dr.taslim

Taslim Poniman, MDErrawan Wiradisuria, MD

Hernia Mesh Design and Material

Medan, May 10th 2011

Introduction•What is a hernia?

Definition Hernia:

„Protrusion of an organ or tissue out of the body cavity in which it normally lies”

(Oxford dictionary of nursing)

Weak points

inguinal canal femoral canal navel (umbilicus) scars after previous incisions

(operations)

Where hernias might occur:

Most important types

- indirect 60 %

- direct 15 %

- incisional11 %

- umbilical11 %

- other hernias3 %

Incisionalhernia

Umbilicalhernia

Directinguinalhernia

Femoralhernia

indirectinguinalhernia

Anatomy of the groin, Inguinal Canal

About 75% of all hernias form in this area.

Hesselbach ligament

inguinal ligament

external inguinal ring

faszia transversalis

internal oblique muscle

internal inguinal ring

rectus muscle

peritoneum

spermatic cord

Hesselbach ligament

spermatic cord

inguinal ligament


fascia transversalis

internal oblique muscle

hernia


rectus muscle

peritoneum

Principle of an indirect inguinal hernia

Principle of an indirect inguinal hernia

Natural anatomy Hernia passing through inguinal canal

About 60 % of all hernias are indirect hernias

Hernia Mesh Products

Indirect Inguinal Hernia

hernia

peritoneumtransverse fascia

transverse m.

internal obligue m.

external oblique m.

rectus m.

superficial fasciaskin



aponeurosis

scrotum with testi

spermatic cord


Direct Inguinal Herniaherniaspermatic cord

peritoneumtransverse fascia

transverse m.

internal obligue m.

external obligue m.superficial fascia

skin

rectus m.

scrotum with testis

aponeurosis


Incisional Hernias

peritoneum

transverse fascia

muscles

superficial fascia

subcutaneous fatskin

hernia

Anatomy of ventral abdominal wall (cross section)

Rectus abdominis muscleExternal oblique muscle

Peritoneum

Linea alba FasciaInternal oblique muscleTransversus abdominis

muscle

Skin

How does a hernia develop?

The wall weakness or tears

The intestine pushes into the sac(reducible hernia)

The intestine may become trapped(non-reducible hernia)

The intestine may become strangulated

Anterior rectus sheath

Rectus abdominis

Sac

Hernia Repair TechniquesHernia Repair Techniques

Open Repairs (conventional/laparotomy) Tissue to Tissue using sutures Lichtenstein “Tension-Free” repair with mesh Plug Repair

Laparoscopic Repairs Transabdominal Preperitoneal (TAPP) Total Extraperitoneal (TEP) Intraperitoneal (IPOM)

Open Hernia Repair Without MeshOpen Hernia Repair Without Mesh Bassini Repair Shouldice Repair

Open Hernia Repair Using MeshOpen Hernia Repair Using Mesh

Lichtenstein “Tension-Free” Mesh Plug Hernioplasty

Tension Free RepairTension Free Repair

Hernia defect Bassini technique of approximating the edges causes distortion and tension

this may cause a new hernia

Reparation with onlay patch avoidssuture-line tension

Lichtenstein RepairLichtenstein Repair•Lichtenstein Tension Free Technique

Advantages of a Advantages of a ““Tension freeTension free”” repair repair

No tension on suture line No distortion (strain) of anatomy Use of mesh is safe Low 0.2 percent recurrence rate

Mesh Plug DesignsMesh Plug Designs

Premilene® Self-Forming Plug - 1997/98 Bard PerFix Plug Ethicon Prolene Hernia System - 1997 Tyco – USSC –HerniaMate - 1999

Mesh Plug HernioplastyMesh Plug Hernioplasty

Initially used for recurrent hernias In the USA now routinely used for primary inguinal

hernia and femoral hernias In Europe the technique is under discussion “Tension-Free” repair Minimum incision and surgical dissection Fast, simple surgical repair Fast recovery Low 0.2% recurrence rates

Plug techniquePlug technique

3 Step Method: Position Insert Stabilize

Premilene Plug

UHS in the Posterior Space

Laparoscopic operationsLaparoscopic operations Operation is performed through trocars Operation is done inside the abdomen Visual control via monitor Using CO2 gas to lift abdominal wall away from inner organs

space is created Usage of an CO2-Insuflator Usage of long lap. instruments (> 30 cm) Usage of an endoscope Usage of a camera system and a light source

