About implants in hernia surgery - VZA - dr.T... · 11-5-2011 1 About implants in hernia surgery Dr. Tim Tollens Imelda Hospital Belgium

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About implants in hernia surgeryAbout implants in hernia surgeryDr. Tim TollensDr. Tim Tollens

Imelda Hospital BelgiumImelda Hospital Belgium

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Aim

No : – recurrence

– pain

– infection

– adhesions

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Waarom laparoscopisch benaderen ?

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25-10-2007

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11-12-2007

Can laparoscopy fail ?

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Laparoscopic Ventral Hernia RepairLaparoscopic Ventral Hernia RepairAdhesiolysis Adhesiolysis

• DON’T EVEN THINK ABOUT IT

LVHR TechniqueLVHR Technique

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Do I really want this job?

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When to give up?When to give up?Pride goes before the fallPride goes before the fall

The Answer changes over time with experience

Medievel times describe barbaric amputationsMedievel times describe barbaric amputations

Egyptians (Ebers Papyrus-3000-2500 B.C.)and

Greeksdescribed inguinal hernias

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Suture repairs 1870 - 1980

1. Marcy ( 1871 )y ( )2. Bassini ( 1884 )3. Halsted ( 1889 )4. Ferguson5. Darn

High recurrency ratesHigh recurrency rates

5. Darn6. McVay7. Shouldice ( 1953 )

Mc Vay

Henry O. Marcy Repair 1871Suture sling of the internal ring

1. Technique• High ligation of the sac• Closure of the internal inguinal ring

2. Indication:• Enlarged internal inguinal ring

• Children• Young adults

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Eduardo Bassini 1884

Registry of 206 ptsRegistry of 206 pts Reconstruction of the inguinal floor Reconstruction of the inguinal floor -- 18841884

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Bassini ( 1844 – 1924 )

Three layer technique with high ligation of the sacThree layer technique with high ligation of the sacwhere muscles in the inguinal canal were stitched togetherwhere muscles in the inguinal canal were stitched togetherin order to build a screen thaty could withstand the intrain order to build a screen thaty could withstand the intra--abdominal pressureabdominal pressure

11ee Layer : Transversalis fasciaLayer : Transversalis fascia22ee Layer : Transverse abdominal muscleLayer : Transverse abdominal muscle33ee Layer : Internal oblique muscleLayer : Internal oblique muscle

Earle Shouldice 1940

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Shouldice 1953

1. Technique :2 continuing sutures4 suture layers

2. Aim : equal partitioning of tensiontension

3. Disadvantage :6 weeks inactivity

Shouldice repairIncision of the transversalis fasciaIncision of the transversalis fascia Starting mediallyStarting medially

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Shouldice repair1st running suture

Shouldice repair2nd running suture + closure of the External oblique2nd running suture + closure of the External oblique

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Sutured – Tension repairs• Too much postoperative pain

6 k lifti t i ti• 6 weeks lifting restrictions

• Unacceptably high recurrence rates – 30%

• We tend to blame the patient : “lifted too soon”“didn’t have good tissue”

• We seldom accept that it was a bad operation or that we made a technical error

It’s the patient’s fault !

History of Prosthetic Use

1894 - Silver Coils - Ag, 47g,

• Introduced for inguinal herniorrhaphy • Laced between fascial layers • Slowly oxidizedSlowly oxidized• Disorganized fibrous reaction

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1903 Silver Filigree (mesh)

History of Prosthetic UseHistory of Prosthetic Use

1903 - Silver Filigree (mesh) • Lace-like, intertwined wire

PROBLEMS• Post-operative painos ope a e pa• Not flexible - metal fatigue• Infection & sinus tract formation

1940 - Tantalum - Ta, 73


,

• Fine wire woven into mesh• Very resistant, non-corrosive• Inguinal & ventral herniorrhaphyInguinal & ventral herniorrhaphy• Long-term fragmentation• Erosion problems similar to

silver prosthesis

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1952 - Stainless Steel


• Alloy of Fe, C, Mn, Si, Cr• Hurricane fence design• Non-reactiveNon reactive• Tolerant of infection

