Download - Prosthesis and fixation device
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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
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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
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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
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Lichtenstein’s Mesh Repair
Tension Free repair• Under LA• Day care• Low recurrence rate!
ConceiveBelieve &Achieve
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Mesh is a must!
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Why Mesh?
Low recurrence rate Tension free & Pain free Quick recovery Quick to learn and easy
to do!
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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
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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.
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Why Mesh? What type of Mesh? Where to place the Mesh? How to place the place?
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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)
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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.
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3 D Mesh
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Composite Mesh
Visceral side: averts adhesion of bowel
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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
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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
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Proceed Mesh (Ethicon)Time line
1 week
2 weeks
Day 1
3 months
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Pro VISC 160
Polyester White Parietal side
Polyurethane Blue smooth visceral
side With Sutures Pre cut in various
sizes
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Parietal side: ProleneVisceral side: e PTFE
Bard (Composix) Gore Dual Mesh
Parietal side: Rough PTFEVisceral side: smooth PTFE
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Frequently Asked Questions! Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh?
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Myopectineal Orifice of Fruchaud
15/10cm to 15/15cmSize do matter…
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Where to place the Mesh?On Lay In Lay
Under Lay IPOM
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Pascal’s Hydrostatic Principle
Onlay Vs Inlay
Effect of Intra abdominal Pressure
Choose a mesh at least 5cm larger than the defect all
round.
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Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh?
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Mesh Fixation Methods…AbsorbaTack (Covidien)
Permasorb (Davol / Bard )
Fibrin sealant
Spiral Tackers
Staples
Fibrin Glue
Suture
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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
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Conclusion
Mesh repair is the Standard of Care. Use Composite mesh for ventral hernia Secure the mesh to prevent recurrence
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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