Piece Of Polypropylene Mesh Research Articles

P049 SAFETY AND EFFICACY OF ABSORBABLE AND NON-ABSORBABLE FIXATION SYSTEMS FOR INTRAPERITONEAL MESH FIXATION: AN EXPERIMENTAL STUDY IN SWINE

Abstract Aim Choice of the best fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of this study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. Material and Methods Fourteen Landrace swine were utilized and the experiment included two stages. Initially, four pieces of polypropylene mesh with hydrogel barrier coating1 were fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. Each mesh was anchored with a different tack device between titanium2, steel3 or absorbable (4,5) fasteners. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy. The primary endpoint was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. Results Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Steel tacks had higher peel strength when compared to titanium and absorbable fasteners. No significant differences were noted regarding the secondary endpoints. Conclusions Steel fasteners provided higher peel strength that the other devices in this swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

En bloc resection and reconstruction of a huge chondrosarcoma involving multilevel upper thoracic spine and chest wall: case report

BackgroundEn bloc resection of malignant tumors involving upper thoracic spine is technically difficult. We surgically treated a patient with grade 2 chondrosarcoma involving T1–5, left upper thoracic cavity, and chest wall.Case presentationA 37 years old, male patient was referred to our hospital for a huge lump involved left shoulder and chest wall. In order to achieve satisfied surgical margins, anterior approach, posterior approach, and lateral approach were carried out sequentially. After en bloc tumor resection, the upper thoracic spine was reconstructed with a 3D-printed modular vertebral prosthesis, and the huge chest wall defect was repaired by a methyl methacrylate layer between 2 pieces of polypropylene mesh. Postoperatively, the patient suffered from pneumonia and neurological deterioration which fully recovered eventfully. At 24 months after operation, the vertebral prosthesis and internal fixation were intact; there was no tumor local recurrence, and the patient was alive with stable pulmonary metastases.ConclusionThis case report describes resection of a huge chondrosarcoma involving not only multilevel upper thoracic spine, but also entire left upper thoracic cavity and chest wall. Although with complications, en bloc tumor resection with combined surgical approach and effective reconstructions could improve oncologic and functional prognosis in carefully selected spinal tumor patients.

CLINICAL OUTCOMES OF LAPAROSCOPIC SACROCOLPOPEXY FOR PELVIC ORGAN PROLAPSE: A RETROSPECTIVE ANALYSIS OF 500 CASES FROM A SINGLE INSTITUTION

(Objectives) Laparoscopic sacrocolpopexy (LSC) is becoming a more popular alternative for pelvic organ prolapse (POP) repair in Japan in the recent years. This study aimed to evaluate the safety and efficacy of LSC. (Patients and methods) This is a retrospective study on all the LSC cases that were performed in Urogynecology center, Kameda Medical Center, Japan from January 2013 to March 2016. Medical records of all the patients were retrieved and details on operating time, estimated blood loss, perioperative complications, anatomical recurrence (postoperative POP-Q stage≥II) rate and reoperation rate were assessed.Our procedure of LSC used two pieces of polypropylene mesh placed on the vesico-vaginal and recto-vaginal space in which the dissection was extended to the level of the bladder neck and levator ani muscle. Subtotal hysterectomy was performed in almost all patients with uterus except in 39 women who chose to preserve their uterus. Additionally, multivariate analysis of risk factors for recurrence-free survival was performed using the Cox regression method. (Results) Five hundred and five patients who were diagnosed as POP (cystocele, rectocele, enterocele, uterine prolapse, vaginal vault prolapse) were included. The mean operating time and estimated blood loss were 236 min and 27.2 ml. There were 2.6% perioperative complication rate and 1.0% severe complication rate (Clavien grade≥IIIa). With a median follow-up of 12 months, anatomical recurrence rate was 8.0%, significant anatomical recurrence (stage≥III) rate was 1.2% and reoperation rate was 1.0%. Preoperative POP-Q stage IV was found as independent risk factors for anatomical recurrence. (Conclusions) The present study demonstrated a relatively low complication rate, low significant anatomical recurrence rate and low reoperation rate. Therefore, LSC is a safe and effective surgical treatment for various types of POP.

