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Surgical Technology International XXII contains 46 articles with color illustrations.

 

Universal Medical Press, Inc.

San Francisco, December, 2012

ISBN: 1-890131-18-0

 

1 year Institutional Subscription 

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Sections

Hernia Repair

 

Covidien
  • Covidien Covidien

Self gripping Parietex Progrip™ Mesh in Laparoscopic Hernia Repair. Have we found the ideal implant?

Dieter Birk MD, PhD, Chairman, Department of Surgery, Medical Director, Carlos Garcia Pardo MD, Registrar Surgeon, Department of Surgery, Protestant Hospital Zweibrücken, Zweibrücken, Germany, Surgical Department of the Protestant Hospital, Zweibrücken, Germany

 

PMID: 23292669

Abstract

Introduction: The goal of modern laparoscopic hernia repair is to achieve a high standard of patient safety with a low threshold of hernia recurrence and chronic inguinal pain. In the absence of fixating devices and the use of the self-gripping Parietene and Parietex ProGrip™ mesh (Covidien AG, Zurich, Switzerland) was evaluated in this prospective clinical study. The incidence of chronic pain, postoperative complications, patient satisfaction, and hernia recurrence at follow-up after 12 and 24 months was recorded.
Methods: Data were collected retrospectively from patient files and were analyzed for 405 male and female patients with 483 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal (TAPP) approach using Parietex ProGrip™ meshes performed in the same clinical center in Germany. Pre-, peri-, and postoperative data were collected and a follow-up after 12 and 24 months was performed prospectively. Complications, pain scored on a 0 to 10 NRS scale, patient satisfaction, and hernia recurrence were assessed.
Results: The only complications were minor and were postoperative: hematoma/seroma (nine cases), secondary hemorrhage through the trocar's site (eight cases), hematuria, emphysema in the inguinal regions (both sides), and swelling above the genital organs (one case for each). Two patients had to be reoperated due to a hematoma in inguinal canal. At mean follow-up at 22.8 months, there were only eight reports of hernia recurrence: 1.9% of the hernias. Most patients (94.9%) were satisfied or very satisfied with their hernia repair with only 1.2% reporting severe pain (NRS score 7 to 10) and 3.6% reported mild pain.
Conclusion: This study demonstrates that, in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietene and Parietex ProGrip™ selfgripping meshes is rapid, efficient, and safe with low pain and low hernia recurrence rate. Since no fixating device or glue is necessary for the procedure, additional cost-effectiveness is achieved.

 

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Prospective Randomized Study Comparing Quality of Life after Shoudice or Mesh Plug Repair for Inguinal Hernia: Short-term Results

Emilie Lermite, MD, PhD, Consultant Surgeon, Digestive Surgery Department, CHU Angers Angers, France, Jean-Pierre Arnaud, MD, Professor of Surgery Digestive Surgery Department, CHU Angers Angers, France

PMID:23023573

Abstract

Postoperative pain is a major obstacle in hernia repair surgery, and the choice of clinically efficacious surgical technique should also result in the least postoperative pain and patients' quality of life (QoL). The aim of this prospective randomized study was to compare two surgical techniques for open inguinal hernia repair by assessing the patients' QoL.
Men (18-to-75 years old) with primary unilateral inguinal hernia underwent Mesh Plug (MP; n=156; Bard® (PerFix Plug®, CR Bard Inc, Murray Hill, NJ) and Shouldice (S; n=144) techniques. We evaluated: 1) Intensity of postoperative pain (visual analog scale [VAS]) and 2) quality of life (QoL; Medical Outcomes Study Short- Form 36 [SF-36]).
Patients undergoing MP had significantly lower VAS scores on postoperative days (POD) 1 (22.1 vs 27.4, p = .003) and 2 (13.2 vs 21.4, p < .0001) compared to those in the S group. The QoL was also improved in patients undergoing MP on PODs 8 and 45. Total duration of operation, length of hospital stay, and cessation of normal activities were significantly shorter in the MP group.
Compared to the S technique, the MP technique results in significantly less postoperative pain and improved QoL.