Laparoscopic hernia repairLaparoscopic hernia repair

First performed in 1990 Approach hernia repair from “inside-out” More complicated procedure Requires more surgical O.R. time Higher costs and more instrumentation General anesthesia 10 - 20 % of hernias are repaired by

laparoscopy

Laparoscopic hernia repairLaparoscopic hernia repair

Reduced pain Faster recovery Bilateral hernias Mesh is always used Low recurrence rates

TAPP TechniqueTAPP Technique

Hernia defect approached via abdominal cavity

Inflate pneumoperitoneum Hernia mesh placed preperitoneally Incise peritoneum from internal ring Remove hernia sac from spermatic

cord Staple or glue in 10 x 15 cm sheet of

mesh over inguinal area from mid line to Cooper’s ligament

Release pneumoperitoneum and move trocars

TransAbdominalPrePeritoneal

TEP TechniqueTEP Technique

TotallyExtraPeritoneal Performed outside of peritoneal cavity Eliminates incision of peritoneum. As a result intra-abdominal adhesions as well

as the risk of bowel injury are avoided Avoids adhesions with mesh prosthesis Inflatable dissection balloons are used to expand pre-peritoneal space A 10 x 15 cm mesh is used

Incisional hernias

Incisional hernia

Incisional hernias An incisional hernia occurs through the scar from a

previous surgical procedure. It can present wherever the scar is located on the

abdomen The hernia protrudes through a weakened abdominal wall

behind the scar and creates a bulge on the surface. Partial dehiscence of muscles and fascial layers Skin remains intact Most develop within a year of surgery Most are “wide necked” but strangulation can occur

Potential incisional hernias

• Incisional hernia is a common complication in abdominal surgery

• Incidence 10% (7,5 – 14%)

Recurrence is the problem!• Wound infection is the major reason for incisional hernia but there• are more risk factors (genetics, diabetes, adipositas, alcohol,• malnutrition...)

• Closure of incisional hernias by suturing may fail in every second

case. • Recurrence rate 30 – 50%

1. recurrence: 56%2. recurrence: 48%3. recurrence: 47%• Prevention of the recurrence is the issue !!!

• Only meshes can guarantee acceptable results:• Recurrence rate: 8 -13%

Incisional Hernia: Conventional surgery or meshes ?

Opinion of the surgeons: Margin-to-margin reconstruction (sutures) in

younger and healthy patients with small hernias (diameter <5 cm) to avoid mesh drawbacks of (traditional) meshes e.g. “stiff abdomen”, „knight‘s armor“.

Meshes for patients with big hernias Meshes for recurrence patients

Incisional hernia

Incisional ventral hernia as result of wound healing complications

Surgical Techniques•Small hernias (diameter smaller 4-5 cm) •A primary incisional hernia are closed by

conventional suture•technique. •Interrupted or running using non-

absorbable monofilament suture.

Surgical Techniques

•

Margin-to-margin techniqueUseful for routine closure of fascia and forsmall primary incisional hernia (smaller 4 cm).In big incisional hernia there is a highrecurrence rate of 25% ( up to 50%).

Fascia doubling acc. MayoAfter suturing of the muscle the mobilised fascia is doubled by interrupted sutures. Not better than margin-to-margin-technique. Recurrence rate 25% to 50%.

Surgical Techniques

• Meshes

• Can considerably reduce recurrence rate.

• Use of nonabsorbable implants (Polypropylene, Polyester, ePTFE-Mesh, Gore-Tex, Polyamide).

• Polyester- und Polypropylene-Meshes are incorporated by connective scar tissue and result in a stable scar formation.

Surgical Techniques

•The implanted, non-absorbable meshes do compensate the mechanical strain and act as matrix for a stable scar tissue generation. •Herniation through the

meshes is impossible. •Recurrence can only occure

at the mesh margins in case of insufficient overlapping.

Mesh Placement Techniques Onlay-Technique

Inlay-Technique

Sublay-Technique

Intraperitoneal (IPOM)

Rectus abdominis muscle

External oblique muscle

Peritoneum

Linea alba

FasciaInternal oblique mTransvers

us abdominis m

Skin

Onlay-Technique

• Poor results! • The mesh is placed on the fascia (e.g. the outer rectus sheeth). • Mesh acts as defect coverage.

• Abdominal wall reinforcement!

