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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
126
Fig. 4.129 RH Implant
Fig. 4.130 Parietex
composite hiatal mesh (All
rights reserved; used with
permission of Medtronic,
Inc.)
K. A. LeBlanc
from Microval (Fig.4.129). It is a permanent non-woven PP coated on one side with
silicon as the tissue-separating component. The larger perforations are used to
suture the mesh in place.
Parietex Composite Hiatal Mesh is made of the same permanent material as the
parent PCO product (Fig.4.130). It possesses a U-shaped defect that is slightly offcenter that is to be positioned below the esophagus. The legs of the product will lie
on the crura. It is available in two other shapes, a heart shape and a horseshoe shape.
Phasix ST has recently been approved for use in this application (Fig.4.4). It does
not have a precut design therefore the surgeon must modify a small at sheet to his
or her specications.
4 Prosthetic Materials forRobot-Assisted Hernia Repair
127
TiLENE Hiatus is made of the titanized PP but in either a rectangle shape with a
curve on one side or in an “hour-glass” conguration. TiSURE is a rectangular mesh
that has a central hole and a ap made from TiMESH (Fig.4.131). It differs from
the other products listed in that it possesses that ap which mandates complete
encirclement of the esophagus. It can be xed with either brin glue or sutures. It is
not recommended to use metal xation devices on this product because of the risk
of complications from these devices.
4.15 Fixation Devices
Fixation devices became prevalent early in the development of the laparoscopic
repair of hernias. They are mostly available as 5mm versions as these have become
the most popular. Most recently, recognition of the fact that these fasteners are only
needed on a temporary basis has lead to the introduction of absorbable platforms.
Currently, there is a variety of these devices that one may choose to xate the
meshes placed in hernia repair, however, the majority of robotic surgeons sew in the
mesh rather than xate it with one of these devices (Table4.21). Surgeon preference
and mesh selection will dictate the decision. One should consider the total length of
these fasteners, as the depth of penetration will be dependent upon the thickness of
the mesh used to repair the hernia. For example, a 5mm fastener will provide no
more of tissue penetration than 4mm when used with 1mm prosthesis. Additionally,
there are signicant differences in the types of “heads” these fasteners possess. The
reader is referred to the specic manufacturer of these products for more indepth
information. Additionally, this is an abbreviated list as many are not available in
large areas of the world. Other sources are available that provide a more complete
listing of these products [13].
AbsorbaTack is a 5mm xation device provides an absorbable synthetic polyester
copolymer screw-like fastener derived from PGLA (Fig.4.132). This device has a
3cm degree of ex that is allowed to re the fastener and has a metric scale on the
Fig. 4.131 TiSURE
128
K. A. LeBlanc
Table 4.21 Fixation devices
for hernia repair
Fig. 4.132 AbsorbaTack
(All rights reserved; used
with permission of
Medtronic, Inc.)
AbsorbaTack, Medtronic, Minneapolis, MN, USA
CapSure, Davol, Inc., Warwick, RI, USA
FasTouch, Via Surgical, Tel Aviv, Israel
iMesh Tacker, Corregio (RE), Italy
Optix, Davol. Inc., Warwick, RI, USA
PermaFix, Davol, Inc., Warwick, RI, USA
ProTack, Medtronic, Minneapolis, MN, USA
ReliaTack, Medtronic, Minneapolis, MN, USA
SecureStrap, Ethicon Inc., Somerville, NJ, USA
SorbaFix, Davol, Inc., Warwick, RI, USA
shaft. It measures 5.1mm in length. The laparoscopic version is available with either
15 or 30 tacks. The tacks are signicantly absorbed within 3–5months with complete
absorption within one year. CapSure is a permanent product, which has a smooth
polyetheretherketone (PEEK) cap and screw theads that are made of 316L stainless
steel. The iMesh tack is also an absorbable PGLA device. It has a depth of purchase
of 5.2mm. Available information states that it has a large variety of loads of 10, 15,
o
20, 25, 30, or 38 tacks. The tip of the delivery device can articulate up to 60
.
