Surgical Meshes and their         Fixation                         Dr. Shahzad Alam Shah                                  ...
“A surgeon can do more for the community by •      operating on hernia cases and seeing that his   recurrence rate is low ...
Massive Incisional HerniasDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Dr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Dr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Conventional Open Repair:The Herniorraphy• Manual Repair• High Recurrence RateDr. Shahzad Alam Shah   Mid City Hospital La...
Hernia: The Methods to Treat• Conventional Open Repair: The Herniorraphy• Open Mesh Hernioplasty• Laparoscopic Mesh repair...
Factors influencing    hernia occurrenceEndogen                        Exogene                        Others•   Age > 45  ...
Abdominal Wall Elasticity     • After the Intra-abdominal      pressure, another important         factor in the abdominal...
Ventral Hernia: AnatomyDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
PressureIn humans the intra-abdominal pressure rangesfrom 0,2kPa (resting) to 20 kPa (maximum).Dr. Shahzad Alam Shah   Mid...
“If we could artificially produce tissues of                            the density and toughness of fascia, the          ...
What should be an Idealreplacement of the Fascia?                                     Tensile strength         •          ...
Burst Strength    •                                                    Compliance     •                                   ...
Types of prostheticsfor hernia repair:      Type 1: totally macroporous prosthesis, pores > 75 •                          ...
•   Polypropylene (Prolene)•   Mersilene•   Vypro•   Ultrapro•   Gore-Tex®•   Teflon®•   Some other polymerTypes of Meshes...
Polypropylene Mesh• Most Commonly used mesh• Reports showed good initial healing but were fraught  with long term complica...
Polyglactene Mesh (vicryl mesh)• Alternative to non-absorbable meshes• Advantage host invasion and subsequent absorption o...
ePTFE• Micro porous, smooth texture minimizes tissue in-  growth and limits adhesion formation and bowel injury    • Combi...
Ethicon Proceed   Multilayered tissue separating mesh   comprised of:    PROLENE* Soft polypropylene Mesh    Designed fo...
Ethicon – Proceed Mesh                                    Lightweight Monofilament Construction                          ...
Thin Filament Size •                                                       Large Pore Construction •                      ...
Mesh PlacementDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Dr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Dr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Ventral hernia mesh positioning: OnlayDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Ventral hernia mesh positioning: InlayDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Ventral hernia mesh positioning: UnderlayDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Ventral hernia mesh positioning:   IntraperitonealDr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
Methods of Mesh Fixation  •   Staples  •   Tacks  •   Glue  •   Anchor  •   SuturesDr. Shahzad Alam Shah   Mid City Hospit...
Potential Mesh-Related Complications:  • Infection  • Intestinal adhesions  • Bowel obstructions  • Erosion of the prosthe...
Conclusion: are we there yet?   •   Tensile strength   •   Pliability   •   Ease of manipulation   •   Durability   •   De...
The ideal mesh has yet to be developed   and the management of complex ventral         hernias remains a challengeDr. Shah...
Thanks:Dr. Shahzad Alam Shah   Mid City Hospital Lahore Pakistan   May-
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Surgical Meshes

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The use of mesh for the repair of hernia is now considered as a modern method of treating hernias. Advancement in the development of quality and fixation of mesh is highlighted in this presentation.

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Surgical Meshes

  1. 1. Surgical Meshes and their Fixation Dr. Shahzad Alam Shah FCPS Consultant Laparoscopic Surgeon Fatima Jinnah Medical College/SGRHL
  2. 2. “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 May-
  3. 3. Massive Incisional HerniasDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  4. 4. Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  5. 5. Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  6. 6. Conventional Open Repair:The Herniorraphy• Manual Repair• High Recurrence RateDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  7. 7. Hernia: The Methods to Treat• Conventional Open Repair: The Herniorraphy• Open Mesh Hernioplasty• Laparoscopic Mesh repairDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  8. 8. Factors influencing hernia occurrenceEndogen 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)Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  9. 9. 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 ShahDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan Lahore Pakistan Mid City Hospital May- May-
  10. 10. Ventral Hernia: AnatomyDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  11. 11. PressureIn humans the intra-abdominal pressure rangesfrom 0,2kPa (resting) to 20 kPa (maximum).Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  12. 12. “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, 1857Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  13. 13. What should be an Idealreplacement 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 May-
  14. 14. 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 May-
  15. 15. Types of prostheticsfor 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 May-
  16. 16. • Polypropylene (Prolene)• Mersilene• Vypro• Ultrapro• Gore-Tex®• Teflon®• Some other polymerTypes of MeshesDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  17. 17. 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 May-
  18. 18. 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 May-
  19. 19. ePTFE• 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 meshDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  20. 20. 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 layersDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  21. 21. 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 customizedDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  22. 22. 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 MeshDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  23. 23. Mesh PlacementDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  24. 24. Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  25. 25. Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  26. 26. Ventral hernia mesh positioning: OnlayDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  27. 27. Ventral hernia mesh positioning: InlayDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  28. 28. Ventral hernia mesh positioning: UnderlayDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  29. 29. Ventral hernia mesh positioning: IntraperitonealDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  30. 30. Methods of Mesh Fixation • Staples • Tacks • Glue • Anchor • SuturesDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  31. 31. Potential Mesh-Related Complications: • Infection • Intestinal adhesions • Bowel obstructions • Erosion of the prosthesis into the adjacent hollow viscous • Contraction of prosthesisDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  32. 32. 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 • .Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  33. 33. The ideal mesh has yet to be developed and the management of complex ventral hernias remains a challengeDr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-
  34. 34. Thanks:Dr. Shahzad Alam Shah Mid City Hospital Lahore Pakistan May-

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