 

 

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Preliminary Results of Surgical and Quality of Life Outcomes of Physiomesh in an International, Prospective Study
Joel F. Bradley, III, MD, Gastrointestinal and Minimally Invasive Surgery Fellow, Carolinas Medical Center, Charlotte, North Carolina, Amanda L. Walters, MS Senior Statistician And Applications Specialist Division of GI And Minimally Invasive Surgery Carolinas Medical Center, Charlotte, North Carolina, Kristopher B. Williams, MD, Gastrointestinal and Minimally Invasive Surgery Fellow, Carolinas Medical Center, Charlotte, North Carolina, Ronald F. Sing, DO, FACS, FCCM, Professor of Surgery Carolinas Medical Center, Charlotte, North Carolina, Blair A. Wormer, MD, General Surgery Resident, Carolinas Medical Center, Charlotte, North Carolina, Igor Belyansky, MD, General And Minimally Invasive Surgeon, Anne Arundel Medical Center, Annapolis, Maryland, Victor B. Tsirline, MD, Assistant Professor of Surgery, Northwestern University, Chicago, Illinois, B. Todd Heniford, MD, Facs, Chief, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina

PMID: 23292674

Abstract

Physiomesh™ is a novel, lightweight, large pore, polypropylene mesh designed to have flexibility that matches the compliance of the abdominal wall in an effort to improve patient quality of life (QOL). The International Hernia Mesh Registry was queried for ventral hernia repair (VHR) and inguinal hernia repair (IHR) with Physiomesh. Demographics, operative and postoperative details, and the Carolinas Comfort Scale (CCS) as a measure of QOL were recorded. Physiomesh was used in 100 patients, 29 IHR and 71 VHR. Their average age was 56.8 ± 13.7, and BMI was 34.0 ± 21.0 kg/m2. For IHR, preoperative pain (CCS > 2) was present in 41%, but decreased at 1, 6, and 12 months postoperatively to 25.9%, 0%, and 1.6%, while movement limitation decreased from 42.9% to 18.5%, 1.6%, and 3.1%. There were no complications or recurrences. The average VHR measured 66.4cm2; 93% underwent a laparoscopic repair. Pain was present in 59.1% preoperatively but 21% at 12 months. Movement limitations reduced from 43.2% to 15.8% at 12 months. Mesh sensation was reported in only 10.5% at 1 year. There was 1 recurrence. Physiomesh is well tolerated by patients undergoing IHR and VHR. It is associated with a very favorable long-term QOL.

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Fixation-free Inguinal Hernia Repair Using a Dynamic Self-retaining Implant
Giuseppe Amato, MD, Consultant Professor, Department of General And Emergency Surgery, Antonino Agrusa, MD, Research Fellow, Department Of General And Emergency Surgery, Giorgio Romano, MD, Associate Professor, Department of General and Emergency Surgery, University of Palermo, Palermo, Italy

PMID: 23065807

Abstract

Inguinal hernia repair remains controversial, despite advances in technique and materials. Conventional implants are typically static (passive) and do not move in concert with the groin’s motility. Inguinal hernia repair with mesh fixation on dynamic groin structures are not tension free, and are associated with tissue tearing, bleeding, hematoma, and nerve entrapment–all which might contribute to mesh dislocation. The poor quality of tissue ingrowth within static meshes/plugs embodies another crucial issue in prosthetic hernia repair. Because the prosthetics used for inguinal hernia repair are incorporated by rigid fibrotic tissue (hence the term “scar plate”), the regressive tissue leads to shrinkage and reduction of the mesh surface area–a significant cause of recurrence and discomfort.
To improve inguinal hernia repair, a new 3D dynamic (inherent recoil), self-retaining implant has been developed. It achieved excellent outcomes in the porcine model, and demonstrated that the dynamic compliant movement and recoil of the 3D prosthetic structure within the groin’s natural tissues allowed for the critical cyclical physiologic loading that is missing with other implants. Because enhanced biologic response and improved quality of tissue ingrowth result from its dynamic interactions with groin tissue, the shrinkage of the implant is nearly absent, even after long-term implantation. We discuss this dynamic hernia repair concept in this report.
The use of this new 3D implant represented a faster and simpler surgical approach to inguinal hernia repair. The procedure was based on the centrifugal expansion of the device, whose design features converted ejection forces into gripping forces, and avoided the need for suturing the implant (eliminating a cause of complications related to prosthesis fixation).

