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9.Irrigation-aspiration instrument:
Fig.221: Irrigation-aspiration instrument. Source [221].
C)Robotic surgery:
A surgical robot usually consists of a robotic arm, a manipulator, and a camera giving the
operating surgeon a view of the patient from their remote-control terminal.
Fig.222: Surgical robot. Source [222].
200
CHAPTER TWELVE: TYPES OF MESH IMPLANTS AND THEIR PROPERTIES.
A.V Protasov ,M.Sh F .Mekhaeel ,S.Sameh
Silver and titanium were the first biomaterials to be used for reinforcement of hernia starting from
the 40’s of the last century, which were replaced by permanent synthetic mesh materials in the
next decade reaching up to 150 types of mesh materials nowadays. The uniqueness of Deeken &
Lake Mesh Classification system over other classifications; is that it clarifies the nuances in order
to explain the properties of the used materials dividing them into 3 main groups; permanent
synthetic, resorbable, and biological tissue-derived materials which are furtherly divided into
subgroups depending on; reinforcement materials, coatings and barriers.
The physical characteristics on which Deeken & Lake system relies on are:
1. Pore sizes; microporous (< 100 ȝm), small pores (100-600 ȝm), medium pores (600-1000 ȝm),
large pores (1000-2000 ȝm).
2. Fiber diameter; very large (> 200 ȝm), large (175-200 microm.), medium (150-175 ȝm.), small
(125-150 ȝm.) and very small (<125 ȝm).
3. Thickness; extra thick (>1.5mm), thick (1-1.5 mm), medium (0.75-1 mm), thin (0.5-0.75mm)
and very thin (<0.5 mm).
4. Area density; heavy weight (>90g/m2), medium weight (50-90g/m2), light-weight (35-50
g/m2) and ultra-light-weight (<35g/m2).
5. Suture retention strength; the maximum load sustained prior to failure of the suture.
6. Tear resistance testing; is the performed effort to understand the resistance of the material
provides against propagation of tear once the tear has been initiated.
7. Ball burst testing; Estimating strain, stiffens and ultimate tensile strength of the tested mesh
material.
8. Uniaxial tensile testing; to understand the resistance of the material provides against tension
applied in two orthogonal directions simulating the conditions of the human abdomen.
9. Lap shear testing; Measuring the maximum load measured in Newton which the suture can
resist achieving tissue reinforcement.
The first category includes permanent synthetic polymers:
1.Polyprolene (PP): A nonabsorbable, high tensile strength, nonpolar, electrostatically neutral,
and highly hydrophobic, coated or uncoated; mono or multifilamentous. Heavy or light weight,
were the latter decreasing the incidence of recurrence through escaping intense inflammatory
reaction and thick scar formation therefore avoids mesh contraction.
2.Polyester (PET): Multifilamentous, polar, hydrophilic, and coated by collagen preventing
adhesions, so be used intraperitoneally degradable during infections.
3.Extended Polytetrafluoroethylene (ePTFE): Having minimal inflammatory reaction and
lower scar density; in comparison to PP and PET. However, its fixation with fine material is
mandatory as it can be easily broken.
4.Polyvinylidene fluoride (PVDF): Is superior to PP and PET regarding its resistance to
degeneration and hydrolysis, moreover, decreasing foreign body response is considered as an
additional advantage as reported in some studies.
Coatings, the permanent anti-adhesive coating group for all current designs possess Titanium.
Moreover, permanent synthetic meshes are paired with resorbable barriers, biological tissuederived barriers or resorbable coatings e.g., Omega 3.
201
Barrier materials which act as an anti-adhesive layer are classified into:
y
p
g
N/cm
p
ght
1.Permanent non-composite, include expanded PTEF (ePTFE).
2.Permanent Composite, include (ePTFE) with the exception of one silicone design (Surgimesh®).
3.Resorbable (biologically-derived) include: Sodium
hyaluronate/carboxymethelcellulose/polyethylene glycol hydrogel,
glycolide/caprolactone/trimethylene carbonate, glycolide/ E caprolactone, type I collagen,
polyglycolic acid/trimethylene carbonate, Polyvinylpyrrolidone/polyethylene glycol and finally
the omega-3 fatty acid which represents the only available resorbable coating.