FasTouch is a unique 5mm device in that it does not employ any of the screwlike fasteners listed in this section (Fig. 4.133). It delivers a suture-like closed
“locked” loop (Fig.4.134). Its shape and size delivers the lowest amount of foreign
body to xate the mesh than any other available product [14]. The permanent fastener is made of poly-carbonate-urethane (PCU). There is also an absorbable
4 Prosthetic Materials forRobot-Assisted Hernia Repair
Fig. 4.133 CapSure
129
Fig. 4.134 iMesh tacker
version of this device that is made of a co-polymer of L-lactide and glycolide
(Fig.4.135). They can be reloaded with either a 10 or 25 reload.
The OptiFix device delivers a poly (D, L)–lactide (PDLLA) fastener that has two
barbs on the end of it and two on the shaft (Figs.4.136 and4.137). They are delivered over an introducer needle. This product is available in either a 15 or 30 shot
shaft. These fasteners are fully absorbed at 16months. PermaFix and SorbaFix each
deliver the same size (6.7mm) screw-type fasteners by an identical delivery mechanism with a pilot tip and mandrel (Figs. 4.138and 4.139). Both of these fasteners
are available in either 15 or 30 devices delivered via a 5mm product. Permax is
130
Fig. 4.135 FasTouch
Fig. 4.136 FasTouch
permanent
K. A. LeBlanc
made of a grey molded permanent (nonabsorbable) polymer. SorbaFix is made of
the same purple absorbable material as OptiFix.
The ProTack is one of the older products that delivers a permanent titanium
helical fastener by a 5mm device that is available with 30 tacks (Fig. 4.140).
These are the easiest xation products to visualize on a plain radiologic study.
They are 3.9mm in total length. ReliaTack is an articulating 5mm device that
also delivers a similar screw like absorbable tack (Fig.4.141). It can be reloaded
with a cartridge that contains either 5 or 10 fasteners. It is supplied with either
a standard 5.1mm device or the deep purchase tack that is 7.0mm in length
4 Prosthetic Materials forRobot-Assisted Hernia Repair
Fig. 4.137 FasTouch
absorbable
131
Fig. 4.138 Optix
(Fig.4.142). It is the only fastener that is available with two different lengths of
tacks from which to choose.
The SECURESTRAP is pre-loaded with 25 absorbable straps (Fig.4.143). The straps
are composed of a blend of polydioxanone and L(-)-lactide and glycolide dyed with
D&C Violet No. 2. This product does not screw into the tissues and has two legs similar
to the staplers. The ends of these straps are barbed to aid in xation. The width between
the points is 3.5mm. The entire devices length is 6.7mm but the distance from the inner
portion of the strap to the point of xation of the strap is 4.9mm (i.e. the “grip”).
132
Fig. 4.139 SorbaFix
and PermaFix
K. A. LeBlanc
Fig. 4.140 ProTack (All rights reserved; used with permission of Medtronic, Inc.)
Fig. 4.141 ReliaTack (All rights reserved; used with permission of Medtronic, Inc.)
4 Prosthetic Materials forRobot-Assisted Hernia Repair
Fig. 4.142 ReliaTack
standard and deep
purchase (All rights
reserved; used
0Medtronic, Inc.)
133
Fig. 4.143 SECURESTRAP (Image courtesy of Ethicon, Inc.)
4.16 Conclusion
The use of a prosthetic material for all hernia repairs is generally considered the
standard of care when using the surgical robot unless there are extenuating circumstances. The purpose of this chapter is to identify and differentiate the products that
can be used in hernioplasties. It is as complete as I could deliver but by the time of
the printing of this textbook others may have become available.
I believe that the ideal material has not yet been developed. There are, however,
many that have been described above that do function quite well for the surgeon and the
patient. Perhaps in the future, the use of genetic engineering will produce a product that
is based from the protein of the patient and will allow the patient to incorporate a “natural” and “native” product into the tissues without fear of infection or adhesions. A
permanent solution to the quest of the perfect biomaterial may be the result.
Acknowledgement I want to acknowledge to the reader that all manufacturer names and prod-
ucts are either registered trademarks, copyrighted or exclusive to that company. These cannot be
used without the permission of the respective company. Although not all of the gures have stated
this, I wish to thank all of these companies for their invaluable assistance in putting the most accurate information into this chapter that I could not have obtained without their assistance.
134
K. A. LeBlanc
References
1. Hesselink VJ, Luiiendijk RW, de Wilt JHW, Heide R.An evaluation of risk factors in incisional
hernia recurrence. Surg Gynecol Obstet. 1993;176:228–34.
