Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
116
K. A. LeBlanc
with a supplied introduction tool. The two mesh layers are sutured together with
ePTFE suture. The Composix L/P is also available with the ECHO PS (Fig.4.110).
The green balloon shown in the gure will be inated to rm up the mesh to allow
for accurate positioning and xation. There is an attached blue tubing on the opposite side (not seen in the gure) that is pulled through the abdominal wall to center
the mesh. It is then cut and attached to a syringe that is used to inate the balloon.
Once xation is completed, the balloon is deated and removed.
DynaMesh IPOM is a similar PP weave as the DynaMesh described earlier in
this chapter (Fig. 4.19) but it is slightly lighter in weight than the latter product
(Fig. 4.111). This version is intertwined with a monolament of polyvinylidene
Fig. 4.110 Composix L/P
mesh with Echo PS
Fig. 4.111 DynaMesh IPOM
4 Prosthetic Materials forRobot-Assisted Hernia Repair
117
uoride (PVDF). Because of this PVDF tissue-separating component it can be
placed onto the viscera. The suture noted in the gure signies which side should be
placed against the abdominal wall, as it is impossible to be certain with the naked
eye which side is the parietal surface. Intra mesh is a combination of nonwoven PP
on one side with a layer of silicone on the other as a tissue separating material
(Fig.4.112). It is one of the few materials available with this silicone barrier. This
side is marked with a cross and “intra side” in black silicone ink. IntraMesh T1 is
similar to the Composix product line in that it is composed of one layer of PP and a
second layer of ePTFE (Fig.4.113). It is the only material that possesses lines on the
product to delineate the midportions of each side to ease positioning for the laparoscopic/robotic approach. Cousin Biotech also sells a “mesh roller” which is a device
to aid in the rolling of these materials to ease insertion into the abdominal cavity
through a trocar. IS 180 is part of the intra-swing composite family, which is a macroperforated three-dimensional POL with a coating of PUR (tissue- separating) on
one surface (Fig.4.114). It is congured in a variety of shapes with or without PP
sutures to aid in xation. The company also has an available Easy-Catch EC device
to be used for laparoscopic introduction of the material into the abdominal cavity.
Prex is similar in concept to the IS 180 but, as shown in the photo, there are
Fig. 4.112 Intra mesh
Fig. 4.113 IntraMesh T1
118
K. A. LeBlanc
preplaced sutures to allow for positioning of the product (Fig.4.115). It is one of the
few products that include pre-attached sutures with straight needles on them.
Plurimesh (PCMC) is a similar concept as the CMC except that it is designed for
incisional or parastomal hernia repair (Fig.4.116). It has sewn seams that can be
Fig. 4.114 IS 180
Fig. 4.115 Prex
4 Prosthetic Materials forRobot-Assisted Hernia Repair
Fig. 4.116 Plurimesh
Fig. 4.117 Rebound
HRD V
119
used to cut the mesh to conform to the needs of the hernia treated. Rebound HRD V
is a unique material in that it is PP that has a ring of nitinol to stiffen the product and
is available as an oval shape for umbilical hernia repair (Fig.4.117). It is designed
for use in the preperitoneal space and does not have a separate coating. It is placed
in this section due to fact that it has signicantly different components. Relimesh is
another product that incorporates the PP on one surface and ePTFE on the other to
allow placement against the viscera. It is a lighter weight product compared to other
HerniaMesh products. Because of this, it can be rolled for insertion via a trocar. It is
marked to aid in positioning and xation. SMH2+ has been previously described in
the preformed inguinal hernia mesh section and is PP and PUR.It is also indicated
for ventral hernias as well (Fig.4.88). SM3+ is polyester with impregnated polyure-
thane and is a at mesh but is also congured in anatomical shapes for inguinal or
femoral hernia repair (Fig.4.118).
SurgiMesh XB has a non-woven, non-knitted structure as does the SurgiMesh
WN described earlier but it has an additional layer of silicone to allow contact with
120
Fig. 4.118 SM3+
Fig. 4.119 Surgimesh XB
K. A. LeBlanc
the viscera and is microperforated (Fig.4.119). This product is available in different
shape including a circular one that has an attached suture as a positioning aid (Tintra
C). TiMesh is the same material that has been described in several locations within
this chapter (Fig.4.37). The titanized PPM can be used in the intraperitoneal location (per the manufacturer). Another titanized PPM is that of TiO
Mesh (Fig.4.40).
2
This is described in the Miscellaneous Flat Mesh section above. Umbilical CMC is
round and includes blue stitching and tethers to aid in positioning (Fig.4.120).
Ventralex is a self-expanding PP device (because of the outer ring of polydioxanone) that has ePTFE on one side to allow placement adjacent to viscera (Fig.4.121).
It is round but smaller than the larger products such as the Composix products
described above. It is intended for use in the smaller defects of the abdominal wall
such as trocar or umbilical hernias. Two long straps are attached that are very long
as this product can be inserted through a laparoscopic trocar to aid in the prevention
of trocar hernias. When used during robotic incisional hernia repair, the straps
4 Prosthetic Materials forRobot-Assisted Hernia Repair
Fig. 4.120 Umbilical
CMC
Fig. 4.121 Ventralex
121
Fig. 4.122 Ventrio hernia
patch
should be removed prior to insertion. The Ventrio Hernia Patch is comprised of two
layers of PP that are stitched to an ePTFE layer as the tissue-separating component
(Fig. 4.122). Within the PP surface there are “tubes” that house an absorbable
polydioxanone (PDO) monolament ring(s) to give the mesh rigidity to aid in positioning and xation. The purple PDO ring is absorbed within 6–8months.
