synthetic and biologic mesh for ventral hernia repair archana ramaswamy md

Synthetic and Biologic Mesh for Ventral Hernia Repair

Archana Ramaswamy MD

Mesh types

• Synthetic– Act as a barrier

• Biologic– Organic source – Resorb• act as scaffold to leave collagen behind

Mesh Types• Multiple types of

mesh

– Synthetic• Polypropylene• ePTFE• Polyester

– Biologic materials• Human Dermis• Porcine Dermis• Porcine small

intestine submucosa• Bovine

pericarduim

Potential disadvantages• Biologic– Initial Strength– Remodeled

tissue Strength

• Synthetic– Infection– Contraction– Foreign body

response• Pain• Inflammation

– Oxidation

Lightweight vs heavy weight mesh

• Lightweight– Large pores• >1mm

– > Elasticity• 20-35%

– < Foreign body reaction

• Heavyweight– Small pores• <1mm

– <Elasticity• 4-16%>

– > Foreign body reaction

Mesh Selection• Procedure performed– Ventral, Inguinal– Location of mesh• Intraperitoneal• Extraperitoneal

• Operative field– Contamination, infection

• Comfort with product

Synthetic Mesh For Inguinal Repair

• Open– Flat sheets– Plugs

• Laparoscopic– Flat sheets– Anatomic sheets• Bard 3-D max• Parietex anatomic

– Barrier mesh

Synthetic Mesh For Ventral Repair

• Open– Flat sheets• Prolene

• Laparoscopic– Solid Barrier mesh– Absorbable Barrier Mesh

Making a Mesh Choice• Mesh in contact with viscera should have a

barrier– Solid (PTFE)– Absorbable• sodium hyaluronate, carboxymethylcellulose, and

polyethylene glycol• Oxidized regenerated cellulose• Collagen• Omega-3 fatty acid

Materials• Polpropylene

• Heavyweight• Lightweight

• Polyester• Polytetrafluoroethylene

• Expanded• Condensed

“smooth” barrier to tissue

ingrowth

“rough”tissue fibroblast/

collagen ingrowth

Composite Mesh

• Designed for intraabdominal placement– Abdominal wall side: Promote ingrowth– Visceral side: Prevent ingrowth

Composite Mesh

- Composix: Polypropylene + PTFE- Proceed: Lightweight PP + Interceed (oxidized regenerated cellulose)- Parietex Composite: Polyester + Collagen- Sepramesh: Polypropylene + Seprafilm–C-Qur: Lightweight PP + Omega 3 fatty acid coating

Mesh for Intraabdominal use

• Solid Barrier – Entirely ePTFE or composite

• Macroporous mesh???

Resorbable Barrier• Hydrogel forms on intraperitoneal surface from

exposure to peritoneal fluid– barrier between mesh and viscera

Sepramesh™ (Genzyme, Corporation, Cambridge, MA)

• mesh co-knitted polypropylene and polyglycolic acid fibers

• polyethylene glycol / sodium hyaluronate / carboxymethylcellulose coating on polyglycolic side (visceral)

PROCEED™ (Ethicon, Inc., Somerville, NJ)

• trilaminate mesh construct • polydioxanone (PDS) polymer film

encapsulating a polypropylene mesh• oxidized regenerated cellulose coating -

visceral side

Parietex® Composite™ (Covidien, Norwalk CT )

• polyethylene terephtalate (polyester) mesh

• Absorbable Film (Visceral Surface)– Type I atelocollagen (60%)– glycerol (12%)

• hydrophilic lipid – osmotic

– polyethylene glycol (20%)• Hydrogel

– H20 (8%)

C-Qur™ Mesh (Atrium Medical Corporation, Hudson, NH)

• Lightweight polypropylene mesh (Prolite)• Bioabsorbable omega-3 fatty acid gel– Thermal crosslinking of fatty acids to mesh

Complications of Mesh

• Problems with mesh– Adhesions• Fistulas and erosions

– Contraction/Shrinkage– Lack of ingrowth– Pain– Infection– Rigidity/Poor Compliance

Biologic Materials• Based on acellular collagen

scaffolds• Natural collagenases break down

the implant, while new collagen is laid down by host fibroblasts

• Can be used in infected surgical field

• Questionable loss of strength (early and ?late)

Biologic Materials

• Materials classified by donor organism and site– Human dermis– Porcine dermis– Porcine small intestine submucosa– Bovine pericardium– Fetal bovine dermis

Biologic Biomaterials•Products: - Surgisis (Cook): Pig small bowel submucosa - Permachol (TSL): Pig skin–Collamend (Bard/Davol): Pig skin–XenMatriX (Brennan): Pig skin

- Alloderm (Lifecell): Cadaver skin–FlexHD (MTF): Cadaver skin–Allomax (Bard/Davol): Cadaver skin–SurgiMend (TEI): Fetal bovine Skin–Tutopatch (Tutogen): Bovine Pericardium

Porcine Dermis

• Permacol (TSL)– Heavily crosslinked

• Collamend (Bard/Davol)– crosslinked

• XenMatriX (Brennan Medical)– Non-crosslinked

• Strattice (Lifecell)– Non-crosslinked

Porcine SIS

• Surgisis (Cook): Pig small bowel submucosa– Non-crosslinked– Resorbed by 12 weeks

Bovine Products

• SurgiMend (TEI): Fetal bovine Skin– Non-crosslinked

• Tutopatch (Tutogen): Bovine Pericardium– Non-crosslinked

• Veritas (Synovis): Bovine Pericardium– Non-crosslinked

SurgiMend

Human Dermis• Alloderm (Lifecell)– Freeze-dried, non-crosslinked

• Allomax (Bard/Davol)– Processed for Bard by Tutogen– Dehydrated, non-crosslinked

• FlexHD (MTF)– Now licensed by Ethicon– Hydrated, non-crosslinked

Biologic Materials for hernia repairUnknowns

• Early strength• Late strength• Individual response• What happens to tissue and when• Lack of long term data