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WL Gore & Associates
  • Gore Gore

Synthetic Bioabsorbable Hernia Plug for Plug and Patch Inguinal Herniorrhaphy: Implantation Technique
Carl Doerhoff, MD, FACS, General Surgeon, University of Missouri Health Care, Capital Region Medical Center, Jefferson City, MO

 

 

 

 

PMID: 23109070

Abstract

New products have led the way in advancements of inguinal hernia repair. None is more impressive than the evolution of the plug patch. In 1968 Irving Lichtenstein introduced the first Marlex mesh plug repair when he rolled a piece of flat polypropylene into the shape of a cigarette to fill a femoral defect. He later expanded his use of the "cigarette plug" to repair recurrent hernias. Today, a wide array of mesh plugs, ranging from nonabsorbable to partially and fully absorbable biomaterials, are available from manufacturers. While some surgeons have used the plug alone for repair, most believe the overlay patch is of greater importance for the durability of the repair. With larger overlays, it is questionable whether a plug should be a permanent, nonabsorbable material. Heavyweight plugs have been reported to erode, migrate, or cause vocational-limiting inguinodynia. Using a fully absorbable plug in inguinal hernia repair minimizes the risk of these complications. This article focuses on the technical refinements associated with using the completely absorbable GORE®BIO-A® Hernia Plug (W.L. Gore & Associates, Inc, Elkton, MD) in combination with macroporous polypropylene or polyester. Additionally, this paper describes the use of GORE® BIO-A® Tissue Reinforcement as an alternative for repair following removal of prior polypropylene plug-patch herniorrhaphy that cause inguinodynia.

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Mesh Fixation Alternatives in Laparoscopic Ventral Hernia Repair
Filip E. Muysoms, MD, Senior Surgeon, Department of General Surgery, AZ Maria Middelares Ghent, Belgium, Iris Kyle-Leinhase, PhD, Abdominal Wall Surgery Study Coordinator, Department of General Surgery, AZ Maria Middelares, Ghent, Belgium, Bengt Novik, MD, Consultant Surgeon, Center for Minimally Invasive Surgery (CFTK), Stockholm, Department of Clinical Science, Technology & Interventions (CLINTEC), Karolinska Institute,Stockholm, Sweden Frederik Berrevoet, MD, PhD, Consultant Surgeon, Department of General and Hepatobiliary Surgery, Liver Transplantation Service, University Hospital, Ghent, Belgium

PMID: 23225589

Abstract

Since the introduction of laparoscopic ventral hernia repair, there has been an ongoing dispute over the optimal method of fixating the mesh against the abdominal wall. In general, one could say that the more penetrating the fixation used, the stronger the fixation, but at the cost of increased acute postoperative pain. The occurrence of chronic pain in some patients has led to the search for less permanent penetrating fixation, but without risking a less stable mesh fixation and increased recurrences due to shift or shrinkage of the mesh. Avoiding transfascial sutures by using a double crown of staples has been proposed and recently absorbable fixation devices have been developed. Some surgeons have proposed fixation with glue to reduce the number of staples, or even eliminate them entirely.
The continuously increasing multitude of marketed meshes and fixating devices leads to unlimited options in mesh fixation combination and geometry. Therefore, we will never be able to get a clear view on the benefits and pitfalls of every specific combination. Clearance of the anterior abdominal wall from peritoneal fatty tissue and correct positioning of the mesh with ample overlap of the hernia defect are possibly as important as the choice of mesh and fixation.
Other topics that are involved in successful outcomes but not addressed in this article are adequate training in the procedure, appropriate selection of patients, and careful adhesiolysis to minimize accidental visceral injuries.

