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Hernia Surgery Simplied

Fig. 5.5: Surgisis ES (Enhanced strength)

Fig. 5.3: Alloderm mesh is an acellular matrix derived

from the donated cadaveric human skin

Fig. 5.4: Gold type

The three-dimensional, extra-cellular matrix (ECM) comprises of collagen and noncollagenous proteins and biomolecules, including glycosaminoglycans, proteoglycans, and glycoproteins. Material is then vacuum-dried and sterilized. When implanted, host tissue cells and blood vessels readily inltrate the graft. Connective and epithelial tissue growth and dierentiation, as well as deposition and maturation of the host ECM components, occur. Finally, tissue remodeling takes place and the graft and the host tissue become indistinguishable.

Fig. 5.6: FortaPerm mesh

Flat Nonabsorbable/Partially Absorbable Mesh

In modern hernia surgery, there are two competing mesh concepts which often lead to controversial discussions, on the one hand the heavyweight small porous model and on the other, the lightweight large porous hypothesis (Figs 5.7 and 5.8). Furthermore, the new mesh concept reveals an optimized foreign body reaction based on reduced amounts of mesh material and, in particular,

Prosthesis Used in Hernioplasty

Fig. 5.7: Large pores Fig. 5.9: Prolene mesh

Fig. 5.8: Small pores

a signicantly decreased surface area in contact with the recipient host tissues by the large porous model. Finally, recent data demonstrate that alterations in the extracellular matrix of hernia patients play a crucial role in the development of hernia recurrence. In particular,

Fig. 5.10A

long-term recurrences months or years after surgery and implantation of mesh can be explained by the extracellular matrix hypothesis. However, if the altered extracellular matrix proves to be the weak area, the decisive question is whether the

Hernia Surgery Simplied

Fig. 5.10B Fig. 5.10C

Figs 5.10A to C: Ultrapro mesh

amount of material as well as mechanical and tensile strength of the surgical mesh are really of signicant importance for the development of recurrent hernia. All experimental evidence and rst clinical data indicate the superiority of the lightweight and large porous mesh concept with regard to a reduced number of long-term complications and particularly, increased comfort and quality of life after hernia repair. Implant materials very quickly absorb a layer of host proteins after implantation—in a process lasting a few seconds, which occurs well before an initial cellular response to the biomaterial can be observed.

Polypropylene Prosthetic Mesh (Flat Type)

Prolene mesh: Prolene polypropylene mesh is constructed of knitted laments of extruded polypropylene identical in composition to that used in prolene* Polypropylene Suture, Nonabsorbable Surgical Sutures, USP (Ethicon, Inc.) (Fig. 5.9). e mesh is approximately 0.020 inches thick. is material, when used as a suture, has been reported to be nonreactive and to retain its strength indenitely in clinical use. Prolene mesh is knitted by a process which interlinks each ber junction and which provides for elasticity in both directions.

is construction permits the mesh to be cut into any desired shape or size without unraveling. e ber junctions are not subject to the same work fatigue exhibited by more rigid metallic meshes. This bidirectional elastic property allows adaption to various stresses encountered in the body.

Actions

Prolene mesh is a nonabsorbable mesh used to span and reinforce traumatic or surgical wounds to provide extended support during and following wound healing. Animal studies show that implantation of Prolene mesh elicits a minimum to slight inflammatory reaction, which is transient and is followed by the deposition of a thin brous layer of tissue which can grow through the interstices of the mesh, thus incorporating the mesh into adjacent tissue. e mesh remains soft and pliable, and normal wound healing is not noticeably impaired. e material is not absorbed nor is it subject to degradation or weakening by the action of tissue enzymes.

Indications

This mesh may be used for the repair of hernia and other fascial deciencies that require the addition of a

Prosthesis Used in Hernioplasty

reinforcing or bridging material to obtain the desired surgical result.

Contraindications

When this mesh is used in infants or children with future growth potential, the surgeon should be aware that this mesh will not stretch signicantly as the patient grows. Prolene mesh in contaminated wounds should be used with the understanding that subsequent infection may require removal of the material. Ethicon ultrapro mesh is the only partially absorbable mesh. It is constructed of polypropylene (nonabsorbable) and poliglecaprone 25 (absorbable) monofilament materials.