The properties of each type of the first-generation mesh implants in the markets: (table 18).
Product
(Manufacturer)
Vicryl®
(Ethicon)
Dexon ®
neture)
(S
Sefil® (B-
Baun)
Marlex ®
(BARD)
3D Max ®
(BARD
Polysoft ®
(BARD)
Prolene ®
(Ethicon)
Surgipro®
(Autosuture)
Prolite ®
(Atrium)
Trelex®
(Meadox)
Atrium ®
(Atrium)
Premilene®
(B-Braun)
Serapren ®
(smooth)
Parietene®
(Covidien)
Prolene Light®
(Covidien)
Optilene®
(B-Baun)
Mersilene®
(Ethicon)
Goretex®
(Gore)
PP: Polypropylene. POL: Polyester. E-PTFE: Expanded polytetrafluoroethylene. PGA. Polyglycolic acid. N.A, Information not
Material Pore
PGA 0.4 Fully
PGA 0.75 Fully
PGA 0.75 Fully
PP 0.8 No 80–100 Multifilament 58.8 N.A. Evokes a
PP 0.8 No 80–100 Multifilament 124.7 Reduced
PP 0.8 No 80–100 Multifilament N. A Eliminates
PP 0.8 No 80–100 Multifilament 156.5 Eliminates
PP 0.8 No 80–100 Multifilament 41.8 Flexible. Incomplete
PP 0.8 NO 80–100 Multifilament 138 Flexible Adhesions.
PP 0.8 No 80–100 Multifilament N. A Flexible Adhesions.
PP 0.8 No 80–100 Multifilament 56.2
PP 0.8 No 80–100 Monofilament 41.4 Flexible. Adhesions.
PP 0.8 No 80–100 Multifilament N.A. Flexible. Adhesions.
PP 0.8 No 80–100 Multifilament 38.9 ±
PP 1-3.6 No 36–48 Monofilament 20 Flexible. Adhesions.
PP 1-3.6 No 36–48 Monofilament 58 Eliminates
POL 1-2 No 40 Multifilament 19 Eliminates
ePTFE 0.003 No Heavy
Absorbability Weight
Size
(mm)
(60–90 days)
(60–90 days)
(60–90 days)
(g/m2)
Wei
Filament Tensile
56 Multifilament 78.2 ±
56 Multifilament N.A. N.A. Adhesions
56 Multifilament N.A. Low risk of
Multifilament 16 Flexible Adhesions.
available.
Advantages Disadvantages
strength
(N/cm)
Eliminates
10.5
infections.
Secondary
infection
ain.
infection.
infection
Tolerance to
infection.
Flexible. Adhesions.
5.2
ain.
infection
Recurrence.
N.A.
chronic
inflammatory
reaction.
Adhesions.
Adhesions
Adhesions
wound
Healin
Adhesions.
Adhesions.
Adhesions.
202
Hybrid meshes are created by combination of two materials aiming to obtain advantages of both;
(
ys)
p
i.e. permanent synthetic and resorbable materials; a co-polymer of glycolide and lactide or
glycolide/ E caprolactone,; providing mechanical support at the sites of defect, followed by gradual
absorption, moreover, the combination of some types of permanent synthetic mesh materials and
biologically tissue derived anti-adhesive barrier i.e. Zenapro® which is a composite of polyprolene
(PP) and a non-cross-linked porcine small cell intestinal submucosa.
The second major category of meshes is furtherly subdivided into: non-coated without barriers
or even reinforced, and coated barriers. Uncoated barriers include:
1.Poly-4-hydroxybutyrate (P4HB).
2.Ultra-pure fibroin from silk.
3.Polyglycolic acid (PGA).
4.Co-polymer of glycolide and lactide.
5.Co-polymer of polyglycolic acid and trimethylene carbonate and Co-polymer of glycolide.
