3. Billroth’s Vision
‘‘If we could artificially produce tissues of the density and toughness of
fascia and tendon the secret of the radical cure of hernia would
be discovered’’.
- Beitrage zur Chirurgie (1878)
Conceive
Believe &
Achieve
4. Inventor of Prosthetic Mesh repair:
Dr. Francis Usher (1908-1980)
• Inventor of Polyehylene(Marlex) and Polypropylene mesh
• Several Animal studies about their inertness
• 20 papers
• Innovative ways of placing the meshes: Inlay,Overlay, Sandwich tech etc
Conceive
Believe &
Achieve
7. Why Mesh?
Low recurrence rate
Tension free & Pain free
Quick recovery
Quick to learn and easy to do!
8. History of Inguinal Hernia Repair
We are in Era ofTension Free Mesh Repair!
10% 1% 0.1%
100%
Recurrence rate
Bassini Shouldice LichtensteinAncient Era
9. Why Mesh?
Pathogenesis of Hernia
Defective Collagen
Reduced ratio of type I and type III collagen
Type I: MatureCollagen, strong and normal tissue
Type III: ImmatureCollagen, weak, in healing wounds
Type I :Type III ratio normally is 4:1
?Genetic defect
Connective tissue pathology is not only a cause of primary
herniation but its presence can prevent cure!
A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia?
Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and
Volker Schumpelick, BMC Med Genet. 2002; 3: 2.
10. Why Mesh?
What type of Mesh?
Where to place the Mesh?
How to place the place?
12. What Type of Mesh?
Light weight Vs Heavy weight?
Light weight Mesh Heavy weight Mesh
Definition Thin fibres,
macro pores (>1.5mm)
Thick fibres,
micro pores (< 1.5mm)
Qualities Flexible
Less FB reaction and pain
Stiffer
More FB reaction and pain
(Problem of adhesion, fistula)
Shrinks more
Stronger! - so what
Examples Ultrapro,Vipro Marlex, Dacron, PTEF
The lightweight and large porous mesh concept for hernia repair.
Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.
15. Parietex Mesh
Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias
using a new composite mesh (Parietex): initial experience.
2001 Surg Laparoc Endosc PercutanTech Apr;11(2):103-6
Proceed Mesh
16. Laparoscopic Ventral Hernia Repair
Choice of Composite Mesh
Name Parietal side Visceral Side Longevity Remarks By
Parietex Polyester Atelocollagen,
PEG, Glycerol
20 days expensive Covidien
Proceed Polypropylene Oxidised (ORC)
regenerated
cellulose/PDS
30 days Ethicon
Sepramesh PP PGA/Hydrogel 30 days Davol
C QUR PP Omega 3 FA Atrium
ProVISC 160 Polyester Polyurethane Life Cost effective Lotus
Dual Mesh e PTFE (rough) e PTFE(smooth) Life Gore
Kugel/
Composix
PP(HW) e PTFE Life Can't trim Bard
26. Ideal Fixation Method
No Type of Fixation Features
1 Trans Fascial suture
fixation
Chronic pain
2 Suturing 2cm apart
3 SpiralTitatinum
Tackers
2cm apart
Double crown technique
Nerve entrapment, adhesion, rarely tacker hernia
4 Absorbable tackers For initial 1 year
5 Fibrin Glue Suitable for inguinal hernia
?Ventral Hernia: Alternative or Adjunct: needs trial.
Closure of Hernia defect to avoid mesh protrusion or displacement
To withstand the intra abdominal tangential force and also shearing
Force due to abdominal muscle contraction
27. Conclusion
Mesh repair is the Standard of Care.
Use Composite mesh for ventral hernia
Secure the mesh to prevent recurrence
28.
29. Forthcoming Courses /Erode ASI
Contact Us: 9843328928/9790028328
3rd ASI Endoscopic course
On 5 days/all Sundays from 8am to 5pm
8th November 2015 : 1st session starting
FIAGES Laparoscopic Fellowship course
Venue: Lotus hospital, at Erode
7th to 9th January 2016