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Prosthesis and fixation device

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hernia mesh and fixation device for laparoscopy

Publicado en: Salud y medicina
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Prosthesis and fixation device

  1. 1. ABDOMINAL WALL HERNIA PROSTHETIC MATERIALS AND FIXATION DEVICES CHOICE & CHALLENGES Dr.S.Easwaramoorthy MS, FRCS(Edin) ,FRCS (Eng) ,FRCS (Glas), FAES, FIAGES, FMAS Consultant Surgeon, Lotus Hospital, Erode EC member, IAGES (South Zone) Treasurer ASITN & P Chapter ICS Hernia Meet Chennai 2015
  2. 2. Billroth’s Vision ‘‘If we could artificially produce tissues of the density and toughness of fascia and tendon the secret of the radical cure of hernia would be discovered’’. - Beitrage zur Chirurgie (1878) Conceive Believe & Achieve
  3. 3. Inventor of Prosthetic Mesh repair: Dr. Francis Usher (1908-1980) • Inventor of Polyehylene(Marlex) and Polypropylene mesh • Several Animal studies about their inertness • 20 papers • Innovative ways of placing the meshes: Inlay,Overlay, Sandwich tech etc Conceive Believe & Achieve
  4. 4. Lichtenstein’s Mesh Repair Tension Free repair •Under LA •Day care •Low recurrence rate! Conceive Believe & Achieve
  5. 5. Mesh is a must!
  6. 6. Why Mesh?  Low recurrence rate  Tension free & Pain free  Quick recovery  Quick to learn and easy to do!
  7. 7. History of Inguinal Hernia Repair We are in Era ofTension Free Mesh Repair! 10% 1% 0.1% 100% Recurrence rate Bassini Shouldice LichtensteinAncient Era
  8. 8. Why Mesh? Pathogenesis of Hernia  Defective Collagen  Reduced ratio of type I and type III collagen  Type I: MatureCollagen, strong and normal tissue  Type III: ImmatureCollagen, weak, in healing wounds  Type I :Type III ratio normally is 4:1  ?Genetic defect  Connective tissue pathology is not only a cause of primary herniation but its presence can prevent cure! A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia? Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and Volker Schumpelick, BMC Med Genet. 2002; 3: 2.
  9. 9.  Why Mesh?  What type of Mesh?  Where to place the Mesh?  How to place the place?
  10. 10. Types of Mesh  Synthetic Mesh  Non absorbable  Polyprophylene(Prolene)  Polyethylene(Marlex)  Polyester(Dacron)  PTFE (Teflon/Gordex)  Absorbable  Vicryl  Combined  Vypro, Ultrapro  Synthetic with Absorbable Barrier( Dual mesh)  Parietex  Proceed  Etc  Biological Mesh  Surgisis ( Porcine submucosa)  Alloderm (Cadaveric human dermis)
  11. 11. What Type of Mesh? Light weight Vs Heavy weight? Light weight Mesh Heavy weight Mesh Definition Thin fibres, macro pores (>1.5mm) Thick fibres, micro pores (< 1.5mm) Qualities Flexible Less FB reaction and pain Stiffer More FB reaction and pain (Problem of adhesion, fistula) Shrinks more Stronger! - so what Examples Ultrapro,Vipro Marlex, Dacron, PTEF The lightweight and large porous mesh concept for hernia repair. Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.
  12. 12. 3 D Mesh
  13. 13. Composite Mesh Visceral side: averts adhesion of bowel
  14. 14. Parietex Mesh Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience. 2001 Surg Laparoc Endosc PercutanTech Apr;11(2):103-6 Proceed Mesh
  15. 15. Laparoscopic Ventral Hernia Repair Choice of Composite Mesh Name Parietal side Visceral Side Longevity Remarks By Parietex Polyester Atelocollagen, PEG, Glycerol 20 days expensive Covidien Proceed Polypropylene Oxidised (ORC) regenerated cellulose/PDS 30 days Ethicon Sepramesh PP PGA/Hydrogel 30 days Davol C QUR PP Omega 3 FA Atrium ProVISC 160 Polyester Polyurethane Life Cost effective Lotus Dual Mesh e PTFE (rough) e PTFE(smooth) Life Gore Kugel/ Composix PP(HW) e PTFE Life Can't trim Bard
  16. 16. Proceed Mesh (Ethicon) Time line 1 week 2 weeks Day 1 3 months
  17. 17. Pro VISC 160  Polyester  White Parietal side  Polyurethane  Blue smooth visceral side  With Sutures  Pre cut in various sizes
  18. 18. Parietal side: Prolene Visceral side: e PTFE Bard (Composix) Gore Dual Mesh Parietal side: Rough PTFE Visceral side: smooth PTFE
  19. 19. Frequently Asked Questions!  Why Mesh?  What type of Mesh?  Where to place the Mesh?  How to fix the mesh?
  20. 20. Myopectineal Orifice of Fruchaud 15/10cm to 15/15cmSize do matter…
  21. 21. Where to place the Mesh? On Lay In Lay Under Lay IPOM
  22. 22. Pascal’s Hydrostatic Principle OnlayVs Inlay Effect of Intra abdominal Pressure Choose a mesh at least 5cm larger than the defect all round.
  23. 23.  Why Mesh?  What type of Mesh?  Where to place the Mesh?  How to fix the mesh?
  24. 24. Mesh Fixation Methods… AbsorbaTack (Covidien) Permasorb (Davol / Bard ) Fibrin sealant SpiralTackers Staples Fibrin Glue Suture
  25. 25. Ideal Fixation Method No Type of Fixation Features 1 Trans Fascial suture fixation Chronic pain 2 Suturing 2cm apart 3 SpiralTitatinum Tackers 2cm apart Double crown technique Nerve entrapment, adhesion, rarely tacker hernia 4 Absorbable tackers For initial 1 year 5 Fibrin Glue Suitable for inguinal hernia ?Ventral Hernia: Alternative or Adjunct: needs trial. Closure of Hernia defect to avoid mesh protrusion or displacement To withstand the intra abdominal tangential force and also shearing Force due to abdominal muscle contraction
  26. 26. Conclusion  Mesh repair is the Standard of Care.  Use Composite mesh for ventral hernia  Secure the mesh to prevent recurrence
  27. 27. Forthcoming Courses /Erode ASI Contact Us: 9843328928/9790028328  3rd ASI Endoscopic course  On 5 days/all Sundays from 8am to 5pm  8th November 2015 : 1st session starting  FIAGES Laparoscopic Fellowship course  Venue: Lotus hospital, at Erode  7th to 9th January 2016

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