6.Lactide and trimethylene carbonate. Coated barriers by resorbable composite include: (Poly-4hydroxybutyarate scaffold paired with a hydrogel of sodium
hyaluronate/carboxymethelcellulose/polyethyleneglycol.
The properties of each type of the second generation meshes in the markets: (table 19).
Product
(Manufacture
r)
Vypro®
Vypro II®
Ethicon)
Gore-Tex
Dual Mesh®
Plus (Gore)
Parietex®
(Covidien)
Composix
EX Dulex®
(BARD)
Proceed®
(Ethicon)
DynaMesh
IPOM®
(FEG
Textiltechnik)
Sepramesh®
(Genzyme)
Ultrapro®
(Ethicon)
Ti-Mesh®
(GfE)
C-Qur®
(Atrium)
PP: Polypropylene. E-PTFE: Expanded polytetrafluoroethylene. POL: Polyester. PVDF: Polyvinylidene fluoride. PGC-25:
Material Pore
PP/polyglacti
n
910
e-PTFE 0.003
POL/collagen >3 Partially
PP/e-PTFE 0.8 No Monofilame
PP/cellulose Large Partially
PP/PVDF 1–2 Partially Monofilame
PP/sodium 1–2 Partially
PP/PGC-25 >3 Partially
PP/titanium >1 No Monofilame
PP/omega 3 >1 Partially
Absorbable Filament Tensile
Size
(mm)
>3 Partially
(42 days)
–
0.022
(20 days)
(120 days)
poliglecaprone 25.N.A, Information not available in literature.
Multifilament 16 25 &
No Multifilament 16 Heavy
Multifilament 16 75 Eliminates
nt
Monofilame
(<30
days)
(<30
days)
(<140
da
nt
nt
Monofilame
nt
Monofilame
nt
nt
Monofilame
nt
Weigh
strengt
h
(N/cm)
N. A Light
56.6 45 Eliminate
11.1 60 Biocompatibilit
N. A 102 Reduces
55 28 Reduced
12 16 Reduced
170 ±
20.1 N
Advantages Disadvantag
t
(g/m2
)
Eliminates pain. Recurrence
30
Weigh
Weigh
Eliminates
adhesions.
t
t
50 N.A. Poor anti-
adhesions.
Minimizes
adhesions.
recurrence
y.
adhesions.
inflammatory
response.
inflammatory
response.
es
Infection.
Infection.
Infection.
Adhesions.
Adhesions.
Non-flexible
Adhesions
Low tensile
strength
adhesion
roperty.
203
The third category of hernia meshes ‘Biological meshes’, which had been introduced to
overcome the complications of synthetic meshes are furtherly divided into: Non-crosslinked: and
Crosslinked.
The properties of each type of the third generation meshes in the markets: (table 20).
Product
(Manufacturer)
Surgisis®
(Cook)
FlexHD®
(J&J)
AlloMax®
(Davol)
CollaMend®
(Davol)
Strattice®
(LifeCell)
Permacol®
(Covidien)
XenMatrix®
(Davol)
Material Tensile Strength
Porcine (small
intestine
submucosa)
Human (acellular
dermis)
Human (acellular
dermis)
Porcine/Bovine
(xenogenic
acellular dermis)
Porcine/Bovine
(xenogenic
acellular dermis)
Porcine/Bovine
(xenogenic
acellular dermis)
Porcine/Bovine
(xenogenic
acellular dermis)
(MPa)
4 No refrigeration is
10 No refrigeration or
23 No refrigeration or
11 No refrigeration or
18 Available in large
39 No refrigeration or
14 Available in large
Advantages Disadvantages
required.
Long history of safety
data
rehydration is required
rehydration is
required.
Available in large
sizes
rehydration is
required.
Available in large
sizes.
sheets.
rehydration is
required.
Available in large
sizes.
sheets.
Requires hydration.
Susceptible to
collagenases.
*N. A
Hydration
required.
*N. A
Limited long-term
follow up.
*N. A
Limited long-term
follow up.
*N.A. Information not available in literature.
