Prosthetics in Complex Bariatric Abdominal Wall Reconstruction<br />Garth R Jacobsen, M.D.<br />Director UCSD Hernia Cente...
Bias?<br />W.L. Gore: 	Honoraria: Speaking, Consulting, 			Writing, Proctering, Fellowship Support<br />Ethicon	Honoraria:...
Bariatric Surgery<br />Obese patients more commonly have hernias<br />Most obesity operations involve transection of the G...
“If we could artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cur...
“Throughout the body, contractile dynamic muscular tissue resists strain and stress better than fascia and ligaments”<br /...
Components Separation<br />
Ramirez Operative Technique<br />
Net Gain<br />Release of external oblique<br />2 cm upper<br />4 cm mid<br />2 cm lower<br />Release of the posterior rect...
Should We Reinforce?<br />No large level 1 data sets exist<br />Traditionally Expensive<br />Anecdotal reports and small c...
Factors associated with performance<br />Raw Material and Design<br />Polymer/tissue<br />Strength<br />Elasticity<br />Ar...
Synthetic Nonabsorbable Polymers<br />
Polypropylene<br />Polypropylene (Most Common)<br />Hydrophobic<br />Resistant to significant degradation<br />Induces bio...
Polyester<br />Polyethylene terephthalate (PET)<br />Hydrophilic<br />Inflamatory response similar to PP<br />Subject to d...
Polytetraflouroethylene<br />ePTFE<br />Good Biocompatibility<br />Highly engineered (3 to 100 um pore sizes)<br />Subject...
Coated Nonabsorbables<br />Attenuate host response to the prosthetic<br />Variations for both PP and PE<br />Useful when p...
Partially Absorbable<br />Reduce the density of the nonabsorbable  polymer component<br />Increase intra-operative handlin...
Composite<br />Multiple mesh types combined into one sheet<br />
Light vs Heavy<br />Most commonly utilized mesh in use today is heavy weight polypropylene<br />Marlex, Prolene, Surgipro,...
What is Lightweight?<br />Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? Surg Clin N...
Lightweight Offerings<br />Davol<br />Bard 3dMax light<br />Bard Composix LP<br />Ethicon Ultrapro<br />Gore Infinit<br />
Biologic Prosthetics<br />
Biologic Prosthetics<br />Based on a collagen scaffold derived from a donor source<br /> Dermal sources<br />Human, porcin...
Biologic Prosthetics Continued<br />CrosslinkedvsNoncrosslinked<br />Crosslinking resists collagenases<br />Crosslinked me...
Cost<br />Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? SurgClin North Am. Feb 2008...
Synthetic “biologics”<br />Synthetic bioabsorbable (glycolide: trimethylene carbonate) copolymer<br />Native collagen ingr...
So Which One is Best?<br />Complex decision with no clear answer<br />Type of procedure being done<br />Clinical situation...
UCSD expierience<br />Retrospective review of a prospectively collected database<br />Inclusion:  Ventral hernia operated ...
Demographics<br />
Operative Intervention<br />
Wound Class<br />
Reconstruction Technique<br />
Mesh Placement<br />
LOS  and Complications<br />
EO to EO onlay Reinforcement<br />
Case Examples<br />Infected crosslinked biologic mesh and 8 months post op BIOA EO to EO after complete components <br />
Case Examples<br />Infected synthetic mesh and 9 months post op BIOA EO to EO after  anterior sheath release<br />
Pet CT 3 months, anterior onlay<br />
Case Examples<br />Post operative infected seroma (proteus/enterococcus) day 15, treated with IR drainage and 8 months pos...
Case Examples<br />54 year old mail with large defect and infected mesh<br />
Completed Components<br />
Large Sheet Anterior Application<br />
Complications<br />Flap Necrosis<br />Both identifiable at 1 week<br />Both required intraoperative debridement and vac pl...
Tracheostomy<br />60 yo female with hx of repair x 7, infected biologic, and 900 sq cm defect.<br />Release of Anterior an...
Seromas<br />3 total<br />1 did not require drainage and spontaneously resolved<br />1 drained in office x 1<br />1 Infect...
Conclusions<br />There are many materials from which to choose from; surgeon knowledge of particular characteristics is ke...
Thanks<br />
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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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