Metal Prosthetics Summary

• Not flexible - fragmentation • Erosion - sinus tract formation• Dense adhesions• Chronic painp• Removal difficult when infection occurs

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Modern Prosthetics1948 – Nylony

• Varying strand diameter and weave tightness

• Tissue in-growth

PROBLEMS• Not strong, not tolerant of infection • Deteriorates over time

1956 – Polyester

Modern Prosthetics

y

• Polymer of ethylene glycol &terephthalic acid

• Strong, pliable, durable Strong, pliable, durable • Tolerated well, even with infection• Initially popular - use decreased

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1957 – Polypropylene

Modern Prosthetics

yp py

• Relatively inert. Less foreign bodyreaction than polyester

• Tolerated well – even with infectionTolerated well even with infection• Easy to use• No fragmentation

Dr. Francis Usher

Polypropylene

1958 : Woven

1962 : Knitted

Usher et al. Am Surg 24:969, 1958Usher et al. Am Surg 24:969, 1958

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Irving Lichtenstein 1970

“For many years when mesh screens became popular,“For many years when mesh screens became popular,I yearned to attempt a tensionI yearned to attempt a tension--free repair for primary inguinal free repair for primary inguinal hernia. I was encouraged to do so by hernia. I was encouraged to do so by Dr. Richard NewmanDr. Richard Newmanof Rawhay N J who in 1956 had utilized a technique almostof Rawhay N J who in 1956 had utilized a technique almostof Rawhay, N.J. who in 1956 had utilized a technique almost of Rawhay, N.J. who in 1956 had utilized a technique almost exactly as I had envisioned it, in 350 cases with a personal exactly as I had envisioned it, in 350 cases with a personal followfollow--up. His recurrence rate was “approximately one per cent.”up. His recurrence rate was “approximately one per cent.”

Irving L. Lichtenstein Irving L. Lichtenstein Hernia Repair Without DisabilityHernia Repair Without Disability, 2, 2ndnd ed. 1987.ed. 1987.

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Lichtenstein repair

– Tensionfree repair

– Introduced in 1986

– Polypropylene

Onlay– Onlay

– Became the new standard of hernia repair

– Multiple variations since 90’s Lichtenstein IL. Am J Surg. 1987;153:553-559.Lichtenstein et al. Am J Surg. 1989;157:188-193.Lichtenstein IL. Am J Surg. 1987;153:553-559.Lichtenstein et al. Am J Surg. 1989;157:188-193.

Why Lichtenstein can fail ?

– Anterior tension-free repairsi f th di l t i l &reinforce the medial triangle &

to varying degrees, parts of the lateral triangle

– Incomplete reinforcement of the MPO

Gilbert et al. Hernia 2000;4:234-237.

– Vulnerable femoral and lateral triangles

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Why Lichtenstein can fail ?

– Following anterior mesh repairs, failures are becoming more common in the lateral triangle

– Interstitial hernias

Gilbert et al. Hernia 2000;4:234-237.

Use of a mesh in an ANTERIOR approachUse of a mesh in an ANTERIOR approach

Lichtenstein 1970Lichtenstein 1970

Biomechanically better to insure reinforcement Biomechanically better to insure reinforcement deep to the defect,deep to the defect,

between peritoneum and muscle,between peritoneum and muscle,i.e. between the defect and the pushing forcei.e. between the defect and the pushing force

POSTERIOR approachPOSTERIOR approachExtensive dissectionExtensive dissection

Created painCreated pain

Rives 1965Rives 1965

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Reduced the dissection in the posterior approach,Reduced the dissection in the posterior approach,but still extensivebut still extensive