 

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DynaMesh
  • DynaMesh DynaMesh
Acell
  • DynaMesh DynaMesh

Reducing Postoperative Pain: The Use of Tisseel for Mesh Fixation in Inguinal Hernia Repair

Giampiero Campanelli, MD, Professor of Sugery, Insubria University of Varese, Chief, Department of General Surgery, Day & Week Surgery
Istituto Clinico Sant'Ambrogio, Milano, Italy, Marta Cavalli, MD, Resident in General Surgery, Insubria University of Varese, Istituto Clinico Sant'Ambrogio, Milano, Italy, Cristina Sfeclan, PhD, Resident in General Surgery, University of Pharmacy and Medicine, Craiova, Romania, Antonio Biondi, MD, Assistant Professor of Surgery, University of Catania, Azienda Ospedaliero Universitaria Policlinico Vittorio Emanuele, Catania, Italy

PMID: 23109074

Abstract

Introduction: The new objective in primary hernia surgery should be the reduction of disabling chronic pain. This article will discuss the safety, efficacy, and reduction of pain of a sutureless glue mesh procedure for primary uncomplicated inguinal hernia repair.
Methods: We began performing sutureless glue mesh repairs in 2004 for primary uncomplicated inguinal hernias with good results. After reduction of the hernia sac, polypropylene medium-weight preshaped flat mesh is fixed to the posterior inguinal wall with 0.5 mL of fibrin glue on the pubic tubercle; another 1.5 mL is sprayed on the entire mesh surface. The cord is positioned in subcutaneous space. The TI.ME.LI (Tissucol/Tisseel® for MEsh fixation in LIchtenstein hernia repair) trial was planned and conducted based on this experience.
Results: In two years, we treated more than 600 primary inguinal hernias with fibrin glue mesh fixation repair. At follow-up (2 to 96 months after surgery), no patients presented with severe pain, 2.7% of patients complained of moderate pain.
Conclusion: Fibrin sealant for mesh fixation in open repair is well tolerated and it should be considered as a first-line option for mesh fixation in open inguinal hernia repair.

 

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Retrospective study on the use of a composite mesh (Physiomesh®) in laparoscopic ventral hernia repair
Tim Tollens, MD, Consultant Surgeon, Imelda Hospital, Bonheiden, Belgium, Beunis Anthony, MD, Imelda Hospital, Bonheiden, Belgium, Elens Maxime, MD, Imelda Hospital, Bonheiden, Belgium, Aelvoet Chris, MD, Chris Aelvoet, MD, Consultant Surgeon, Imelda Hospital, Bonheiden, Belgium, Imelda Hospital Bonheiden, General Surgery Department, Bonheiden, Belgium

PMID: 23225592

Abstract

The ideal mesh suited for intraperitoneal placement should address both requirements of tissue separation on the visceral surface and tissue integration on the parietal surface. Meshes with bioresorbable coatings have recently been demonstrated to be successful. In this article, the results are shown of a study with a new type of tissue-separating lightweight mesh with a bioresorbable coating (Physiomesh ®; Ethicon, Somerville, NJ) in laparoscopic ventral hernia repair. In this single-center retrospective analysis, 88 patients (50 men, 38 women) undergoing hernia surgery between November 16, 2010 and August 10, 2012 at the Imelda Hospital Bonheiden were included. Patients were asked to score their pre- and postoperative pain (1 month after surgery) on a visual analogue scale (VAS), as well as the chronic postoperative pain (pain at more than 6 months after surgery). The time period after which patients were pain free and after which they could return to work was also noted. Our results demonstrate that Physiomesh is a good alternative to the existing meshes leading to significant pain reduction, early return to work, acceptable complications, and low recurrence and reintervention rates.

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