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  • 1. 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
  • 2. Bias?
    W.L. Gore: Honoraria: Speaking, Consulting, Writing, Proctering, Fellowship Support
    Ethicon Honoraria: Speaking, Consulting, Research Grants, Proctering, Fellowship Support
    USGI: Honoraria: Speaking, Consulting, Research Grants, Proctoring
    Covidien Honoraria: Speaking
    LifeCell: Honoraria: Speaking, Consulting
    Davol: Honorarium, Speaking
    MTF: Honorarium, Writing
    Novus: Honoraria; Consulting
  • 3. Bariatric Surgery
    Obese patients more commonly have hernias
    Most obesity operations involve transection of the GI tract
    Well followed group
  • 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”
    Theodore Billroth
  • 5. “Throughout the body, contractile dynamic muscular tissue resists strain and stress better than fascia and ligaments”
    Ralph Ger 1983
  • 6. Components Separation
  • 7. Ramirez Operative Technique
  • 8. Net Gain
    Release of external oblique
    2 cm upper
    4 cm mid
    2 cm lower
    Release of the posterior rectus sheath
    3 cm upper
    5 cm mid
    3 cm lower
    Total Gain
    5 cm upper
    9 cm mid
    5 cm lower
  • 9. Should We Reinforce?
    No large level 1 data sets exist
    Traditionally Expensive
    Anecdotal reports and small case series report recurrence rates from zero to 35%
    Onlay, Underlay, Lateral, Sandwich?
  • 10. Factors associated with performance
    Raw Material and Design
    Pore Size
    Fiber Size
  • 11. Synthetic Nonabsorbable Polymers
  • 12. Polypropylene
    Polypropylene (Most Common)
    Resistant to significant degradation
    Induces biologic reactivity
    Weight, filament size, pore size, and architecture
  • 13. Polyester
    Polyethylene terephthalate (PET)
    Inflamatory response similar to PP
    Subject to degradation over time
    Subject to contraction
    Brand Names
    Mersiline – Ethicon
    Parietex – Covidien
  • 14. Polytetraflouroethylene
    Good Biocompatibility
    Highly engineered (3 to 100 um pore sizes)
    Subject to contracture
    Adhesion Resistant
  • 15. Coated Nonabsorbables
    Attenuate host response to the prosthetic
    Variations for both PP and PE
    Useful when prosthetic is exposed to viscera
    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
  • 16. 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)
  • 17. Composite
    Multiple mesh types combined into one sheet
  • 18. 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
  • 19. 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.
  • 20. Lightweight Offerings
    Bard 3dMax light
    Bard Composix LP
    Ethicon Ultrapro
    Gore Infinit
  • 21. Biologic Prosthetics
  • 22. 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
  • 23. Biologic Prosthetics Continued
    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*
  • 24. 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.
  • 25. Synthetic “biologics”
    Synthetic bioabsorbable (glycolide: trimethylene carbonate) copolymer
    Native collagen ingrowth
    Fully resorbable in 6 months
  • 26. 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
  • 27. 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
  • 28. Demographics
  • 29. Operative Intervention
  • 30. Wound Class
  • 31. Reconstruction Technique
  • 32. Mesh Placement
  • 33. LOS and Complications
  • 34. EO to EO onlay Reinforcement
  • 35. Case Examples
    Infected crosslinked biologic mesh and 8 months post op BIOA EO to EO after complete components
  • 36. Case Examples
    Infected synthetic mesh and 9 months post op BIOA EO to EO after anterior sheath release
  • 37. Pet CT 3 months, anterior onlay
  • 38. Case Examples
    Post operative infected seroma (proteus/enterococcus) day 15, treated with IR drainage and 8 months post op BIOA EO to EO after complete components
  • 39. Case Examples
    54 year old mail with large defect and infected mesh
  • 40.
  • 41. Completed Components
  • 42. Large Sheet Anterior Application
  • 43. 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
  • 44. 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.
  • 45. 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
  • 46. 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.
  • 47. Thanks