Stoppa 1968Stoppa 1968

but still extensivebut still extensive

GOLDEN PRINCIPLEGOLDEN PRINCIPLEMINIMAL INVASIVE POSTERIOR APPROACHMINIMAL INVASIVE POSTERIOR APPROACH

Reduction of unnecessary tissue damageReduction of unnecessary tissue damage

1985 Laparoscopic approach1985 Laparoscopic approach

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Laparoscopy

• TAPP : TransAbdominal PrePeritoneal

• TEP : Totally ExtraPeritoneal

Hypogastric NerveTransversalis Fascia

Inguinal Ligament

External Oblique

Cooper’s Ligament

Ilioinguinal Nerve

External Ring

Iliopubic Tract

Cooper s Ligament

Lacunar Ligament

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The anatomyThe anatomyof the inguinal region

is misunderstoodby surgeons of all levels of seniority

Robert E. Condon, MD

Lateral triangleMedial triangle

Hesselbach’s triangle

Myopectineal orificeMyopectineal orifice

Femoral triangle

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Importance of not only treating the current defect,but also prevent the future defects

Champions of the Preperitoneal Repair

Henri Fruchaud Lloyd Nyhus Robert E. Condon

Rene E. Stoppa George Wantz Arthur I. Gilbert

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A t f Li ht i ht M hA t f Li ht i ht M hArguments for Lightweight Meshes Arguments for Lightweight Meshes in Hernia Surgeryin Hernia Surgery

Dr. Tim TollensDr. Tim TollensImelda Hospital BelgiumImelda Hospital Belgium

Suture repairSuture repairsimple fascial closuresimple fascial closure ~ 50%~ 50%

HistoryHistory Rec. rateRec. rate

Keel repairKeel repairMayo technique….Mayo technique….

Mesh repairMesh repairOpen mesh repairOpen mesh repair

Laparoscopic mesh repairLaparoscopic mesh repair< 10 %< 10 %

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Lightweight meshesLightweight meshes

HistoryHistory19581958

Description for Description for hernia repairhernia repair

20092009>100 different mesh modifications>100 different mesh modifications

> 1 million mesh implantations> 1 million mesh implantations“Gold standard” for the treatment of “Gold standard” for the treatment of

incisional herniasincisional hernias

> 100 modifications


Hernia surgeryHernia surgery

Mesh surgeryMesh surgery

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Heavyweight Lightweight

Maximum mechanical stability Mimic the physiology of the abdominal wall

Stiff, nonflexible deviceinducing

maximum scar tissue

Significant reduction of scar tissue formationresulting in

a long-term flexible repair

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MarlexMarlex ULTRAPROULTRAPRO

MaterialMaterial PolypropylenePolypropylene Polypropylene, Polypropylene, poliglecapronepoliglecaproney yy y poliglecapronepoliglecaprone

Weight Weight (g/m(g/m22)) 9595 2828

Pore size Pore size (mm)(mm) 0.60.6 4.04.0

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Dr. Francis UsherRaymond Usher

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Mesh related complicationsMesh related complications

MinorMinor

Seromas

Discomfort

MajorMajor

Recurrencies

Chronic pain – Contraction - ShrinkageDiscomfort

Decreased abdominal wall mobilityRigidity / Loss of complianceStifness

Infection

Fistula formation

Poor ingrowth

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Loss of complianceLoss of compliance

80% of patients with heavyweight mesh80% of patients with heavyweight meshcan feel the meshcan feel the mesh

17% of patients with heavyweight mesh17% of patients with heavyweight meshwill have some functional restrictionwill have some functional restrictionwill have some functional restrictionwill have some functional restriction

Todd Heniford

Heavyweight meshesHeavyweight meshes

Mesh complicationsMesh complicationsRecurrence / shrinkageRecurrence / shrinkage

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Shrinkage

As PLUG contracts, the DEFECT persists

PLUG Hernia Defecte a e ect

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Mesh complicationsMesh complicationsStiffness / RigidityStiffness / Rigidity

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Mesh complicationsMesh complicationsInfectionInfection


Mesh complicationsMesh complicationsInfectionInfection


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Mesh complicationsMesh complicationsSS


Mesh complicationsMesh complicationsSeromaSeroma

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Mesh complicationsMesh complicationsSS Mesh complicationsMesh complicationsSeromaSeroma



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Mesh complicationsMesh complicationsPain / ShrinkagePain / Shrinkage

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Polypropylene

InguindoyniaInguindoynia

Cord

Polypropylene

Direct invasion of the perineurion

n

p

• Patients who have pain as their primary complaint pre-op, are p y p p pmore likely to complain of pain post-op

• Tell my patient that I will fix their h i b t t fi th i i !hernia, but may not fix their pain !