2. Luijendijk RW, Hop WCJ, van den Tol P, de Lange DC, Braaksma MM, IJzermans JN,
Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J.A comparison of suture repair with mesh repair for incisinoal hernia. N Engl J Med. 2000;34(6):393–8.
3. Kokotovic D, Bisgaard T, Helgstrand F.Long-term recurrence and complications with elective
incisional hernia repair. JAMA Surg. 2016;316(15):1575–82.
4. LeBlanc KA, Booth WV.Laparoscopic repair of incisional abdominal hernias using expanded
polytetrauoroethylene: preliminary ndings. Surg Laparosc Endosc. 1993;3:39–41.
5. Gonzales A, Escobar E, Romero R, Walker G, Mejias J, Gallas M, Dickens E, Johnson CJ,
Rabaza J, Kudsi OY.Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical
outcomes. Surg Endosc. 2017;31(3):1342–9.
6. Bucknall TE, Cox PJ, Ellis H.Burst abdomen and incisional hernia: a prospective study of
1129 major laparotomies. BMJ. 1982;284:931–3.
7. Goepel R. Uber die verschliersung von bruchpforten durch einleilung gerochtener fertiger
silberdrahtnetze. Verh Deutsch Ges Pathol. 1900;29:4.
8. Kirschner M.Die praktischen Ergebnisse der freien Fascien-Tranaplantation. Arch Klin Chir.
1910;92:888–912.
9. Cumberland O.Ueber die Verschliessung von Bauchwunden und Brustpforten durch Bersenkte
Siberdragrnetze. Zentralbl Chir. 1900;27:257.
10. Scales JT.Discussion on metals and synthetic materials in relation to soft tissues: tissue reac-
tions to synthetic materials. Proc R Soc Med. 1953;46:647.
11. Kalaba S, Gerhard E, Winder JS, Pauli EM, Haluck RS, Yang J.Design strategies and applica-
tions of biomaterials and devices for hernia repair. Bioact Mater. 2016:2–17.
12. Rosen MJ, Bauer JJ, Harmaty M, Carbonell AM, Cobb WS, Matthews B, Goldblatt MI, Selzer
DJ, Poulose BK, Hansson BME, Rosman C, Chao JJ, Jacobsen GR.Multicenter, prospective
longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh. Ann Surg. 2017;265:205–11.
13. LeBlanc KA. Prostheses and products for hernioplasty. In: LeBlanc KA, Kingsnorth AN,
Sanders D, editors. Management of abdominal wall hernias. 5th ed. Springer; 2018. p.109–172.
14. Cook T, LeBlanc KA.Fixation tacks add signicant weight to hernia repair. SAGES Annual
Meeting, Boston, MA, March 16–19; 2016.
Algorithm ofOpen/Laparoscopic/
Robotic Repair
ArchanaRamaswamy
Inguinal and ventral hernias are common complaints with a lifetime incidence of
developing an inguinal hernia estimated at 30% for men. Umbilical and incisional
hernias are also relatively common in men and women with an incidence of 10–20%.
The surgical treatment of hernias was rst described with some success for
inguinal hernias with the Bassini repair in 1887 [1]. Polypropylene mesh was introduced in the 1950s, and laparoscopic repair in the 1990s. Similarly, umbilical and
incisional hernia repair techniques have evolved, from tissue repair to muscle
release to prosthetic reinforcement [2]. Since introduction of the rst robotic system
in the 2000s, the procedures for abdominal wall reconstruction have been progressing to include additional minimally invasive approaches.
5
5.1 Inguinal Hernia
5.1.1 Indications forRepair
Patients with symptomatic inguinal hernias are routinely offered surgical repair,
unless there are signicant medical comorbidities where the risks potentially outweigh the benets. It had been common practice to offer repair to all patients with
an inguinal hernia, due to the concerns of development of incarceration and the risks
of emergent surgery. However, as 30% of individuals present with minimally symptomatic or asymptomatic hernias, this traditional dogma was challenged and watchful waiting has been studied as an option for men with unilateral inguinal hernias.
The outcomes of the study performed in North America demonstrated a 32%
crossover rate to surgery at 3.2years and an estimated cumulative crossover rate of
68% at 10years [3]. A UK study demonstrated similar outcomes with a crossover
A. Ramaswamy (*)
University of Minnesota, Minneapolis VA Medical Center, Minneapolis, MN, USA
e-mail: ramaswam@umn.edu
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_5
135