synthetic and biologic mesh for ventral hernia repair archana ramaswamy md
TRANSCRIPT
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