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Mesh complicationsMesh complicationsPain/ShrinkagePain/Shrinkage


Mesh complicationsMesh complicationsStiff scar formationStiff scar formation

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Mesh complicationsMesh complicationsStiff scar formationStiff scar formation

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Mesh complicationsMesh complicationsFistula / ErosionFistula / Erosion



Fistula / ErosionFistula / Erosion Mesh complicationsMesh complications

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Fistula / ErosionFistula / Erosion Mesh complicationsMesh complications


Mesh complicationsMesh complicationsAdhesion / ErosionAdhesion / Erosion

Plug

Small bowel

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Mesh complicationsMesh complicationsAdhesionsAdhesions




Explanted mesh with mesh adhered to small bowel

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What isWhat isthe role of the meshthe role of the mesh

in hernia repairin hernia repairPhysiology and mechanics of the abdominal wall

Define basic elements of the textile structure

Understand the significance of the mesh construction itself

Enhance integration of the mesh into the recipient tissues

WhatWhatWhatWhatisis

the ideal meshthe ideal meshthe ideal meshthe ideal mesh

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The ideal mesh should …The ideal mesh should …

Restore the abdominal wall functionRestore the abdominal wall function

Be integrated physiologically into the abdominal wallBe integrated physiologically into the abdominal wallbased on a maximum of biocompatibilitybased on a maximum of biocompatibility

Have optimal handling characteristicsHave optimal handling characteristics

Restore the abdominal wall functionRestore the abdominal wall function

Mean distension at physiologic strain of 16 NMean distension at physiologic strain of 16 Nranges between ranges between 11 and 32 %11 and 32 %

Heavyweight meshes reveal an elasticityHeavyweight meshes reveal an elasticityof of 44--6 %6 % at 16 Nat 16 N

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Anatomical study

14 anterior abdominal walls

of fresh corpses

7 male, 7 female

68mean age 68 years

range 48 – 86 years

calculated elasticity at 16 N


Elasticity of Elasticity of 25% in vertical 25% in vertical

and 15% in horizontal and 15% in horizontal direction at 16 Ndirection at 16 N

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But ….But ….significantly lower tensile strengthsignificantly lower tensile strength

in lightweight meshesin lightweight meshesin lightweight meshesin lightweight meshes

Law of LaplaceLaw of Laplace

Tensile strength = 32 N/cm in large hernias Tensile strength = 32 N/cm in large hernias g gg g

Tensile strength = 16 N/cm in small hernias Tensile strength = 16 N/cm in small hernias

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Normal intraNormal intra--abdominal pressureabdominal pressurein healthy adults ( according to Todd Heniford )in healthy adults ( according to Todd Heniford )

Activity Mean IAP

Sitting 16,6 mmHg

Standing 20 mmHg

Lifting 10 pound weights 22,5 mmHg

Bending at the knees 22,5 mmHg

Coughing 107,6 mmHg

Jumping 171 mmHg

Obesity + Chronic cough 254 mmHg

Comparison of Abdominal Pressure with Mesh Burst Strength2

1504 13 44 59

1650

700650620

430110

0

500

1000

1500

Pres

sure

(mm

Hg)

0

**Measured after absorption of absorbable components

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Integration into the abdominal wall :Integration into the abdominal wall :BiocompatibilityBiocompatibility

Physical & chemical stabilityPhysical & chemical stabilityPhysical & chemical stabilityPhysical & chemical stability

Wide variety of adverse responsesWide variety of adverse responses

InflammationInflammation

FibrosisFibrosis

CalcificationCalcification

ThrombosisThrombosis

InfectionInfection

Why doWhy doWhy doWhy doinert,inert,

stable,stable,nontoxic,nontoxic,

nonimmunologicnonimmunologicnonimmunologic,nonimmunologic,materialsmaterials

induce this type of inflammationinduce this type of inflammation

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All mesh materials All mesh materials induce a induce a chronic chronic

inflammatory processinflammatory processwith an increased cell with an increased cell

turnover and turnover and connective tissueconnective tissueconnective tissue connective tissue

formation formation (“chronic wound”)(“chronic wound”)