 • Strong,securerepair  • Flexiblescarletsabdominalwallmovenaturally  • Trusted,provenmaterials.

Ultrapro (Poliglecaprone-25/ Polypropylene)Synthetic Partially Absorbable Mesh

Ultrapro mesh (Figs 5.10A to C) incorporates the three most important characteristics of lightweight design: thin lament size, large pore construction, and absorbable materials.

 • Leavesbehind65% lessforeignmaterials than

traditional weight polypropylene mesh

 • Withstandsfour timesthemaximum abdominal

pressure (Fig. 5.11)

 • Excellenttissuein-growth.

Proceed mesh: Ethicon’s Proceed Multilayer tissue-separating mesh for open and laparoscopic incisional hernia repair. New Proceed Surgical Mesh features a thin, bioresorbable fabric layer that eectively separates its strong, supportive mesh from underlying viscera. A composite of proven products from Ethicon Products, Proceed Mesh can be placed both below the muscle layer and outside of the peritoneum, or in the intra-abdominal cavity and oers the following benets:

 • Eectivelyseperatesmeshfromunderlyingviscera  • Doesnotharborbacteriathatcanleadtoinfection  • Lightweightmonolamentconstructionforpatient

comfort.



Proceed incisional hernias.

is now the preferred mesh in the repair of



Surgical Mesh-

Open-Skirted Flap for Increased Rigidity and Accessible Fixation

Parietex Composite OS Series skirted mesh provides a new level of control during open ventral repair. based on clinically proven Parietex Composite mesh, the OS Series design has increased rigidity for easier handling

Fig. 5.11: Ultrapro mesh

Fig. 5.12: Parietex mesh (Right/Left sided

for inguinal hernias)

Hernia Surgery Simplied

Fig. 5.13: Parietex mesh (for ventral hernia)

Reliable Treatment for Paraesophageal and Hiatal Hernia (Fig. 5.14)

The Parietex Composite 2H Series makes surgical

treatmentofgastroesophagealreuxdisease(GERD)and

hiatal hernia viable. While ordinary meshes carry the risk of in-growth into the esophagus, Parietex Composite is coated on one side with a protective collagen-based barrier to help prevent tissue attachment. e 2H Series is created in the shape of the hiatus to buttress the primary repair by reinforcing the approximation of the crus on either side of the esophagus.

 • Non-resorbablepolyester meshallowsfast and

complete tissue in-growth on one side for ecient reinforcement

 • Resorbablehydrophiliclm provides a temporary

barrier, minimizing tissue attachment to mesh

 • Polyestermesh is easyto placeandmanipulate

around the esophagus.

Fig. 5.14: Parietex mesh (for hiatus hernia)

during implantation. e skirted ap on the parietal side of the mesh provides more easily accessible xation points in the open approach (Fig. 5.12).  • Parietex Composite dual-sided mesh provides

optimal tissue in-growth and fewer visceral attachments

 • eskirtonparietalsideprovidesaccessible,secure

xation points

 • Increasedrigidity duringimplantation allows

superior handling

 • epolyestermaterialsoftensandconformstothe

anatomy once implanted

 • Protectsviscerafromxationpoints(Fig.5.13).

Devices for Inguinal Hernioplasty

Prolene* Polypropylene Hernia System (Fig. 5.15)

e Prolene* polypropylene hernia system (PHS) is a sterile, preshaped, three dimensional device constructed of an onlay patch connected by a mesh cylinder to an oblong or circular underlay patch. e material is undyed

PROLENE* Polypropylene Mesh constructed of knitted

nonabsorbable polypropylene laments.

Fig. 5.15: Polypropylene hernia system

Prosthesis Used in Hernioplasty

e Prolene Hernia System is a nonabsorbable mesh used to reinforce or bridge inguinal hernia deciencies to provide extended support during and following wound healing. Animal studies show that implantation of Prolene Mesh elicits a minimum to slight inammatory reaction, which is transient and is followed by the deposition of a thin brous layer of tissue which can grow through the interstices of the mesh, thus incorporating the mesh into adjacent tissue. e mesh remains soft and pliable, and normal wound healing is not noticeably impaired. The material is neither absorbed nor is it subject to degradation or weakening by the action of tissue enzymes.

