Current management of incisional hernia

types of mesh available and principles of mesh repair for incisional hernia, why we should use mesh and if so what mesh and where to place

1. Endoscopy Conclave One Day Live Endoscopic Workshop & CME 01.09.2013 Sunday, 8am-6pm AC Auditorium-Level V @ Lotus hospital, Erode Hosted by IMA TN SB- AMS Wing IMA Erode Branch ASI Erode City Chapter Delegates: Rs:1000/- Postgraduates: Rs: 500/-

2. Morning Session: ( 8am-1`pm) Live Endoscopy workshop: Basic Diagnostic/ Banding of Varices / Sclerotherapy Dilatation of Stricture esophagus 10 min Lectures on ‘Endoscopic Practice Guidelines ‘ Endoscopic management of Corrosive stricture: When and How?: Management of variceal bleeding: Before and after endotherapy : Role of endoscopy in Upper GI malignancy FB esophagus: Live Endoscopy Workshop: Advanced Stent deployment/Glue Injection of Fundal varices Polypectomy ‘ Futuristic’ Lectures: Tomorrow’s World of Endoscopy Why surgeons should always be doing endoscopy?: Endoscopy in the era of Laparoscopy: Endo quiz: Post Lunch Session(2-4pm) Panel Discussion: Team approach in the management of GI disorders: GERD, Achalasia , Upper GIBleeding , Bile duct stones, Live Colonoscopy/ERCP Workshop Colonoscopic polypectomy Bile duct stone removal/ Stenting Pancreatic endotherapy Challenging situations for endoscopist Upper GI bleeding with normal endoscopy: How to proceed?: Difficulty reaching caecum during Ccolonoscopy : Tricks of the Trade: Post Tea Session( 4-6pm) Humour in Gastroenterology Convocation and Award Ceremony at 4.30pm

3. Current Management of IncisionaL HERNIA Dr.S.Easwaramoorthy Dr.TC.Gnanasekaran Dr.KV.Durairaj ASI Erode City Branch PROF.JR.SANKARAN SYMPOSIUM @ TN&P ASICON 2013

4. Symposium on Management of Incisional hernia. Dr.S.Easwaramoorthy 20min Pathogenesis of Incisional hernia Prevention of incisional hernia Evaluation and Current management of incisional hernia All, we should know about Mesh for hernia! Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional hernia Case scenarios and discussion 10min

5. Why it happens?...

6. Incisional Hernia Why it happens? Patient factors Surgeon factors Disease factors

7. Patient Factors Obesity Diabetes Renal Failure Anaemia and Hypoproteinemia Post Operative Chest Infection

8. Disease Factors Peritonitis Visceral Cancer/ ascites Colostomy

9. Surgeon’s Factors Incision Low midline/ Subcostal Drain/Stoma Wound Protection Suturing Technique

10. Suturing Technique Type of Suture material Absorbable : Vicryl /PDS/ Dexon Non absorbable : Nylon/ Prolene / Ethibond Size of Suture Technique of Suturing

11. Peritoneum? 1 cm across and 1 cm apart Rule of 4

12. Clinical Assessment Lying Standing

13. Loss of Abdominal Domain

14. Role of Imaging in Incisional Hernia CT Abdomen

15. How to manage Incisional hernia? Open procedure (with Abdominoplasty ) Anatomical Repair Component Separation technique Mesh repair Sublay , Inlay, Onlay Laparoscopic repair IPOM

16. How to manage Incisional hernia? Open procedure (with Abdominoplasty ) Anatomical Repair Component Separation technique Mesh repair Laparoscopic repair Mesh repair Mesh is a must…

17. Why Mesh? Low recurrence rate Inguinal hernia repair Bassini’s repair : 10% Shouldice repair : 1% Lichtenstein’s Mesh repair : <1% Ventral hernia Suture Vs Mesh: : 50% Vs 10% Tension free & Pain free Quick recovery Quick to learn and easy to do!

18. Why Mesh? Pathogenesis of Hernia Defective Collagen Reduced ratio of type I and type III collagen Type I: Mature Collagen, strong and normal tissue Type III: Immature Collagen, weak, in healing wounds Type I : Type III ratio normally is 4:1 Connective tissue pathology is not only a cause of primary herniation but its presence can prevent cure! Increased matrix metalloproteinase activity (MMP ) ‘Understand the Wound Biology’ 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.