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Amount of materialAmount of materialApoptosisApoptosis

20

25

30

35

40

45

50

L po

sitiv

e ce

lls (%

)

Strong correlationbetween amount of material

and amount of FBR

0

5

10

15

Mersilene Marlex Prolene Atrium Vypro

TUN

EL

PolypropylenePolypropylene

PolyesterPolyester

ePTFEePTFE

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Classical mesh materialsClassical mesh materials


Mersilene®polyester

Gore-Tex®

Teflon®polytetrafluorethylene (PTFE)

trade namepolymer

polyester

Marlex®, Prolene®

Atrium®, Surgi-pro ®polypropylene

PolyesterPolyesterParietex® Mersilene®


Parietex®, Mersilene®

large pore sizeheavy-/low weightstiffexcellent biocompatibilityhydrolytically splittinghydrolytically splittinglow long-term stability

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Gore Tex® Teflon®PolytetrafluorethylenePolytetrafluorethylene


Gore-Tex® , Teflon®

filmheavy weight stiffmore susceptibleto infectionto infectionno tissue integrationdue to microporous concept capsula formationdisintegration (?)

PolypropylenePolypropyleneMarlex® Atrium® Prolene® Surgi pro®


Marlex®, Atrium®, Prolene®, Surgi-pro®

small pore sizeheavy weightstiffintensive foreign body reactionbody reactionStable & nondegradableAcceptable compatibility

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Characteristicsof

the new mesh generation

Reduced amount Large pore size> 1 mm

Thinner filaments

Elasticity of 20 – 35 % : Stretchy

Minimal physiologic tensile strength of 16 - 32 N/cm

Made out of Polypropylene

Handling characteristicsHandling characteristics

Pure Lightweight meshesPure Lightweight meshesare oftenare oftenare oftenare often

too soft & too smoothtoo soft & too smooth

By combining absorbable and nonabsorbable polymersBy combining absorbable and nonabsorbable polymersy g p yy g p ymore stable textile structures are developedmore stable textile structures are developed

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Vypro IIVypro II

… out of the package … after absorption of VICRYL

UltraproUltrapro

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Connective tissue

LongLong--term biocompatibility :term biocompatibility :ComplicationsComplications

M M

Scar net

Scar plate

Mesh Foreign body granuloma

M M

p

Vypro® 3058 µm

Bridgingoccurs in all mesh modifications

with a granuloma size around each mesh fiberexceeding more than half of the pore size of the mesh

M l ®Marlex® 379 µm

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Summary

All mesh shrinks All mesh shrinks –– some more than otherssome more than others

Avoid heavyweight polypropylene meshAvoid heavyweight polypropylene mesh

Mesh are like women’s shoes

• One size does not fit all

• There are different shapes, colors and styles

• Some seem way to expensive

• More is better

• The most popular may be the most painful

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Requirements Requirements f Fi if Fi ifor Fixationfor Fixation

in Laparoscopic Incisional in Laparoscopic Incisional Hernia RepairHernia RepairHernia RepairHernia Repair

Tollens Tim MD

Imelda Hospital

Belgium

What do we want in LIHR?

• The “perfect” fixationPicture courtesy of Dr. Dirk Jentschura

– Strong, consistent & reliable– No migration of the mesh– No pain– No adhesions– No recurrences– Removable– User friendly– Disposable– Economic

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Picture courtesy of Dr. Georg Pistorius

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Picture courtesy of Dr. Georg Pistorius

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Picture courtesy of Dr. Dirk Jentschura

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What do we want in LIHR?

• The “perfect” fixation

– Strong, consistent & reliable– No migration of the mesh– No pain– No adhesions– No recurrences– Removable– User friendly– Disposable– Economic

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Fixationdevices

•Staples, tackers, sutures, Q‐rings, glue, …

•Absorbable↔ Non-absorbable

•Single row↔ Double crown

• Intervals & position

Transfascial•Tied↔ Untied

Controversiesin mesh fixation

suturesversus nosutures

•Absorbable↔ Non-absorbable

• Intervals of fixation

•Position of the fixation devices

We need meshesWe need meshesin majorityin majority

of open and laparoscopicof open and laparoscopich i ih i ihernia repairshernia repairs

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How do weHow do wek th h t t ?k th h t t ?make the mesh to stay ?make the mesh to stay ?

