Meshes and bariatric surgery for argentina

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Meshes and bariatric surgery for argentina

  1. 1. Prosthetics in Complex Bariatric Abdominal Wall Reconstruction<br />Garth R Jacobsen, M.D.<br />Director UCSD Hernia Center<br />Surgical Program Director<br />Center for the Future of Surgery<br />UC San Diego Department of Surgery<br />
  2. 2. Bias?<br />W.L. Gore: Honoraria: Speaking, Consulting, Writing, Proctering, Fellowship Support<br />Ethicon Honoraria: Speaking, Consulting, Research Grants, Proctering, Fellowship Support<br />USGI: Honoraria: Speaking, Consulting, Research Grants, Proctoring<br />Covidien Honoraria: Speaking<br />LifeCell: Honoraria: Speaking, Consulting<br />Davol: Honorarium, Speaking<br />MTF: Honorarium, Writing<br />Novus: Honoraria; Consulting<br />
  3. 3. Bariatric Surgery<br />Obese patients more commonly have hernias<br />Most obesity operations involve transection of the GI tract<br />Well followed group<br />
  4. 4. “If we could artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernias would be discovered”<br />Theodore Billroth<br />1829-1894<br />
  5. 5. “Throughout the body, contractile dynamic muscular tissue resists strain and stress better than fascia and ligaments”<br />Ralph Ger 1983<br />
  6. 6. Components Separation<br />
  7. 7. Ramirez Operative Technique<br />
  8. 8. Net Gain<br />Release of external oblique<br />2 cm upper<br />4 cm mid<br />2 cm lower<br />Release of the posterior rectus sheath<br />3 cm upper <br />5 cm mid<br />3 cm lower<br />Total Gain<br />5 cm upper<br />9 cm mid<br />5 cm lower<br />
  9. 9. Should We Reinforce?<br />No large level 1 data sets exist<br />Traditionally Expensive<br />Anecdotal reports and small case series report recurrence rates from zero to 35%<br />Onlay, Underlay, Lateral, Sandwich?<br />
  10. 10. Factors associated with performance<br />Raw Material and Design<br />Polymer/tissue<br />Strength<br />Elasticity<br />Architecture<br />Pore Size<br />Fiber Size<br />Density<br />Weave<br />Bioreactivity<br />
  11. 11. Synthetic Nonabsorbable Polymers<br />
  12. 12. Polypropylene<br />Polypropylene (Most Common)<br />Hydrophobic<br />Resistant to significant degradation<br />Induces biologic reactivity<br />Weight, filament size, pore size, and architecture<br />
  13. 13. Polyester<br />Polyethylene terephthalate (PET)<br />Hydrophilic<br />Inflamatory response similar to PP<br />Subject to degradation over time<br />Subject to contraction<br />Brand Names<br />Mersiline – Ethicon<br />Parietex – Covidien<br />
  14. 14. Polytetraflouroethylene<br />ePTFE<br />Good Biocompatibility<br />Highly engineered (3 to 100 um pore sizes)<br />Subject to contracture<br />Adhesion Resistant<br />
  15. 15. Coated Nonabsorbables<br />Attenuate host response to the prosthetic<br />Variations for both PP and PE<br />Useful when prosthetic is exposed to viscera<br />Examples:<br />C-Qur (Atrium)<br />Omega-3 FA<br />80 Days <br />Proceed (Ethicon) <br />Oxidized Regenerated Cellulose (ORC)<br />Absorbable PDS (polydiaxanone)<br />14 days<br />Physiomesh (Ethicon)<br />Monocryl backing <br />Parietex Composite<br />Polyethlene Glycol, Glycerol <br />14 days<br />
  16. 16. Partially Absorbable<br />Reduce the density of the nonabsorbable polymer component<br />Increase intra-operative handling characteristics<br />Vypro II (Ethicon) <br />PP and Polyglactin (Vicryl)<br />Ultrapro (Ethicon)<br />PP Poliglecaprone-25 (Monocryl)<br />
  17. 17. Composite<br />Multiple mesh types combined into one sheet<br />
  18. 18. Light vs Heavy<br />Most commonly utilized mesh in use today is heavy weight polypropylene<br />Marlex, Prolene, Surgipro, 3D Max<br />Good handling characteristics<br />High surgeon satisfaction<br />Mechanically over engineered<br />26 N/cm vs >50 N/cm<br />Potentially higher rates of pain, fistula formation, infection and mesh contraction<br />Less compliant abdominal wall<br />
