Synthetic and Biologic Mesh for Ventral Hernia Repair Archana Ramaswamy MD

Mesh types Synthetic Biologic Act as a barrier Organic source Resorb act as scaffold to leave collagen behind

Mesh Types Multiple types of mesh Synthetic Biologic materials Polypropylene ePTFE Polyester Biologic materials Human Dermis Porcine Dermis Porcine small intestine submucosa Bovine pericarduim

Potential disadvantages Synthetic Infection Contraction Foreign body response Pain Inflammation Oxidation Biologic Initial Strength Remodeled tissue Strength

Lightweight vs heavy weight mesh Large pores >1mm > Elasticity 20-35% < Foreign body reaction Heavyweight Small pores <1mm <Elasticity 4-16%> > Foreign body reaction

Mesh Selection Procedure performed Operative field Ventral, Inguinal Location of mesh Intraperitoneal Extraperitoneal Operative field Contamination, infection Comfort with product

Synthetic Mesh For Inguinal Repair Laparoscopic Flat sheets Anatomic sheets Bard 3-D max Parietex anatomic Barrier mesh Open Flat sheets Plugs

Synthetic Mesh For Ventral Repair Open Flat sheets Prolene Laparoscopic Solid Barrier mesh Absorbable Barrier Mesh

Making a Mesh Choice Mesh in contact with viscera should have a barrier Solid (PTFE) Absorbable sodium hyaluronate, carboxymethylcellulose, and polyethylene glycol Oxidized regenerated cellulose Collagen Omega-3 fatty acid

barrier to tissue ingrowth tissue fibroblast/ collagen ingrowth Materials Polpropylene Heavyweight Lightweight Polyester Polytetrafluoroethylene Expanded Condensed “smooth” barrier to tissue ingrowth “rough” tissue fibroblast/ collagen ingrowth

Composite Mesh Designed for intraabdominal placement Abdominal wall side: Promote ingrowth Visceral side: Prevent ingrowth

Composite Mesh - Composix: Polypropylene + PTFE - Proceed: Lightweight PP + Interceed (oxidized regenerated cellulose) - Parietex Composite: Polyester + Collagen - Sepramesh: Polypropylene + Seprafilm C-Qur: Lightweight PP + Omega 3 fatty acid coating

Mesh for Intraabdominal use Solid Barrier Entirely ePTFE or composite Macroporous mesh???

Resorbable Barrier Hydrogel forms on intraperitoneal surface from exposure to peritoneal fluid barrier between mesh and viscera

Sepramesh™ (Genzyme, Corporation, Cambridge, MA) mesh co-knitted polypropylene and polyglycolic acid fibers polyethylene glycol / sodium hyaluronate / carboxymethylcellulose coating on polyglycolic side (visceral) This is just as true in the year 2001 as it was in 1948 While this is a fairly broad and bold statement, it does hold truth today for those of us who are repairing ventral hernias

PROCEED™ (Ethicon, Inc., Somerville, NJ) trilaminate mesh construct polydioxanone (PDS) polymer film encapsulating a polypropylene mesh oxidized regenerated cellulose coating - visceral side This is just as true in the year 2001 as it was in 1948 While this is a fairly broad and bold statement, it does hold truth today for those of us who are repairing ventral hernias

Parietex® Composite™ (Covidien, Norwalk CT ) polyethylene terephtalate (polyester) mesh Absorbable Film (Visceral Surface) Type I atelocollagen (60%) glycerol (12%) hydrophilic lipid – osmotic polyethylene glycol (20%) Hydrogel H20 (8%)

C-Qur™ Mesh (Atrium Medical Corporation, Hudson, NH) Lightweight polypropylene mesh (Prolite) Bioabsorbable omega-3 fatty acid gel Thermal crosslinking of fatty acids to mesh

Complications of Mesh Problems with mesh Adhesions Fistulas and erosions Contraction/Shrinkage Lack of ingrowth Pain Infection Rigidity/Poor Compliance

Biologic Materials Based on acellular collagen scaffolds Natural collagenases break down the implant, while new collagen is laid down by host fibroblasts Can be used in infected surgical field Questionable loss of strength (early and ?late)

Biologic Materials Materials classified by donor organism and site Human dermis Porcine dermis Porcine small intestine submucosa Bovine pericardium Fetal bovine dermis

Biologic Biomaterials Products: - Surgisis (Cook): Pig small bowel submucosa - Permachol (TSL): Pig skin Collamend (Bard/Davol): Pig skin XenMatriX (Brennan): Pig skin - Alloderm (Lifecell): Cadaver skin FlexHD (MTF): Cadaver skin Allomax (Bard/Davol): Cadaver skin SurgiMend (TEI): Fetal bovine Skin Tutopatch (Tutogen): Bovine Pericardium

Porcine Dermis Permacol (TSL) Collamend (Bard/Davol) Heavily crosslinked Collamend (Bard/Davol) crosslinked XenMatriX (Brennan Medical) Non-crosslinked Strattice (Lifecell)                       

Porcine SIS Surgisis (Cook): Pig small bowel submucosa Non-crosslinked Resorbed by 12 weeks

Bovine Products SurgiMend (TEI): Fetal bovine Skin Non-crosslinked Tutopatch (Tutogen): Bovine Pericardium Veritas (Synovis): Bovine Pericardium SurgiMend

Human Dermis Alloderm (Lifecell) Allomax (Bard/Davol) FlexHD (MTF) Freeze-dried, non-crosslinked Allomax (Bard/Davol) Processed for Bard by Tutogen Dehydrated, non-crosslinked FlexHD (MTF) Now licensed by Ethicon Hydrated, non-crosslinked

Biologic Materials for hernia repair Unknowns Early strength Late strength Individual response What happens to tissue and when Lack of long term data