Using the Sytem

For indirect hernia repair, a high dissection of the neck of the hernia sac to utilize the potential of the preperitoneal space can be performed to insert the Prolene Hernia System. e oblong/circular or bottom underlay portion of the Prolene Hernia System is folded and is inserted through the internal ring allowing the mesh to expand to the underlay position. Surgical manipulation may be used to facilitate the expansion of the device to the underlay position. No sutures are necessary in the bottom underlay patch. e top onlay patch, which is designed to cover the posterior wall (oor of the canal), is then modied as needed to accommodate the cord structures. If one end of the oval onlay patch is longer than the other, the Prolene Hernia System is positioned so that the longer end covers the posterior wall (oor of the canal) and overlaps the pubic tubercle. Sutures or clips may be used to secure the top onlay patch in place. e cord structures then lie on top of the medial portion of the onlay patch. For direct hernia, the defect is circumscribed at its base, the contents fully reduced, and the preperitoneal space is actualized prior to the insertion of the Prolene Hernia System. e circular, or bottom underlay portion of the Prolene Hernia System is folded and is inserted through the defect or the internal ring allowing the mesh to expand to the underlay position. e underlay portion should expand under the defect in the oor of the inguinal canal. Surgical manipulation may be used to facilitate the expansion of the device to the underlay position. Sutures or clips may be used to secure the top onlay patch in place. For repair of ventral/incisional or umbilical hernias the sac is dissected free down to the abdominal fascia.

Dissectionthenproceedsundertheanteriorabdominal

fascia to create a submuscular space that is anterior to the posterior fascia and peritoneum. An additional space

is created anterior to the rectus muscle and posterior to the anterior rectus sheath. A Prolene Hernia System of appropriate size for the defect is then selected. e hernia sac is reduced and the underlay mesh is placed posterior to the rectus muscle and anterior to the posterior rectus sheath. Adequate overlap with the rectus muscle is assured. e overlap mesh is then positioned anterior to the rectus muscle and posterior to the anterior rectus sheath. Sutures or clips may be used to secure the top onlay and/or the bottom underlay patch in place.

Ultrapro* Hernia System (Fig. 5.16)

e Ultrapro* Hernia System (UHS) is a sterile, pre-shaped, three dimensional device constructed of an undyed onlay patch: (1) connected by a mesh cylinder (connector), (2) to an underlay patch, (3) which is reinforced by a at undyed absorbable lm of Poliglecaprone-25 (Monocryl). e underlay patch is marked with dyed polypropylene fibers to be clearly distinguishable from the onlay patch. e onlay patch, connector and underlay patch are manufactured from approximately equal parts of absorbable Poliglecaprone-25 monolament ber and non-absorbable polypropylene monolament ber. e polymer of the undyed and dyed polypropylene bers (phthalocyanine blue, color index no.: 74160) is identical to the material used for dyed/undyed Prolene material. Poliglecaprone-25 ber consists of a copolymer containing glycolide and e-caprolactone. is copolymer

Fig. 5.16: Ultrapro hernia system

suture

Hernia Surgery Simplied

is also used for Monocryl* suture material. After absorption of the Poliglecaprone-25 components only the polypropylene mesh remains. e structure and size of this remaining mesh are designed for the physiological stresses to which the abdominal wall is subject. For indirect hernia, a high dissection of the neck of the hernia sac can be performed to utilize the preperitoneal space for insertion of the UHS. e underlay patch of the device (marked with blue threads) is folded and inserted through the internal ring, allowing the underlay patch to deploy in the preperitoneal space (beneath the epigastric vessels) and cover the entire myopectineal orice. Correct expansion of the underlay patch may be supported by surgical manipulation, if necessary, to ensure that it is free of folds. For direct hernia, the defect is circumscribed at its base, the contents fully reduced, and the preperitoneal space is entered. After adequate dissection, the underlay patch of the device (marked with blue threads) is folded and inserted through the defect allowing the underlay patch to expand and to cover the myopectineal orice. Correct expansion of the underlay patch may be supported by surgical manipulation, if necessary, to ensure that it is free of folds. For indirect as well as for direct hernia the onlay patch of the device is designed to cover the oor of the canal. It is necessary to modify the onlay patch as needed to accommodate the cord structures. is can be done by creating a slit in the mesh. e longer side of the onlay patch should be positioned parallel to the inguinal ligament. e onlay patch should be positioned without folds, and should be adequately xed (e.g. sutures, staples) in order to avoid edge rollup and/or folding and to minimize the risk of hernia recurrence. It is recommended that points of xation be placed at a distance approximately 1 cm (0.4”) from the edge of the mesh. e tails created to accommodate the cord structures need to be xated.

