Prosthetics in Complex Bariatric Abdominal Wall Reconstruction Garth R Jacobsen, M.D. Director UCSD Hernia Center Surgical Program Director Center for the Future of Surgery UC San Diego Department of Surgery
Polypropylene Polypropylene (Most Common) Hydrophobic Resistant to significant degradation Induces biologic reactivity Weight, filament size, pore size, and architecture
Polyester Polyethylene terephthalate (PET) Hydrophilic Inflamatory response similar to PP Subject to degradation over time Subject to contraction Brand Names Mersiline – Ethicon Parietex – Covidien
Polytetraflouroethylene ePTFE Good Biocompatibility Highly engineered (3 to 100 um pore sizes) Subject to contracture Adhesion Resistant
Coated Nonabsorbables Attenuate host response to the prosthetic Variations for both PP and PE Useful when prosthetic is exposed to viscera Examples: C-Qur (Atrium) Omega-3 FA 80 Days Proceed (Ethicon) Oxidized Regenerated Cellulose (ORC) Absorbable PDS (polydiaxanone) 14 days Physiomesh (Ethicon) Monocryl backing Parietex Composite Polyethlene Glycol, Glycerol 14 days
Partially Absorbable Reduce the density of the nonabsorbable polymer component Increase intra-operative handling characteristics Vypro II (Ethicon) PP and Polyglactin (Vicryl) Ultrapro (Ethicon) PP Poliglecaprone-25 (Monocryl)
Composite Multiple mesh types combined into one sheet
Light vs Heavy Most commonly utilized mesh in use today is heavy weight polypropylene Marlex, Prolene, Surgipro, 3D Max Good handling characteristics High surgeon satisfaction Mechanically over engineered 26 N/cm vs >50 N/cm Potentially higher rates of pain, fistula formation, infection and mesh contraction Less compliant abdominal wall
What is Lightweight? 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.
Biologic Prosthetics Based on a collagen scaffold derived from a donor source Dermal sources Human, porcine and fetal Other sources Porcine small intestinal submucosa (layered) Bovine pericardium Decellularized to leave only organized collagen and extracellular ground tissue
Biologic Prosthetics Continued CrosslinkedvsNoncrosslinked Crosslinking resists collagenases Crosslinked meshes can last for years, uncrosslinked will be resorbed in 3 months Potential Advantages Potential for infection resistance Low adhesion formation*
Cost Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? SurgClin North Am. Feb 2008;88(1):101-112, ix.
So Which One is Best? Complex decision with no clear answer Type of procedure being done Clinical situation Desired handling characteristics Products available at your institution Cost of the product
UCSD expierience Retrospective review of a prospectively collected database Inclusion: Ventral hernia operated upon with the goal to restore native anatomy with investigation of a novel bio absorbable buttress
Complications Flap Necrosis Both identifiable at 1 week Both required intraoperative debridement and vac placement Pt 1: 66 yo female, bmi 30, 180 cm defect, repair 6, panniculectomy, onlay Bio-A, 1 year fu doing well Pt 2: 66 yo female, bmi 26, 6 cm defect, repair 3, panniculectomy, onlay Bio-A, 50 days post op, scheduled for scar revision
Tracheostomy 60 yo female with hx of repair x 7, infected biologic, and 900 sq cm defect. Release of Anterior and posterior sheath Onaly Bio A Butress ICU Paralytics for high Compartment pressures Trach day 8 Decannulated and discharged postoperative day 15 7 months out and doing well.
Seromas 3 total 1 did not require drainage and spontaneously resolved 1 drained in office x 1 1 Infected requiring IR drainage Initial operation was MRSA mesh excision
Conclusions There are many materials from which to choose from; surgeon knowledge of particular characteristics is key New classes of mesh may provide cost and patient advantage Bio Absorbable matrices are proving successful as a supportive adjuncts to complex abdominal wall restoration.