Surgical Meshes and their Fixation

Dr. Shahzad Alam Shah

FCPS Consultant Laparoscopic Surgeon Fatima Jinnah Medical College/SGRHL

A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence rate is low than he can by operating on cases of malignant disease .
Sir Cecil Wakely, 1948 President Royal College of Surgeons

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Massive Incisional Hernias

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Conventional Open Repair: The Herniorraphy

Manual Repair High Recurrence Rate

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Hernia: The Methods to Treat

Conventional Open Repair: The Herniorraphy Open Mesh Hernioplasty Laparoscopic Mesh repair

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Factors influencing hernia occurrence

Endogen
Age > 45 BMI > 25 previous operation anemia shock smoker Corticods Aneurysm/Marfan (+30% risks)

Exogene
Sutures length of incision contamination Medication Type of incision

Others
emergency intra abdominal pressure

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Abdominal Wall Elasticity

After the Intra-abdominal pressure, another important factor in the abdominal wall repair plays a role, it is the

Abdominal wall elasticity.

Dr. Shahzad Alam Shah Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan Lahore Pakistan Mid City Hospital

2012May2012May-

Ventral Hernia: Anatomy

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Pressure

In humans the intra-abdominal pressure ranges from 0,2kPa (resting) to 20 kPa (maximum).
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

If we could artificially produce tissues of the density and toughness of fascia, the secret of the radical cure of hernia would be discovered. Theodore Billroth, 1857

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

What should be an Ideal replacement of the Fascia?

Tensile strength Pliability Ease of manipulation Durability Degree of tissue in-growth Infection rate Inflammatory response / adhesion formation Seroma formation Cost
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

2012May-

Burst Strength Compliance Foreign Body Response Degree of Shrinkage Increased Pore Size

Which mesh to choose?

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Types of prosthetics for hernia repair:

Type 1: totally macroporous prosthesis, pores > 75 microns; example prolene, Type 2: totally microporous prosthesis; pores < 10 microns; example gortex or dual mesh Type 3: macroporous prosthesis with microporous components; example Teflon, mersilene Type 4:

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Polypropylene (Prolene) Mersilene Vypro Ultrapro Gore-Tex Teflon Some other polymer

Types of Meshes
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Polypropylene Mesh

Most Commonly used mesh Reports showed good initial healing but were fraught with long term complications

Those complications are chronic infection, fistula formation, erosion into bowels or through skin grafts
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Polyglactene Mesh (vicryl mesh)

Alternative to non-absorbable meshes Advantage host invasion and subsequent absorption of implant

There is less infection complication, increase recurrence rate (satisfactory short term solution in infected hernias but not generally indicated when prolonged tensile strength is required)

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

ePTFE
Micro porous, smooth texture minimizes tissue ingrowth and limits adhesion formation and bowel injury
Combined with a large pore second layer it can adhere well to the abdominal wall

Disadvantages Mesh infection is not well treated by antibiotics and requires mesh removal Does not integrate well into host tissue when not combined with a large pore mesh

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Ethicon Proceed

Multilayered tissue separating mesh comprised of: PROLENE* Soft polypropylene Mesh Designed for strength, durability, and adaptability Oxidized regenerated cellulose (ORC) fabric Creates a flexible, secure bond between the mesh and ORC layers

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Ethicon Proceed Mesh

Lightweight Monofilament Construction Less foreign mass Flexible scar tissue Strong tissue incorporation Excellent Handling Lightweight, macro porous, monofilament mesh structure Allows fluid flow-through Conforms to anatomy Readily customized

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Thin Filament Size Large Pore Construction Absorbable Components

Strong, Secure repair Clear Visualization of anatomy Excellent Handling 65% foreing materials Physiological compatible with abdominal wall

UltraPro Mesh
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Mesh Placement

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Ventral hernia mesh positioning: Onlay

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Ventral hernia mesh positioning: Inlay

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Ventral hernia mesh positioning: Underlay

Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-

Ventral hernia mesh positioning:

Intraperitoneal

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Methods of Mesh Fixation

Staples Tacks Glue Anchor Sutures

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Potential Mesh-Related Complications:

Infection Intestinal adhesions Bowel obstructions Erosion of the prosthesis into the adjacent hollow viscous Contraction of prosthesis

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Conclusion: are we there yet?

Tensile strength Pliability Ease of manipulation Durability Degree of tissue in-growth Infection rate Inflammatory response / adhesion formation Seroma formation Cost .
Mid City Hospital Lahore Pakistan 2012May-

Dr. Shahzad Alam Shah

The ideal mesh has yet to be developed and the management of complex ventral hernias remains a challenge

Dr. Shahzad Alam Shah

Mid City Hospital Lahore Pakistan

2012May-

Thanks:
Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan 2012May-