folding and to minimize the risk of hernia recurrence. It is recommended that points of xation be placed at a distance approximately 1 cm (0.4”) from the edge of the mesh. e patches can be cut to size as required using scissors or a scalpel; do not use thermal devices.

Ultrapro* Plug (Figs 5.17A to D)

Prolene 3D Patch

It is a polypropylene three-dimensional system consisting of a flat onlay patch, securely linked to a diamondshaped plug, which can be deployed through the use of

Ventral/Incisional or Umbilical Hernias

e hernia sac is dissected free down to the abdominal

fascia.Dissectionthenproceedstocreateapreperitoneal

space. An additional space is created anterior to the rectus sheath. A UHS of appropriate size for the defect is then selected. e hernia sac is reduced and the underlay patch is deployed in the preperitoneal space. e onlay patch is then positioned anterior to the rectus sheath. After tension-free placement of the device without folds, the onlay patch should be adequately xed (e.g. sutures, staples) in order to avoid edge rollup and/or

Figs 5.17A and B

Prosthesis Used in Hernioplasty

Figs 5.17C and D

Figs 5.17A to D: Ultrapro plug, prolene 3D patch

an integrated looped non-absorbable suture. e new mesh, measuring 12.5 × 5.5 cm, is available in two types: the Extended Overlay type which is lozenge-shaped and mainly used for, but not limited to, direct hernia and women’s hernia, and the Preshaped Overlay type, with its opening and hole specic for men’s spermatic cord. e plug is hollow and available in two sizes: medium size measuring 4.8 × 2.3 cm, and small size measuring 3.5 × 1.9 cm. e plug must be placed in the preperitoneal space through the deep inguinal ring or through the direct defect, while the at onlay patch, either the Extended or Preshaped Overlay type, shall lie on the inguinal oor; pulling the suture will cause the deployment of the plug, which will expand attened

inthe oppositeside.In thenew3D patchsystem,the

onlay portion is not a rigid mesh but exible, with good memory and, at the same time, well resistant; which is already an advantage as it ts quite well the groin area, thus reducing, in our view, all troubles linked to patient’s movement and his postural changes. e plug is diamond-shaped and this ergonomic form makes the insertion easier into the deep inguinal ring or the direct defect, without the need to dissect the preperitoneal space; besides it’s hollow and this implies an overall reduction of the prosthetic material used. e plug, once inserted, is attened by pulling the looped suture, therefore the deep repair becomes “bidimensional”and more subject to tissue ingrowth by broblasts, if compared to the various non-at type plugs;

furthermore, since the two parts of the new device are joint together, the plug migration is duly prevented.

Proceed* Surgical Mesh

Proceed* Surgical Mesh is a sterile, thin, exible laminate mesh designed for the repair of hernias and other fascial deciencies. e mesh product is comprised of an oxidized regenerated cellulose (ORC) fabric, and Prolene* Soft Mesh, a nonabsorbable polypropylene mesh, which is encapsulated by a polydioxanone polymer. e polypropylene mesh side of the product allows for tissue ingrowth while the ORC side provides a bioresorbable layer that physically separates the polypropylene mesh from underlying tissue and organ surfaces during the woundhealing period to minimize tissue attachment to the mesh. e polydioxanone provides a bond to the ORC layer. e Prolene Soft Mesh component is constructed of knitted laments of extruded polypropylene identical in composition to that used in Prolene* Polypropylene Suture, nonabsorbable surgical sutures, USP (Ethicon, Inc.). is material, when used as a suture, has been reported to be nonreactive and to retain its strength indenitely in clinical use. e Prolene Soft Mesh aords excellent strength, durability and surgical adaptability, with a porous structure to enable mesh incorporation into surrounding tissues. The ORC component is an absorbable off-white knitted fabric prepared by the controlled oxidation of