Mesh fixation using tacks, screws, or clips has led to numerous postoperative complications,
including, vascular injury, bowel obstruction, mesh migration and neuralgia which are avoided by
using Self-gripping meshes: ProGrip™ is PP self-gripping, lightweight, isoelastic; macroporous
knitted monofilament, hydrophilic mesh with absorbable micro-grips providing self-adhesive
fixation during the first months after implantation with an absorption time more than 18 months.
Moreover, absorption of 40% of the mesh weight decreases postoperative foreign body sensation
and chronic pain. In addition to providing a tack-free fixation during laparoscopic hernioplasty
with superior fixation strength compared to Bard 3D Max™ light textile with SorbaFix™ tacks or
fibrin sealant, fast recovery, easy to use, and faster than tacks and glue decreasing the cost of
laparoscopic inguinal procedure are additional advantages of ProGrip™ orienting it to be a part of
the green medical market products.
Adhesix™ is a self-gripping, double-sided mesh, made of two components. A knitted,
monofilament polypropylene mesh (rough side) covered by a resorbable layer of polyethylene
glycol (PEG) and polyvinylpyrrolidone (PVP) (smooth side), which upon moistening form a
hydrogel that cross-links to the underlying tissue within 5 minutes and resolves within 7 days
reducing, mesh weight to <40 g/m2 allowing easy movement and repositioning. However, poor
integration, seroma formation and shrinkage are drawbacks of meshes Adhesix™.
204
Antibiotic coated mesh shows the following spectrums of bacterial strain inhibitions.
1.Ampicillin coated PP meshes: S. aureus and E. coli.
2.Gentamicin coated polyprolene/ poliglecaprone (PP/ PGC) and PE—polyester: S. aureus and
when coated to PVDF—polyvinylidenfluoride: S. aureus E. coli, S. epidermidis.
3.Cefazolin coated PGA-TMC—polyglycolic acid– trimethylene carbonate; S. aureus while when
loaded on PE—polyester meshes: MRSA infection.
4.Vancomycin coated PE—polyester meshes: S. aureus and MRSA infections.
5.Levofloxacin coated PP and PCL—polycaprolactone meshes: S. aureus, E. coli, while when
loaded with silver on PLLA—poly-L-lactide mesh: MRSA infection.
6.Ciprofloxacin coated PP meshes: S. aureus, E. coli infection. PCL/L-DOPA meshes coated by
ofloxacin have the same zone of prevention.
7.Rifampicin coated meshes: S. aureus and E. coil, while when loaded with other antibiotics like
minocycline or ofloxacin: MRSA infection.
3D meshes:
3D printing is bio-dimensional imaging of surgical meshes via layer-by-layer deposition of
materials on the mesh surface which is obtained by 7 procedures: (i) fused deposition model
(FDM), also known as material extrusion, (ii) powder bed fusion, (iii) vat photopolymerization,
(iv) material jetting, (v) binder jetting, (vi) sheet lamination, and (vii) directed energy deposition,
were the choice of procedure depends on many factors; type of mesh material, time of production,
cost, availability of equipment, and technical expertise; i.e. FDM is used for the development of
non-biological, while powder bed fusion has applications in drug delivery systems.
The advantage of such layer-by-layer fabrication system is that the printed layers and compounds
used can be tailored to achieve a coordinated balance between drug release and device degradation
therefore enhancing tissue repair, moreover, upon loading with contrast-materials, 3D printed
meshes were visible on CT.
Moreover, 4D-printing seems to resolve the limitations of 3D-printed devices to recapitulate the
dynamics of living tissues by introducing “time” as a new factor, where smart thermo-polymers
capable of shape changes in response to physicochemical or biochemical stimuli (e.g., temperature,
pressure, presence of molecules, pH) which can be extruded via FDM approaches. These stimuliresponsive polymers allow the mesh to progressively adapt and respond to changes in the hosttissue environment, enhancing tissue ingrowth and implant compliance. Moreover, this technology
can optimize drug delivery systems, enabling drug-loaded printed meshes to release their
medication only and specifically when needed e.g., release of antibiotics in the presence of
bacterial toxins, release of cytokines and growth factors to stimulate cell migration and
vascularization.
205
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