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Materials for abdominal wall reconstruction:
from chemistry to biology
Domenico D’UGOFull Professor of Surgery
Catholic University - Rome
History of Prosthetic Hernia Repair
Direct Direct approximationapproximation
Prostethic repair
Autogenous Graft
Fascia Lata
Metals
Stainless steel
Silver
Tantalum
1910 1930
Mesh
Syntethic
filaments of
carbon polymer
late 50’s
PROSTHETIC
TENSION-FREE REPAIR
Sutured tissue strength
late 70’s 2000’sOverwhelming evidence of mesh superiority1900
Mesh concept
Monofilamented Polypropylene
(heavyweight)
Marlex ®
Monofilamented Polypropylene
(midweight)
Prolene Soft ® Parietene ®
Polysoft ® Evolution ®
Polypropylene + Poliglecaprone or Polilactic acid
(lightweight / partially absorbable)
Ultrapro ®
Evolution of prosthetic materials
Inertness
Permanence
Rapid fibrinous fixation
Ideal prosthesisIdeal prosthesis Amid, 1995Amid, 1995
Host tissue incorporation
1.
2.
3.
4.
Foreign body reaction
Fibroblast ingrowth
Heavyweight Marlex ® 90 - 95 0.6 - 0.9
Texture Type Examples Weight(g/m2)
Pore size (mm)
MidweightProlene Soft ®
Parietene ® Polysoft ® Evolution ®
45 - 75 1.5 - 3.0
Lightweightpartially absorbable
Ultrapro ® 28 - 40 2.0 - 4.0
Evolution of prosthetic materials
Cobb WS et al. J Surg Res, 2006
Physical features A new concept of “host reaction”
Cobb WS et al. J Surg Res, 2006
Physical features A new concept of “host reaction”
HeavyweightMidweightLightweight Native fascia
Cobb WS et al., 2006
Physical featuresPhysical features
Burst loadBurst load
Ideal Ideal syntheticsynthetic mesh: Has it arrived? mesh: Has it arrived?
No contraction
Durable tensile strength
Hypoallergenic
Resistance to infection
1.
2.
3.
4.
Effective tissue ingrowth (without excessive inflammation or foreign body reaction)
5.
6. Cost effectiveness
Novitsky YW, SAGES 2008
Biocompatibility
Proceed ®
New solutions for biocompatibilityNew solutions for biocompatibility Prolene Soft + PDS + Oxidized Regenerated CelluloseProlene Soft + PDS + Oxidized Regenerated Cellulose
Double layer biocompatible meshesDouble layer biocompatible meshes
Many products, many manufacturersMany products, many manufacturers
Mesh Manufacturer Permanent Barrier
Parietex CompositeTM Covidien Polyester Atelocollagen Type 1, polyethylene
glycol, glycerol
C-QurTM Atrium PP Omega-3 fatty acid
PROCEEDTM Ethicon PP Oxygenated regenerated cellulose +
polydioxanone (PDS)
SeprameshTM Davol PP Seprafilm
DualmeshTM Gore PTFE -
Surgimesh WNTM Aspide PP Silicone
New solutions for biocompatibilityNew solutions for biocompatibility
Polytetrafluoroethylene (PTFE)Polytetrafluoroethylene (PTFE)
Gore Infinit Mesh ®
reconstructiondegradation
STRE
NG
TH
TIME
Bio-ImplantNative Fascia Burst Strenght
Ideal prosthesisIdeal prosthesis
Next level biomaterialsNext level biomaterials
Ideal prosthesisIdeal prosthesis
Next level biomaterialsNext level biomaterials
2000’s1980
138 PubMed items(1980-2000)
272 PubMed items(2000-2008)
History of Biomaterials
Gaertner B et al, J Gastrointest Surg 2007
Why use Biomaterials ?
“Ideal” for a contaminated field (infection “tolerant”)
Vascular ingrowth allows for clearance of bacteria
…for who ?
Infected/exposed mesh
Complex recurrence
Gaertner B et al, J Gastrointest Surg 2007
BiomaterialsBiomaterials Physical features
Biomaterials PTFE Polypropylene
B = Biomaterials P = PTFE F = Fascia
B-F P-F B-B F-F
BiomaterialsBiomaterials
Many products, many manufacturersMany products, many manufacturers
Biomesh Type Products, Manufacturers
Human acellular dermis AlloDerm®, LifeCell
Flex HDTM, J&J
AlloMaxTM, Davol
Xenogenic acellular dermis PermacolTM (porcine), Tissue Science Laboratories
SurgiMendTM (bovine,calf), TEI Biosciences
CollaMendTM (porcine), Davol
XenMatriX® (porcine), Brennen Medical LLC; Brennenmed.com
StratticeTM, LifeCell
Porcine small intestine submucosa Surgisis®, Cook Medical
FortaGen®, Organogenesis
Bovine pericardium Peri-Guard® and Veritas®, Synovis Surgical Innovations
Alloderm ®
BiomaterialsBiomaterials
Human Cadaver-DerivedHuman Cadaver-Derived
Più pubblicato, più costoso, di più piccole dimensioni
Veritas ®
BiomaterialsBiomaterials
Bovine-DerivedBovine-Derived
Permacol ®
BiomaterialsBiomaterials
Porcine-DerivedPorcine-Derived
Surgisis ®
LiteratureLiterature
Minimal long-term follow-up
True prospective data are scarce
No published clinical data for many of the biologics on the market
Nanotechnology
Future perspectivesFuture perspectives
Tissue EngineeringTissue Engineering
Cell adhesion on biomimetic scaffold“Evolution offer
maximum mechanical integrity and stability
and mimes the mechanical features
of the abdominal wall”
Ciardelli G, 2008Dpt. of Mechanics - Industrial Bioengineering
Polytechnic University of Turin
Inert, Inactive, Permanent Materials
Viable, Cellular, Differentiable Materials
Whole Organ Regenerates
Bioactive, Conductive, Remodelable Materials
Biocomplexity
Biocomplexity
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