1. Synthetic and Biologic Mesh for Ventral Hernia Repair
Archana Ramaswamy MD

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

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

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

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

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

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

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

9. 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

10. 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

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

12. 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

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

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

15. 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

16. 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

17. 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%)

18. 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

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

20. 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)

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

22. 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

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

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

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

26. 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

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