19. Lichtenstein’s Mesh Repair Tension Free repair Under LA Day care Low recurrence rate!

20. 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)

21. 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

22. Stoppa’s Mesh Repair Pre peritoneal Mesh Over Myopectineal Orifice GPRVS ‘‘In the adult, repairing inguinal hernias in the inguinal canal and femoral hernias in the femoral canal is like closing the curtain instead of shutting the window’’

23. Mesh repair of Incisional Hernia Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

24. Types of Mesh Synthetic Mesh Non absorbable Polyprophylene ( Prolene ) Polyethylene( Marlex ) Polyester(Dacron) PTFE (Teflon/ Gordex ) Absorbable Vicryl Combined Vipro Synthetic with Absorbable Barrier ( Dual mesh) Parietex Proceed Etc Biological Mesh Surgisis ( Porcine submucosa ) Alloderm (Cadaveric human dermis)

25. What Mesh Light weight Vs Heavy weight? Light weight Mesh Heavy weight Mesh Definition? Light wt, thin fibres , macro pores (>1.5mm) Less amt of FB Heavy wt, thick fibres , micro pores (< 1.5mm) So more amount of FB 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.

26. 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 Pro VISC 160 Polyester Polyurethane Life Cost effective Lotus Dual Mesh e PTFE (rough) e PTFE(smooth) Life Gore Kugel / Composix PP(HW) e PTFE Life Cann’t trim Bard

27. Parietex Mesh Features: Polyester with Collagen cover on the visceral side No adhesion or infection Handles well during Lap Holds sutures well Can be trimmed 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 Percutan Tech Apr;11(2):103-6

28. Proceed Mesh (Ethicon) Parietal Side PP(LW) encapsulaed in PDS Blue stripped side Visceral Side ORC ( Oxidised regenerated cellulose) Macroporous Conforms to anatomy Can be trimmed Downside: Ensure meticulous hemostasis or else adhesions likely Shrinks by 30% Delamination and seroma

29. Proceed Mesh (Ethicon) Time line 1 week 2 weeks Day 1 3 months

30. Pro VISC 160 Polyester White Parietal side Polyurethane Blue smooth visceral side With Sutures Pre cut in various sizes

31. Parietal side: PP Visceral side: e PTFE Bard ( Composix ) Gore Dual Mesh Parietal side: Rough PTFE Visceral side: smooth PTFE

32. Mesh repair of Incisional Hernia Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

33. Where to place the Mesh? On Lay In Lay Under Lay IPOM

34. Pascal’s Hydrostatic Principle Onlay Vs Inlay Effect of Intra abdominal Pressure Choose a mesh at least 5cm larger than the defect all round.

35. Mesh repair of Incisional Hernia Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

36. Mesh Fixation Methods… AbsorbaTack ( Covidien ) Permasorb ( Davol / Bard ) Fibrin sealant Spiral Tackers Staples Fibrin Glue Suture

37. Trans Facial Suture Fixation

38. Ideal Fixation Method No Type of Fixation Features 1 Trans Fascial suture fixation Chronic pain 2 Suturing 2cm apart 3 Spiral Titatinum 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 with stand the intra abdominal tangential force and also shearing Force due to abdominal muscle contraction

39. Mesh repair of Incisional Hernia Why Mesh? What type of Mesh? Where to place the Mesh? How to fix the mesh? Mesh related complications

40. Mesh Related Complications… Infection Surgeon’s nightmare Intestinal adhesions Composite mesh for laparoscopic ventral hernia repair Bowel obstructions Erosion of the prosthesis into the adjacent hollow viscus Contraction of prosthesis At least 5cm larger than the size of the defect

41. Prevention of Mesh infection Consider Patient factors Smoking DM Obesity Re operation Big incision Type of Mesh Macroporous vs microporous Impregnated mesh Technique Lap Vs Open On lay Vs In lay Prophylactic antibiotics Avoid unplanned enterotomy Infected field Absorbable mesh Biological mesh Ventral hernia repair Risk of infection is 3-10% in Open mesh repair Risk of infection is < 1% in Lap Mesh repair

42. Conclusion Mesh repair of abdominal wall hernia is the Standard of Care. Composite mesh has to be used for ventral hernia Avoid Mesh related complications , if possible

43. Next Dr.T.G.Gnanasekaran 15min Open mesh repair and abdominoplasty Dr.K.V.Durai raj 15min Laparoscopic mesh repair of incisional hernia Case scenarios and discussion 10min

44. 21year old lady, Para 1 Large Incisional hernia following c -section Yet to complete her family Surgery Vs Conservative treatment Pregnancy after a mesh repair Mesh repair during C-section Case 1

45. 40 year old obese lady Abdominal hysterectomy 5 years ago Incisional Hernia in Lower midline scar Has Symptomatic Gall stones Open /Laparoscopic/Combined Case 2

46. 35 year old lady Laparoscopic hysterectomy 6 months ago Umbilical Port site Hernia Why? Suture Vs Mesh? Case 3

47. Endoscopy Conclave One Day Live Endoscopic Workshop & CME 01.09.2013 Sunday, 8am-6pm AC Auditorium-Level V @ Lotus hospital, Erode Hosted by IMA TN SB- AMS Wing IMA Erode Branch ASI Erode City Chapter Delegates: Rs:1000/- Postgraduates: Rs: 500/-

48. Thank You