surgical meshes
DESCRIPTION
The use of mesh for the repair of hernia is now considered as a modern method of treating hernias. Advancement in the development of quality and fixation of mesh is highlighted in this presentation.TRANSCRIPT
Surgical Meshes and their Fixation
Dr. Shahzad Alam ShahFCPS
Consultant Laparoscopic Surgeon
Fatima Jinnah Medical College/SGRHL
•“A surgeon can do more for the community by operating on hernia cases and seeing that his
recurrence rate is low than he can by operating on cases of malignant disease”
•.•Sir Cecil Wakely, 1948
•President•Royal College of Surgeons
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Massive Incisional Hernias
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Conventional Open Repair: The Herniorraphy
• Manual Repair• High Recurrence Rate
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Hernia: The Methods to Treat
• Conventional Open Repair: The Herniorraphy• Open Mesh Hernioplasty• Laparoscopic Mesh repair
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Factors influencing hernia occurrence
Endogen Exogene Others
• Age > 45 Sutures emergency• BMI > 25 length of incision intra abdominal • previous operation contamination pressure• anemia Medication• shock Type of incision• smoker• Corticoïds• Aneurysm/Marfan• (+30% risks)
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Abdominal Wall Elasticity
• After the Intra-abdominal pressure, another important
factor in the abdominal wall repair plays a role, it is the
Abdominal wall elasticity.
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ventral Hernia: AnatomyMay-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
In humans the intra-abdominal pressure ranges from 0,2kPa (resting) to 20 kPa (maximum).
Pressure
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
“If we could artificially produce tissues of
the density and toughness of fascia, the secret of the radical cure of hernia would
be discovered.”
Theodore Billroth, 1857
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
•Tensile strength•Pliability •Ease of manipulation•Durability•Degree of tissue in-growth•Infection rate•Inflammatory response / adhesion formation•Seroma formation•Cost
What should be an Ideal replacement of the Fascia?
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Which mesh to choose?
•Burst Strength•Compliance•Foreign Body Response•Degree of Shrinkage•Increased Pore Size
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Types of prosthetics for hernia repair:
•Type 1: totally macroporous prosthesis, pores > 75 microns; example prolene ,
•Type 2: totally microporous prosthesis; pores < 10 microns; example gortex or dual mesh
•Type 3: macroporous prosthesis with microporous components; example Teflon, mersilene
•Type 4:
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Types of Meshes
• Polypropylene (Prolene)• Mersilene• Vypro• Ultrapro• Gore-Tex®• Teflon®• Some other polymer
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Polypropylene Mesh
• Most Commonly used mesh
• Reports showed good initial healing but were fraught with long term complications
• Those complications are chronic infection, fistula formation, erosion into bowels or through skin grafts
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Polyglactene Mesh (vicryl mesh)
• Alternative to non-absorbable meshes
• Advantage host invasion and subsequent absorption of implant
• There is less infection complication, increase recurrence rate
• (satisfactory short term solution in infected hernias but not generally indicated when prolonged tensile strength is required)
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
ePTFE
• Micro porous, smooth texture minimizes tissue in-growth and limits adhesion formation and bowel injury
• Combined with a large pore second layer it can adhere well to the abdominal wall
• Disadvantages• Mesh infection is not well treated by antibiotics and requires
mesh removal
• Does not integrate well into host tissue when not combined with a large pore mesh
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ethicon Proceed
Multilayered tissue separating mesh comprised of: PROLENE* Soft polypropylene Mesh Designed for strength, durability, and
adaptability Oxidized regenerated cellulose (ORC)
fabric Creates a flexible, secure bond between
the mesh and ORC layers
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ethicon – Proceed Mesh
Lightweight Monofilament Construction Less foreign mass
Flexible scar tissue Strong tissue incorporation
Excellent Handling Lightweight, macro porous, monofilament mesh structure
Allows fluid flow-through Conforms to anatomy Readily customized
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
UltraPro Mesh
•Thin Filament Size•Large Pore Construction•Absorbable Components
•Strong, Secure repair•Clear Visualization of anatomy•Excellent Handling•65% foreing materials•Physiological compatible with abdominal wall
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Mesh Placement
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
May-2012
Ventral hernia mesh positioning: Onlay
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ventral hernia mesh positioning: Inlay
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ventral hernia mesh positioning: Underlay
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Ventral hernia mesh positioning: Intraperitoneal
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Methods of Mesh Fixation
• Staples• Tacks• Glue• Anchor• Sutures
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Potential Mesh-Related Complications:
• Infection
• Intestinal adhesions
• Bowel obstructions
• Erosion of the prosthesis into the adjacent hollow viscous
• Contraction of prosthesis
May-2012
• Tensile strength• Pliability • Ease of manipulation• Durability• Degree of tissue in-growth• Infection rate• Inflammatory response / adhesion formation• Seroma formation• Cost• .
Conclusion: are we there yet?
May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
The ideal mesh has yet to be developed and the management of complex ventral
hernias remains a challenge
May-2012
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan
Thanks:
May-2012