Hernia Surgery Simplied

regenerated cellulose. e ORC layer is absorbed from the site of implantation within four (4) weeks. Absorption rate depends upon several factors including the amount used and implantation site. e polydioxanone components made from the polyester, poly (p-dioxanone)

polymerthatisidenticaltothepolymerusedinPDS* II

(polydioxanone) Suture, Synthetic Absorbable Suture, USP (ETHICON, Inc.). e polydioxanone polymer has been found to be nonantigenic, nonpyrogenic and to elicit only a mild tissue reaction during absorption. e polydioxanone component is absorbed within six (6) months.

Actions/Performance

Proceed Mesh is a laminate mesh, whose Prolene Soft Mesh component is knitted with nonabsorbable bers, used to reinforce or bridge traumatic or surgical wounds to provide extended support during and following wound healing. e ORC is intended to physically separate the mesh from underlying tissue and organ surfaces during the critical wound healing period, thereby reducing the severity and extent of tissue attachment to the mesh.

 AnimalstudiesshowthatimplantationofPROCEED

Mesh elicits a transient inammatory reaction that does not interfere with integration of the mesh into adjacent tissue. e mesh remains soft and pliable, and normal wound healing is not noticeably impaired. The ORC and polydioxanone components are essentially absorbed within six (6) months, whereas the polypropylene material is not absorbed, nor is it subject to degradation or weakening by the action of tissue enzymes. Minimal visceral tissue attachment has been demonstrated in animal studies that show reduction in the extent and severity of adhesions to the mesh.

Indications

Proceed Mesh is used for the repair of hernias and other fascial deciencies that require the addition of a reinforcing or bridging material to obtain the desired surgical result.

Instructions

Correct surface orientation is critical for Proceed Mesh to function as intended. e polypropylene mesh side (side with the blue stripes) of the product should be placed adjacent to those tissues where tissue ingrowth is desired. The other surface, the ORC side, should

be placed adjacent to those tissues where minimal tissue attachment is desired (i.e. visceral surfaces). e orientation is essential. Uncontrolled and/or active bleeding should be controlled prior to placement of the Proceed Mesh. The mesh should be shaped in such a way that sufficient overlap of the fascial defect on all sides is achieved, thereby allowing adequate stabilization of each of the fascial borders. To avoid dislodging, crinkling or curling of the edges, a sucient number of xation points should be placed along the borders of the Proceed Mesh. Fixation may be accomplished with devices such as tackers, anchors, staples or nonabsorbable sutures. It is recommended that points of xation be placed 6.5 mm to

12.5 mm (1/4” to 1/2”) apart at a distance approximately

6.5 mm (1/4”) from the edge of the mesh. Fixation of this product with tissue adhesives has not been evaluated.

Proceed* Ventral Patch

PartiallyAbsorbableMeshDevice.

Description

Proceed* ventral patch (PVP) is a sterile, self-expanding, partially absorbable, flexible laminate mesh device designed for the repair of hernias and other fascial deciencies such as those caused by trocar use. e mesh patch is comprised of multiple layers of absorbable and nonabsorbable materials, laminated together with an absorbable polydioxanone polymer. e bottom layer of the patch, facing underlying tissue and organ surfaces is comprised of an oxidized regenerated cellulose (ORC) fabric bonded to Prolene* Soft Mesh, a nonabsorbable, macroporous polypropylene mesh. e polypropylene mesh side of the product allows for tissue ingrowth. e ORC side of the patch provides a bioresorbable layer that physically separates the polypropylene mesh from underlying tissue and organ surfaces while minimizing tissue attachment to the polypropylene mesh during the critical wound healing period. e polypropylene mesh

layerisencapsulatedwithlayersofPDS* lm.

e parietal side of the patch contains a polydioxanone polymer reinforcement film and positioning ring, which provide memory to the patch. These patch reinforcements offer stability to help the clinician achieve proper placement. Vicryl* Mesh is placed on top of the polydioxanone polymer reinforcement lm to facilitate placement of the mesh. e Vicryl Mesh layer is