What’s the problem inLaparoscopic Incisional Hernia Repair ?Laparoscopic Incisional Hernia Repair ?

PAIN !PAIN !

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Why is PAIN the big issue inLaparoscopic Incisional Hernia Repair ?Laparoscopic Incisional Hernia Repair ?

FIXING is to be compared as a

MASS INJURY

Picture courtesy of Dr. Ralph Lorenz

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Mesh fixation• Sutures

• Transfascial sutures

• Staples• Staples

• Spiral tacks

• Q‐rings

• I‐clips

• Protack

• AbsobaTack

• Easy Tac

• Salut• Salut

• PermaSorb

• SorbaFix

• EMS

• Glues

• ….

Various fixation devices : Protack

– Titanium helical tack

– Fixates by spiraling into tissue

– Titanium, non‐resorbable

– 3.7 mm length

– 5 mm trocar

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Various fixation devices : ProtackLimitatons

– Tissues are compressed and contorted by spiraling fixation

– Only 3,7 mm penetration

– Sharp point facing bowels and tissues

– Reports on adhesions to the tacker

Various fixation devices : ProtackLimitatons

– Papers on inguinal pain, tacker migration, nerve entrapment, volvulus & death

– Very difficult to remove tackers

– Permanent materials

– 30 tacker device only

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Why should we useabsorbable tackers ?

Why should we useabsorbable tackers ?

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Various fixation devices : AbsorbaTack

Ab b bl th ti l t– Absorbable synthetic polyester

– Absorbable copolymer tacker derived from lactic and glycolic acid

– Good circular motion

– 10 & 20 shot configuration

– 5 mm tacker

– Fully resorbed at 12 months

Various fixation devices : AbsorbaTackLimitations

– Shaft is too short– Shaft is too short

– Application is not so easy

– Significant absorption rate seen from 3 to 5 months

– 4.1 mm length

– Shape of tacker leads to a loss of 77% shear strength retention in first 2 months

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Various fixation devices : Permasorb or EasyTack

– Poly (D,L) lactid pin

– 6.4 mm length

– 5mm trocar

– Resorbable after 16 months

Various fixation devices :SorbaFix

P l (D L) l tid– Poly (D,L) lactide

– 6.8 mm length, smooth head

– 5 mm obturator with piloting tip

– Absorption complete

after 12 months to 16 months

– 15 and 30 count tacker

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Fixation devices in 5 mm

3,7 mm 4,1 mm 6,4 mm 6,8 mm 6,7 mm, , , , ,

Protack Absorbatack Easy tack Sorbafix Securestrap


3,7 mm 4,1 mm 6,4 mm 6,8 mm 6,7 mm, , , , ,


Mesh

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3,7 mm 4,1 mm 6,4 mm 6,8 mm 6,7 mm, , , , ,


Mesh

Fat


3,7 mm 4,1 mm 6,4 mm 6,8 mm 6,7 mm, , , , ,

Muscle&

fascia


Mesh

Fat

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6.7 mm 4.9 mm grip

3.5 mm

2 point fixation

Counter pressure is the key

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Porosity in relation to fixation

• Poor ingrowthP d h i kMicroporousMicroporous • Pronounced shrinkage

• Need for life long fixation• Need for greater overlap

MicroporousMicroporous

meshesmeshes

• Strong ingrowthMM • Limited shrinkage

• Temporary fixation possible• Limited overlap most likely sufficient

MacroporousMacroporous

meshesmeshes

Hernia type and sizein relation to fixation

• Remaining wall stabilityH i ti f ↓↓↓• Herniation forces ↓↓↓

• Calculable overlap• Bulging is no problem• Less mesh retention strengthSwiss Swiss CheeseCheese