Rectus abdominis muscle


Peritoneum

Linea alba

FasciaInternal oblique muscleTransversus abdominis

muscle

Skin

Inlay-Technique•Poor results! •Mesh is placed between dehisced rectus muscles. •High recurrence rate (up to 46 %)•Function of mesh as defect filler! •No rectus muscle adaptation = tension-free

•Abdominal wall replacement!Anterior rectus sheath

Rectus abdominis

Sac

Sublay-Technique•Good results !!! •Mesh is placed preperitoneally between inner rectus sheeth and f.•transversalis

•Abdominal wall reinforcement!

connective tissue

rectus muscleabdominal

wall

abdominal cavity

meshperitoneum

Intraperitoneal (IPOM)

• Mesh placed between peritoneum and bowel. • The mesh must be coated to avoid adhesions.• Alternatively PTFE patches are used• (Gore Dualmesh).

• Abdominal wall replacement!Rectus abdominis muscle


Peritoneum

Linea alba

FasciaInternal oblique muscleTransversus abdominis

muscle

Skin

Intraperitoneal Onlay Mesh

Rectus abdominis

Sac

No rectus muscle adaptation !!! => tension-free

At what site would you do your „repair procedure“?

At the site where the pressure origins

(the water comes in) ! = sublay

Conclusions for the treatment of incisional hernias

Incisional hernia is a high potential surgery Different surgical technique are used, depending on the size

of the hernia and the patients situation Meshes for big hernias became standard and show acceptable

results Non-absorbable meshes are used for life-long support Implantation of meshes mostly sublay- technique. (First line of

defence = There where the pressure is!) Technique is not the highest priority!Important is: Sufficient mesh overlapping of the wound margins and A sufficient mesh fixation (herniation when fixation is lost) Further mesh improvements necessary

Soft Tissue Wound HealingSoft Tissue Wound Healing

• Mesh material such as Polypropylene mesh stimulates fibroplasia (growth of fibroblasts through the pores of the mesh) which permits a stronger layer of collagen deposition.

3 Major Processes of Wound Healing3 Major Processes of Wound Healing

Inflammatory Phase Proliferative Phase Remodeling Phase

Phase 1: InflammationPhase 1: Inflammation

• Time Period: Days

Inflammatory Cells 10 microns

Polypropylene Mesh

Phase 2: ProliferationPhase 2: Proliferation

• Time Period: Days - Weeks

Fibroblast 15x50

microns

Polypropylene Mesh

FibroblastFibroblast

Phase 3: RemodelingPhase 3: Remodeling

• Time Period: Weeks - Months

Collagen Remodeling

Polypropylene Mesh

Definition of Mesh characteristicsDefinition of Mesh characteristics

1. Materiala. Polypropelene Mesh

e.g B.Braun Premilene Mesh, Optilene Mesh

b. Polyethylene/Polyester Mesh e.g Parietex

c. Expanded Polytetrafloroethylene Mesh (ePTFE) e.g B.Braun Omyra Mesh

d. Titanium Mesh e.g TiMesh

TiMESH:

The titanium layer is so thin (approx. 30nm) that it is as flexible as plastic

d. Polygecaprone Mesh e.g Ultrapro Mesh

The body has to absorb/handle the foreign body material and the absorption takes up to 120 days

2. Mesh weight and Pore Sizes

1. Cause less inflammatory reactione.g: B.Braun Optilene Mesh LP; weigth: 36 g/m2

for inguinal hernia repair2. Leading to less shrinking of the mesh3. Easier to handle4. Reduce the foreign body feeling5. Produce more flexible scar for better abdominal wall

movement» Large pores Pore size > 1mm» Small pores Pore size < 1mm

Larger pore for better tissue ingrowthe.g: B.Braun Optilene Mesh Elastic; pore size: 3mm

Large pores:Why?

Small pores (solid scar plate) „Bridging“

Large pores (flexible „scar-mesh“)

Scar plate

„scar-mesh“

Mesh Filaments

Mesh Filaments

Optilene® Mesh Elastic

Result of incisional hernia repair

If not like this… …then hopefully like this

Ideal Mesh PropertiesIdeal Mesh Properties Inertness (no reaction) Biocompatibility Resistance to infection Molecular permeability Pliability and good handling characteristics Transparency Ideal insertion and spread characteristics Mechanical adaptation to body movements (Comformable) IPOM: Low incidence of adhesion formation on one mesh-

side

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