surgical meshes

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Surgical Meshes and their Fixation Dr. Shahzad Alam Shah FCPS Consultant Laparoscopic Surgeon Fatima Jinnah Medical College/SGRHL

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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.

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Page 1: Surgical Meshes

Surgical Meshes and their Fixation

Dr. Shahzad Alam ShahFCPS

Consultant Laparoscopic Surgeon

Fatima Jinnah Medical College/SGRHL

Page 2: Surgical Meshes

•“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

Page 3: Surgical Meshes

Massive Incisional Hernias

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 4: Surgical Meshes

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 5: Surgical Meshes

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

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Conventional Open Repair: The Herniorraphy

• Manual Repair• High Recurrence Rate

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 7: Surgical Meshes

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

Page 8: Surgical Meshes

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

Page 9: Surgical Meshes

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

Page 10: Surgical Meshes

Ventral Hernia: AnatomyMay-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 11: Surgical Meshes

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

Page 12: Surgical Meshes

“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

Page 13: Surgical Meshes

•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

Page 14: Surgical Meshes

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

Page 15: Surgical Meshes

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

Page 16: Surgical Meshes

Types of Meshes

• Polypropylene (Prolene)• Mersilene• Vypro• Ultrapro• Gore-Tex®• Teflon®• Some other polymer

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 17: Surgical Meshes

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

Page 18: Surgical Meshes

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

Page 19: Surgical Meshes

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

Page 20: Surgical Meshes

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

Page 21: Surgical Meshes

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

Page 22: Surgical Meshes

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

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Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Mesh Placement

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Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

May-2012

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Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

May-2012

Page 26: Surgical Meshes

Ventral hernia mesh positioning: Onlay

May-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Page 27: Surgical Meshes

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Ventral hernia mesh positioning: Inlay

May-2012

Page 28: Surgical Meshes

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Ventral hernia mesh positioning: Underlay

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Page 29: Surgical Meshes

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Ventral hernia mesh positioning: Intraperitoneal

May-2012

Page 30: Surgical Meshes

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Methods of Mesh Fixation

• Staples• Tacks• Glue• Anchor• Sutures

May-2012

Page 31: Surgical Meshes

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

Page 32: Surgical Meshes

• 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

Page 33: Surgical Meshes

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

Page 34: Surgical Meshes

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

Thanks:

May-2012