Surgical Meshes

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Surgical Meshes and their Fixation

Dr. Shahzad Alam ShahFCPS

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

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

Massive Incisional Hernias

Conventional Open Repair: The Herniorraphy

• Manual Repair• High Recurrence Rate

Hernia: The Methods to Treat

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

Factors influencing hernia occurrence

Endogen Exogene Others

• Age > 45 Sutures emergency• BMI > 25 length of incision intra abdominal • previous operation contamination pressure• anemia Medication• shock Type of incision• smoker• Corticoïds• Aneurysm/Marfan• (+30% risks)

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.

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

Ventral Hernia: AnatomyMay-2012Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan

In humans the intra-abdominal pressure ranges from 0,2kPa (resting) to 20 kPa (maximum).

Pressure

“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

•Tensile strength•Pliability •Ease of manipulation•Durability•Degree of tissue in-growth•Infection rate•Inflammatory response / adhesion formation•Seroma formation•Cost

What should be an Ideal replacement of the Fascia?

Which mesh to choose?

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

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:

Types of Meshes

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

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

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)

• Micro porous, smooth texture minimizes tissue in-growth 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

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

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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

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UltraPro Mesh

•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

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Mesh Placement

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Ventral hernia mesh positioning: Onlay

Ventral hernia mesh positioning: Inlay

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Ventral hernia mesh positioning: Underlay

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Ventral hernia mesh positioning: Intraperitoneal

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Methods of Mesh Fixation

• Staples• Tacks• Glue• Anchor• Sutures

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Potential Mesh-Related Complications:

• Infection

• Intestinal adhesions

• Bowel obstructions

• Erosion of the prosthesis into the adjacent hollow viscous

• Contraction of prosthesis

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• Tensile strength• Pliability • Ease of manipulation• Durability• Degree of tissue in-growth• Infection rate• Inflammatory response / adhesion formation• Seroma formation• Cost• .

Conclusion: are we there yet?

The ideal mesh has yet to be developed and the management of complex ventral

hernias remains a challenge

May-2012

Thanks:

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Surgical Meshes

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