122
K. A. LeBlanc
4.13 Stomal Hernia Prevention andRepair Products
The development of a hernia wherever a stoma is created has been the challenge in
the life of all patients with some type of an ostomy. Traditionally, relocation or primary closure was used to repair these hernias but this is now considered a poor
choice as this method or repair is fraught with failure in most cases. Consequently,
the use of a prosthetic material has become nearly standard to repair these hernias.
In fact, recent trends indicate that the use of a mesh of some type when the stoma is
created may be the preferred option. Prevention has become the new effort in mesh
construction (Table 4.19). Many of these involve the use of one of the biologic,
synthetic absorbable or permanent products described earlier in this chapter. As
with many of the other products in this chapter, these can generally be used with the
open or laparoscopic/robotic techniques. The materials are specic to ostomy hernia repair but other techniques such as the Sugarbaker onlay utilize one of the at
meshes described earlier in this chapter.
Colostomy Mesh is a single layer PP product (Fig.4.123). It has a ve-centimeter
hole in the center of the material through which the intestine can be placed during
stomal creation. Of course, the mesh can be cut if this product is used in the repair
of a parastomal hernia. It is available in a “rigid” and a “semi-rigid” construction. It
is not coated and must not be place in the intraperitoneal space.
DynaMesh-IPST, like its parent material, is made of both PVDF and PP
(Fig.4.124). It is preshaped and three-dimensional through which the intestine is
placed. This is generally used during the creation of the ostomy rather than during
Fig. 4.123 Colostomy
mesh
4 Prosthetic Materials forRobot-Assisted Hernia Repair
123
the repair of a parastomal hernia in an effort to prevent the development of a hernia.
If used in that fashion it, too, would need to be cut to allow placement around the
stomal hernia repair. Parietex Composite Parastomal Mesh is of the same material
(polyester) as that described previously during descriptions of the Parietex products.
This device is supplied in two sizes and is available with a hole or without a hole but
with a central band (Figs.4.125 and 4.126). The available opening of the hole can
Table 4.19 Stomal
prostheses
Fig. 4.124 DynaMesh
IPST
Colostomy Mesh, HerniaMesh, Torino, Italy
DynaMesh-IPST, FEG Textiltechnik mbH,
Aachen, Germany
Parietex Composite Parastomal Mesh,
Medtronic, Minneapolis, MN
Plurimesh Clear Mesh Composite (PCMC),
Di.pro Medical Devices, Torino, Italy
TiLENE Guard, GfE Medizintechnik,
Nuremburg, Germany
Fig. 4.125 Parietex
parastomal with hole (All
rights reserved; used with
permission of Medtronic,
Inc.)
124
K. A. LeBlanc
either be 3.5cm or 5.0cm. Plurimesh (PCMC) has already been described for incisional and ventral hernia repair. It can also be used for parastomal hernia repair
(Fig.4.116). It is supplied in such a manner that it can be cut to conrm to whatever
the size the surgeon chooses.
TiLENE Guard is of titanized PP that contains a ap, which is closed after the
intestine is placed through the central hole (Fig.4.127). It is supplied in the light and
Fig. 4.126 Parietex
parastomal without hole
(All rights reserved; used
with permission of
Medtronic, Inc.)
Fig. 4.127 TiLENE guard
4 Prosthetic Materials forRobot-Assisted Hernia Repair
125
dual-weight (light and medium) meshes. There is a set, which contains TiLENE
mesh that is to be applied as a “sandwich” technique to repair or prevent herniation
through the stomal exit location.
4.14 Hiatal Hernia Repair Products
The use of permanent meshes to repair hiatal hernias has been commonplace
for many years. The introduction of the biologic products has resulted in a
decline in the application of the permanent products at this position. The real
concern is of erosion of the product into the esophagus or infection with a permanent prosthesis. While the application of flat meshes such as unprotected PP
or POL has been used, these products were designed to mitigate against these
concerns (Table4.20).
Bio-A is the same material discussed at the beginning of this chapter and is not
permanent. It is made of the PGA-TMC but is congured into a shape that can be
modied by the surgeon if desired (Fig.4.128). It can be glued or sutured in place.
The Biodesign Hiatal Hernia Graft is the same family of products described in the
biologic section but this has been congured similar to the Bio-A with a “U”-shaped
cutout of the material. RH Implant is of the similar material of the other products
Fig. 4.128 Bio-A hiatal
Table 4.20 Hiatal hernia
repair products
Bio-A Hiatal, W.L Gore & Associates, Elkhart,
DE, USA
Biodesign Hiatal Hernia Graft, Cook Medical,
Bloomington, IL, USA
RH Implant, Microval, Saint-Just-Malmont,
France
Parietex Composite (PCO) Hiatal Mesh,
Medtronic, Minneapolis, MN, USA
Phasix ST, C.R.Bard, Warwick, RI, USA
TiLENE Hiatus, GfE Medizintechnik,
Nuremburg, Germany
TiSURE, GfE Medizintechnik, Nuremburg,
Germany