  19. 19. What is Lightweight?<br />Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? Surg Clin North Am. Feb 2008;88(1):101-112, ix.<br />
  20. 20. Lightweight Offerings<br />Davol<br />Bard 3dMax light<br />Bard Composix LP<br />Ethicon Ultrapro<br />Gore Infinit<br />
  21. 21. Biologic Prosthetics<br />
  22. 22. Biologic Prosthetics<br />Based on a collagen scaffold derived from a donor source<br /> Dermal sources<br />Human, porcine and fetal<br />Other sources<br />Porcine small intestinal submucosa (layered)<br />Bovine pericardium<br />Decellularized to leave only organized collagen and extracellular ground tissue<br />
  23. 23. Biologic Prosthetics Continued<br />CrosslinkedvsNoncrosslinked<br />Crosslinking resists collagenases<br />Crosslinked meshes can last for years, uncrosslinked will be resorbed in 3 months<br />Potential Advantages<br />Potential for infection resistance<br />Low adhesion formation*<br />
  24. 24. Cost<br />Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? SurgClin North Am. Feb 2008;88(1):101-112, ix.<br />
  25. 25. Synthetic “biologics”<br />Synthetic bioabsorbable (glycolide: trimethylene carbonate) copolymer<br />Native collagen ingrowth<br />Fully resorbable in 6 months <br />
  26. 26. So Which One is Best?<br />Complex decision with no clear answer<br />Type of procedure being done<br />Clinical situation<br />Desired handling characteristics<br />Products available at your institution<br />Cost of the product<br />
  27. 27. UCSD expierience<br />Retrospective review of a prospectively collected database<br />Inclusion: Ventral hernia operated upon with the goal to restore native anatomy with investigation of a novel bio absorbable buttress<br />
  28. 28. Demographics<br />
  29. 29. Operative Intervention<br />
  30. 30. Wound Class<br />
  31. 31. Reconstruction Technique<br />
  32. 32. Mesh Placement<br />
  33. 33. LOS and Complications<br />
  34. 34. EO to EO onlay Reinforcement<br />
  35. 35. Case Examples<br />Infected crosslinked biologic mesh and 8 months post op BIOA EO to EO after complete components <br />
  36. 36. Case Examples<br />Infected synthetic mesh and 9 months post op BIOA EO to EO after anterior sheath release<br />
  37. 37. Pet CT 3 months, anterior onlay<br />
  38. 38. Case Examples<br />Post operative infected seroma (proteus/enterococcus) day 15, treated with IR drainage and 8 months post op BIOA EO to EO after complete components <br />
  39. 39. Case Examples<br />54 year old mail with large defect and infected mesh<br />
  40. 40.
  41. 41. Completed Components<br />
  42. 42. Large Sheet Anterior Application<br />
  43. 43. Complications<br />Flap Necrosis<br />Both identifiable at 1 week<br />Both required intraoperative debridement and vac placement<br />Pt 1: 66 yo female, bmi 30, 180 cm defect, repair 6, panniculectomy, onlay Bio-A, 1 year fu doing well<br />Pt 2: 66 yo female, bmi 26, 6 cm defect, repair 3, panniculectomy, onlay Bio-A, 50 days post op, scheduled for scar revision<br />
  44. 44. Tracheostomy<br />60 yo female with hx of repair x 7, infected biologic, and 900 sq cm defect.<br />Release of Anterior and posterior sheath<br />Onaly Bio A Butress<br />ICU Paralytics for high Compartment pressures<br />Trach day 8<br />Decannulated and discharged postoperative day 15<br />7 months out and doing well. <br />
  45. 45. Seromas<br />3 total<br />1 did not require drainage and spontaneously resolved<br />1 drained in office x 1<br />1 Infected requiring IR drainage<br />Initial operation was MRSA mesh excision<br />
  46. 46. Conclusions<br />There are many materials from which to choose from; surgeon knowledge of particular characteristics is key<br />New classes of mesh may provide cost and patient advantage<br />Bio Absorbable matrices are proving successful as a supportive adjuncts to complex abdominal wall restoration. <br />
  47. 47. Thanks<br />

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