Guy Voeller, MD, FACSProfessor of Surgery, University of TennesseePast President, The American Hernia Society

SUTURE FIXATION• Van’t Riet 2002• Pig model using PPM• Used sutures vs tacks (1-5/7cm mesh)• Tensile strength

67N vs 28N for single fixation(p<0.001)

115N vs 42N for double(p<0.001) 150N vs 82N for 5 fixation points(p<0.05)

SUTURE FIXATION• Increasing fixation > 3 per 7cm did not

improve TS (every 1.8cm)• The TS is up to 2.5 times greater when

sutures are used instead of tacks• Sutures are preferable for LVH repair

Evaluation of Mesh Fixation Strength

Time

Control

TitaniumTitanium

Spiral TacksSpiral Tacks

15.4N15.4N

NitinolNitinol

AnchorsAnchors

7.4 N7.4 N

PolypropylePolypropylenene

SutureSuture

39.1 N39.1 N

Polyglactin Polyglactin 910910

SutureSuture

40.0 N40.0 N

Funded – Society of American Gastrointestinal Endoscopic Surgeons

Normal Intraabdominal Pressure

Stand Valsalva 5 N/cm (3.9-6.8)

Stand cough 15 N/cm (7.5-18.1)Jumping 15 N/cm (8.5-19.1)Sitting 2 N/cm (1.3-2.3)Stairs 4.8 N/cm (4.0-5.7)Squat 2.3 N/cm (1.2-2.9)

* CMC “normals” study*

PIONEERSLeBlanc (Louisiana)

Toy and Smoot (Delaware)

Gagner , Park and Pomp (Canada)

Franklin (Texas) and Ramshaw (Atlanta)

Voeller and Mangiante (Memphis)

LeBlancSurg Laparosc Endosc 1993

5 cases; ePTFE

5 trocars

Staples only; no sutures

Extension of his IPOM technique

Toy and SmootExtension of their IPOM for inguinal

Developed mesh spreader

Developed suture passer

Used ePTFE

FranklinSurg Laparosc Endosc 1998176 patients from 1991-1998ePTFE and PPM; sutures and staplesFirst to try to close defect if possibleF/U 1-84 months1.1% recurrenceNo mention of % f/u

Voeller and MangianteFirst case in 1993 with staples onlyRecurred 6 months laterMangiante taught Rives repair by George

WantzRealized mimic Rives was criticalFirst to use 5mm tacking deviceFirst to do with all 5mm portsIntroduced Ioban® as part of procedureFirst course in the world in 1995 in Memphis

Park, Gagner and Pomp1996 Surg Laparosc Endosc

30 cases

ePTFE and PPM; sutures

One recurrence at 18 mo f/u

Minimal morbidity

Prospective, Multicenter Study of Laparoscopic Ventral Hernioplasty. Preliminary ResultsToy, Bailey, Carey, Chappius, Gagner, Josephs,

Mangiante, Park, Pomp, Smoot, Uddo, VoellerSurg Endosc 1998Hernias > 4 cm2- ePTFE; sutures and staples

(tacks)144 patients over first 2 yearsMean OR time was 120 minMean f/u was 355 days with 95% f/u4.2% RR; D/C at mean of 2.3 daysReturn to normal activity at 15 days

RAMSHAWAm Surg 1999Retrospective study of lap vs open3 year period, 1995-1998Mean f/u was 21 months36 recurrences in open and 2 in the lap groupComplications much less

VOELLERACS 1999Heniford, Park, Ramshaw, Voeller407 repairsF/U 2-5 yearsRR 3.4% majority due to mesh removal for

infection

PARKAmerican Surgical AssociationPublished AOS 2003Heniford, Park , Ramshaw, Voeller850 patients13% morbidityMean f/u was 20 months4.7% RR

ConclusionsLAP has fewer wound problemsLAP has fewer mesh infectionsLAP has quicker return to activityLAP and OPEN same recurrence rateQOL is same after LAP and OPENLAP does not reconstruct abdominal wallNeed a study to see if lack of reconstruction

matters

Abdominal Wall FunctionRectus muscles act as stays to stabilize

Linea alba is a larger area than a “line”

Lateral muscles insert on midline via rectus sheath

Length of muscle fibers are short in upper, long in the middle and nonexistent in lower

Incisional HerniaMore than a hole in the abdominal wall

Different from groin, epigastric or umbilical hernias

Rives called it “eventration disease”

Extent of eventration dictates for the most part what I do for incisional hernia

Eventration DiseaseRespiratory insufficiency

Abdominal wall moves in and out during both inspiration and expiration

Bowels are pushed out on inspiration and eventually the bowels lose their right of domain

Back muscles are not counterbalanced by abdomen

Eventration Disease (cont.)Postural changes occur i.e. lordosis

Lateral abd. muscles retract

Muscles become fatty and fibrotic

Lateral retraction makes defect larger

Last changes are dermatologic - skin ischemia, ulcers

Components Separation Technique

Ramirez O. Plast Reconstr Surg. 1990: 86:519)

Utilizes overlapping redundant layers of abdominal wall for coverage; can gain 6 cm laterally from each side

COMPONENTS SEPARATION• Bleichrodt the Netherlands JACS 2003• 43 patients with ventral hernias• Mean f/u of 15 months in 38 patients• 17 with complications• 12 of 38 (32%) with recurrence• Best in contaminated situation where mesh

should not be used

MIS Components SeparationFirst group to do was Lowe PRS 2000

Maas and Bleichrodt used hernia balloon

Rosen popularizing in USA

Combine MIS CS with closure of the defect laparoscopically to “reconstruct” the abd. wall

FutureSILSNotesSelf-Adhering meshMeshes impregnated with agents to fight

infectionMeshes impregnated with agents to decrease

painAbdominal wall transplant

ADHESIVELadurner, Eur J Med Res 2008

Cyanoacrylat glue vs tacks vs sutures

Animal model of LVIH

Glue equal to tacks in tensile strength

NOTESFong, Endoscopy 2007Transcolonic5 pigs2 x 3 cm pieces of meshUsed magnetsTransfascial suturesAll meshes intact and no infection at sacrifice

NOTESSurg Endosc, Miedema 2009Transgastric; 5 pigs13 x 15 cm Surgisis with sutures deliveredSacrificed at 2 weeksOR time 215 minCulture positive abscesses present in 3 of 5

meshesAdhesions varied from 2-100%

NOTESJacobsenHernia 200938 y.o. femalePainful recurrent umbilical herniaRepaired transvaginally

NOTESLomanto 20095 pigsMesh placed and fixed transvaginally; fibrin

glueSacrificed at 2 weeksAll meshes in placeOne subQ abscess

Self-Adhering MeshChampault Hernia 2009LW PPM; Adhesix® (Cousin Biotech, France)Coated with glue on one sideImplanted laparoscopically in pigsRemoval at 1 day, 1 week and 1 month post-

opExcellent integrationNo migration or shrinkage

Thank youThank you