Simple and safe technique for closure of midline abdominal wound dehiscence.

The aim of this study was to assess an alternative technique for closure of burst abdomen. After reduction of the viscera and toilet of abdominal cavity with debridement of any necrotic tissues in the skin or fascia, the skin was undermined to expose the aponeurosis all-around the defect edges for at least 5-6cm. The greater omentum is spread in the floor of the wound and fixed to the inner side of the defect. A piece of polypropylene mesh designed according to the size and shape of the defect and sutured to its external edge continuously. Another larger mesh is placed to cover the smaller one and extend over the aponeurosis exceeding the defect edges by at least 5-6cm and fixed to it. Six males and five females were included. Mean age was 49.3year. Mean follow-up period was 17.8months. Wound infection occurred in 5 patients (45.4%). Mean hospital stay was 18.7days. No patients developed abdominal compartment syndrome, recurrence or intestinal fistula. No mortality was reported. Two cases developed mild local bulge. This technique provides a simple, safe and effective alternative in the treatment of burst abdomen.

Subcutaneous placement of lap band port without fascial fixation provides safe and durable access.

Laparoscopic adjustable gastric band access port has been routinely sutured to the anterior fascia of the abdominal wall using nonabsorbable sutures. We present our technique demonstrating that nonfascial fixation with using a mesh allows for a safe and durable placement of the port in the superficial subcutaneous tissue. Retrospective chart review included 102 consecutive patients who had Lap band surgery performed by single surgeon (EA) from June 2011 until April 2013. The port was sutured to a piece of polypropylene mesh and tunneled in the subcutaneous tissue away from the incision. Patients' demographics were analyzed as well as the following parameters: OR time for port placement, follow-up, port complications requiring revision, difficult access facilitated by fluoroscopy imaging, port infection, and skin erosion. The study included 102 consecutive patients (23 males and 79 females), mean age was 49 years old, mean weight was 284.7 lb, mean height was 66.2 in., and mean body mass index (BMI) was 46.3 kg/m(2). The average operative time for port placement was 4 min, mean follow-up was 12 months, port complications occurred in 2 % of the patients while fluoroscopy for difficult port access was required in 3 %. No cases of port infections or skin erosions occurred. Superficial subcutaneous placement of Lap Band Port using mesh fixation without anchoring the port to the fascia provides safe and durable access. Deep incisions to secure the port directly to the fascia might not be necessary.

Evaluation of surgical instrument handling on polypropylene mesh using scanning electron microscopy

To evaluate the effect of surgical instruments handling on polypropylene mesh using scanning electron microscopy (SEM). We applied different surgical instruments, including a few robotic ones, to pieces of polypropylene mesh. SEM was used to evaluate the morphological changes with this intervention. Straight hemostat, laparoscopic atraumatic grasper, laparoscopic needle driver, and robotic instruments (Bipolar forceps, Cadiere forceps, PK dissecting forceps and SutureCut) were applied to the mesh. SEM images of tool-affected mesh regions in specimens handled by different instruments along with the images of intact mesh were obtained. Average mesh fiber diameters, as well as the average parameters characterizing instrument-affected regions, were measured. There was substantial widening of the fibers in specimens handled by hemostat or a needle holder. An elliptical but much longer and narrower tool marking with more surface roughness was observed in mesh handled by a grasper. A ∼25-μm-wide and ∼200-μm-long strap was split on one side from the core of the fiber caused by Cadiere. There are morphological changes to polypropylene mesh caused by instrument handling. These changes are different depending on the instrument used. These alterations vary from changes in the surface creating roughness of the fiber, compression of the mesh with narrowing of the fiber in at least one direction or actual splitting or pitting of the fiber. Since there are no data regarding the effect of these morphological changes to the ultimate functioning of the mesh, surgeons should minimize mesh handling by instruments.