• No remaining wall stability• No remaining wall stability• Herniation forces↑↑↑• Overlap ↑• Bulging ↑↑↑• Stronger fixation requiredSolitarySolitary defectdefect

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Mesh‐Fixation

• Fixation along the mesh margin with one tack in every 1,5 cm in order to avoid small bowel y ,obstruction

• Hollinsky stated that there is no added physical stability when using more frequently than 1 tacker in every 1,8 cm

• 20 x 30 cm mesh margin length = 100 cm + doublecrown

• Ca 80‐90 tacks necessary : Pain and cost ↑

Plea for trimming the mesh

4 x radius

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Plea for trimming the mesh

3.14 x radius

-25 % of tacks

by using circular or oval meshes

Tackers, transfascial sutures or both ?Tackers, transfascial sutures or both ?

• Metallic devices alone do not provide d t fi ti i t ti i th &adequate fixation prior to tissue ingrowth & mesh stabilisation (1)

• On the other hand, the majority of tissue ingrowth and strength has occurred by twoingrowth and strength has occurred by two weeks after implantation (2)

(1) Joels et al. Surg Endosc 2005;19:780-785(2) Majercik et al. Surg Endosc 2006; 20:1671-1674

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Tacks versus staplesTacks versus staplesHollinsky C, Goebl S (1999) Hollinsky C, Goebl S (1999)

Bursting strength evaluation after different types of mesh fixation in laparoscopic hernioraphy. Bursting strength evaluation after different types of mesh fixation in laparoscopic hernioraphy. Surg Endosc 13:958Surg Endosc 13:958‐‐961961

The stress‐bearing capacity

( shear force resistance )of a mesh

fixed by a helical fastener

is up to 4 TIMES

that of a mesh fixed by a stapler

Tacks versus transfascial suturesTacks versus transfascial suturesvan Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, Steyerberg EW, Bonjer HJ.van Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, Steyerberg EW, Bonjer HJ.Tensile strength of mesh fixation methods in laparoscopic incisional hernia repairTensile strength of mesh fixation methods in laparoscopic incisional hernia repair

(2002)Surg Endosc DOI:10.1007/s00464(2002)Surg Endosc DOI:10.1007/s00464‐‐001001‐‐92029202‐‐77

The tensile strength of transabdominal sutures

is up to 2.5 TIMES greater

than the tensile strength of tacks

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Hollinsky et al. Surg Endosc 2009, DOI 10.1007/s00464-009-0767-x


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Adhesion score


Transfascial sutures

• Higher tensile strength

• Longer retention strength

• Cause less adhesions than tacks

• What about chronic pain ?

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Positioning the transfascial sutures

Positioning the transfascial sutures

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Picture courtesy of Dr. Thilo Wedel

Patient or hernia charateristics influencing fixation strength

• Obesity, especially the depth of penetration into the tissue layers

• Vicinity of bony landmarks, role of anchoring the mesh…

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Patient or hernia charateristics influencing fixation strength

Optimizing mesh fixationOptimizing mesh fixation

1. By choice of mesh

• Use of macroporous meshes eliminates the need for life‐long fixation

• Ingrowth in megaporous meshes leads to less stifness

• Mesh materials with limited shrinkage cause less pain, probably less recurrences

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2. By choice of fixation device

• Slowly absorbable/ Non‐absorbable transfascial sutures

• Slowly absorbable fixation devices

• Adequate depth of fixation

» Thickness of mesh

» Structure of abdominal wall

» Preperitoneal fat layer thickness

Variable length of fixation tacks is required !


3. Technique of fixation

• No tension on transfascial sutures

• Cross formation of cardinal sutures

• Decreasing number of tacks, ‐ pain, ‐ cost

• Cautious fixation in vicinity of ribs, on diaphragm, in vicinity of nerves, in lateral position

• Increase of overlap in areas of risk to diminish the tension on the mesh itself

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What about glue as fixation ?

What about glue as fixation ?

11-5-2011

104

Documents

About implants in hernia surgery - VZA - dr.T... · 11-5-2011 1 About implants in hernia surgery Dr. Tim Tollens Imelda Hospital Belgium