Prosthesis Used in Hernioplasty

encapsulatedwithlayersofPDSlm.Anchoringstraps

of the patch are designed to facilitate placement and xation of the mesh device. An Ethibond* polyester suture is attached to each anchoring strap enabling tension to be placed on the patch prior to xation. After the patch has been xated, the sutures should be removed and discarded. The ORC component is an absorbable off-white knitted fabric prepared by the controlled oxidation of regenerated cellulose. e ORC layer is absorbed from the site of implantation within four (4) weeks. Absorption rate depends upon several factors including the amount used and implantation site. The Prolene Soft Mesh components are constructed of knitted filaments of extruded polypropylene, identical in composition to that used in Prolene* Polypropylene Suture, nonabsorbable surgical suture, USP (Ethicon, Inc.). This material, when used as a suture, has been reported to be nonreactive and to retain its strength indenitely in clinical use. e Prolene Soft Mesh aords excellent strength, durability and surgical adaptability, with a porous structure to enable mesh incorporation into surrounding tissues. The polydioxanone components are made from poly (p-dioxanone) polymer that is identical to the

polymer used in PDS* II Polydioxanone Suture,

Synthetic Absorbable Suture, USP (ETHICON, Inc.). The polydioxanone polymer has been found to be nonantigenic, nonpyrogenic, and to elicit only a mild tissue reaction during absorption. e polydioxanone component is essentially absorbed within six (6) months. The Vicryl Mesh component is prepared from polyglactin 910, a synthetic absorbable copolymer of glycolide and lactide, derived respectively from glycolic acid and lactic acids. Polyglactin 910 polymer is identical to the polymer used in Vicryl* Polyglactin 910 Synthetic Absorbable Suture, USP (Ethicon, Inc.). e polyglactin 910 polymer has been found to be nonantigenic, nonpyrogenic, and to elicit only a mild tissue reaction during absorption. e polyglactin 910 component is essentially absorbed within 56 to 70 days.

Actions/Performance

Proceed ventral patch (PVP) is a laminate mesh device, whose Prolene Soft Mesh component is knitted with nonabsorbable fibers, used to reinforce or bridge traumatic or surgical wounds to provide extended support during and following wound healing. e ORC is intended to physically separate the mesh from underlying

tissue and organ surfaces during the critical wound healing period, thereby reducing the severity and extent of tissue attachment to the mesh. An animal model shows that implantation of PVP elicits a mild inflammatory reaction that does not interfere with integration of the mesh into adjacent tissue. e mesh remains soft and pliable, and normal wound healing is not noticeably impaired.

 The ORC, VICRYLMesh, and polydioxanone

components are essentially absorbed within six (6) months, whereas the polypropylene material is not absorbed, nor is it subject to degradation or weakening by the action of tissue enzymes. Minimal visceral tissue attachment has been demonstrated in an animal model that shows reduction in the extent and severity of adhesions to the mesh.

Indications

Proceed ventral patch (PVP) is intended for the repair of hernias or other abdominal fascial defects that require the addition of a reinforcing or bridging material to obtain the desired surgical result. PVP is also indicated for the repair of tissue deciencies caused by trocar use.

Instructions for Use

Correctsurface orientationiscritical forPROCEED VentralPatchtofunctionasintended.eVICRYLMesh

side (side with straps) should be placed adjacent to those tissues where tissue ingrowth is desired. e ORC side (uniformly o-white) should be placed adjacent to those tissues where minimal tissue attachment is desired (e.g. visceral surfaces). Uncontrolled and/or active bleeding should be

controlledpriortoplacementofPROCEEDVentralPatch.

Hernia Repair Technique

Just prior to insertion, dip mesh patch in saline for ease of use and to avoid attachment of tissue during insertion. Fold the mesh patch into a semi-circle with the ORC side facing outward (straps folded in) for insertion into the defect.

 During insertion,secure suture loopswith aclamp

or fingers. When using a mesh clamp, be certain to avoid kinking the mesh. Be sure to refold as previously described if re-insertion is needed. Once the mesh patch has been inserted into the defect, manipulate the suture loops to facilitate proper positioning of the patch. Pulling up on the suture loops allows the mesh patch to

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