Strategies to Minimize Adhesions to Intraperitoneally Placed Mesh in Laparoscopic Ventral Hernia Repair

Adhesions to mesh/tacks in laparoscopic ventral hernia repair are often cited as reasons not to adopt its evidence-based superiority over conventional open methods. This pilot study assessed the occurrence of adhesions to full-sized Polypropylene and Gore-tex DualMesh Plus meshes and the possibility for adhesion prevention using fibrin sealant. Two 10-cm to 15-cm pieces of mesh were placed and fixed laparoscopically in pigs (25kg to 55kg). Group I: 2 animals with Polypropylene mesh on one side and DualMesh on other side. Group II: 2 animals with DualMesh on each side with fibrin sealant applied to the periphery of mesh and staples to one side. Group III: 1 animal with 2 pieces of Polypropylene mesh with fibrin sealant applied to the entire mesh. All animals underwent laparoscopy 3 months later to assess the extent of adhesions, and full-thickness specimens were removed for histological evaluation. More Polypropylene mesh was involved in adhesions than DualMesh. However, with the DualMesh involved in adhesions, more of the surface area was involved in forming adhesions than with Polypropylene mesh. None of the implanted DualMesh had visceral adhesions, while 2 out of 3 Polypropylene meshes had adhesions to both the liver and spleen but none to the bowel. Implanted Polypropylene mesh with fibrin sealant had no adhesions. DualMesh had shrunk more significantly than Polypropylene mesh. Histological evaluation showed absence of acute inflammatory response, significantly more chronic inflammatory response to DualMesh compared to Polypropylene and complete mesothelialization with both meshes. There was extensive collagen deposition between Polypropylene mesh fibers, while fibrosis occurred on both sides of DualMesh with synovial metaplasia over its peritoneal surface akin to encapsulation. DualMesh caused fewer omental and visceral adhesions than Polypropylene mesh did. Fibrin sealant eliminated adhesions to DualMesh and prevented adhesions to Polypropylene mesh when applied over the entire surface. These results support our current use of DualMesh and fibrin sealant in LVHR.

Lomas-Cooperman technique for rectal prolapse in the elderly patient

A variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases. Across a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach. A total of 22 patients (20 female) with a mean age of 84 years (range, 72-93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min(range, 20-60 min) and mean hospital stay was 4.5 days (range, 2-17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4-84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1+/-0.62 to 3.4+/-1.61 (p<0.0001) after surgery. Anal cerclage with the Lomas-Cooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP.

Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia.

Over a 15-month period, 39 patients (37 men) of mean age 52 years underwent laparoscopic inguinal hernia repair. Seven patients had bilateral hernia. Forty-six hernias (33 indirect, five direct, eight both direct and indirect) were repaired. A piece of polypropylene mesh measuring 8 x 10 cm was used to cover the direct and indirect spaces with an endoscopic multifeed hernia stapler. The mean operating time for unilateral and bilateral repair was 49 and 63 min respectively (range 25-90 min). One-third of patients required no postoperative analgesia and only seven had more than one injection of pethidine. The median postoperative stay was 1 (range 1-3) days. The mean period to resumption of daily activities was 7 (range 4-21) days. Three patients complained of paraesthesia of the lateral aspect of the thigh and one developed a hydrocele. Two recurrences were noted on follow-up at 3 months.

Spiral tacks may contribute to intra-abdominal adhesion formation.

With the inception of laparoscopic ventral hernia repair came a novel device not used in conventional hernia repair; the spiral tack. We conducted an experimental study on pigs to determine whether spiral tacks contribute to adhesion formation. Using a standard laparoscopic technique in pigs, pieces of polypropylene mesh were fixed to the fascia on the upper abdominal wall, with polypropylene sutures on a randomly chosen side (side 1), and with 5-mm spiral tacks on the opposite side (side 2). The extent, type, and tenacity of the adhesions were assessed on postoperative days (PODs) 30 and 90. The mesh fixed to the abdominal wall with spiral tacks tended to increase the extent, type, and tenacity of adhesions more than the mesh fixed with polypropylene sutures (P < 0.05). Spiral tacks contributed to the formation of adhesions more than polypropylene mesh did. Although this was a small-scale animal study, our findings suggest that the effect of spiral tacks used in laparoscopic ventral hernia repair should be assessed and the consequences monitored more closely.

