November 2015 : 1st session starting

FIAGES Laparoscopic Fellowship course Venue: Lotus hospital, at Erode 7th to 9th January 2016