Schwartz–pregenzer urethropexy

Objective: To report the results of our laparoscopic urethropexy using polypropylene mesh graft and laparoscopic stapler.Methods: Women with hypermobile proximal urethra and genuine stress incontinence underwent direct video laparoscopic extraabdominal bladder neck suspension. A 1 × 3 cm piece of polypropylene mesh was placed in the space of Retzius and stapled to the bladder neck using about 5–6 staples over a wide area to ensure appropriate elevation and then stapled to the ipsilateral Cooper’s ligament.Results: Eighty women (aged 31–79 years) underwent the Schwartz–Pregenzer urethropexy over a 4-year period. The average blood loss was less than 25 mL (range 20–100 mL) and the average operative time 25 minutes (range 13–45 min). Most patients are discharged 4–6 hours after surgery. Success was defined as a negative cotton swab test result and remaining continent. Over an average follow-up of 36 months, the procedure has resulted in satisfactory urethrovesical support in 78 women with an overall success of greater than 98%.Conclusions: The Schwartz–Pregenzer urethropexy offers a rapid, cost-effective, efficient, and effective cure for genuine stress incontinence. It also has very low morbidity and shorter hospitalization and recovery time when compared with open and other laparoscopic techniques.

Prosthetic Inguinal Hernia Repair Using a Laparoscopic Extraperitoneal Approach

The preperitoneal technique offers several advantages over conventional anterior approaches in the surgical repair of inguinal hernias: direct access to the posterior inguinal anatomy, clear visibility of all possible hernial defects, ability to circumvent scar tissue and intra-abdominal adhesions, and ease of effecting difficult repairs. A preperitoneal prosthetic procedure has been successfully used, performed laparoscopically, to repair 163 indirect, 163 direct, and one femoral inguinal defects. In the approach used, a piece of polypropylene mesh, placed extraperitoneally, is used to reinforce or replace the transversalis fascia. In only one of 197 patients (0.5%) was it necessary to convert to an open procedure; this patient had a severely incarcerated hernia. Almost all patients were discharged on the day of surgery, and all returned to normal activities within 7 days. There were few complications, and the recurrence rate in the series of 300 repairs was only 0.3%. One patient required a second procedure because of a retained indirect hernia. Based upon these results and the experience of others using a similar approach, the laparoscopic extraperitoneal prosthetic repair is advocated for patients with recurrent, as well as bilateral and complicated inguinal defects.

Double-buttress laparoscopic herniorrhaphy.

To determine if laparoscopic inguinal herniorrhaphy can be performed safely in unselected patients, the authors' first 100 consecutive laparoscopic inguinal hernia repairs were reviewed. All patients with inguinal hernias who were candidates for general anesthetic were accepted for the study. Their ages ranged from 18 to 84 years. One hundred and six hernias were laparoscopically repaired in 95 males and 4 females. One male patient required an open hernia repair. The first 14 patients were repaired with a preperitoneal patch and plug technique, and the next 85 with the double-buttress transabdominal preperitoneal approach. Two pieces of polypropylene mesh were stapled to the transversalis fascia, ileopubic tract, and Cooper's ligament after the preperitoneal dissection of the hernia was completed. The first piece was placed over the indirect space, with a slit for the cord medially, and the second piece was placed over the entire direct and indirect area. Patients have been followed from 8-18 months. To date, no recurrence has developed. Complications have included seroma, inferior epigastric bleeding, trocar hernia, and neuralgia. Patients have returned to work and normal activity in 2 days to 2 weeks, with an average of 1 week.