CINA-2007-TENSION-FREE-SLIDING-MESH(ppt文档).ppt

“TENSION FREE SUTURE LESS SLIDING MESH-HERNIOPLASTY”BEIJING,1616 OCTOBER 2007 OCTOBER 2007Francesco Abbonante M.D.Francesco Abbonante M.D.Catanzaro-ItalyCatanzaro-Italyfrancescoabbonantetin.itfrancescoabbonantetin.it Mesh is necessary in hernioplasty to prevent tension and then,recurrences 1.sutures prevent 1.sutures prevent mesh migration,wrinkling and curling mesh migration,wrinkling and curling 2.But suturing is:2.But suturing is:time consuming time consuming create tension,create tension,postoperative pain,postoperative pain,n nerve entrapment Light mesh needs sutures to stay flat in placeit is necessary to make a mesh which stay flat without sutures 1.There is no need for mesh suturing if mesh is rigid,macroporous,and has flat shape memory.2.heavy mesh does not migrate,wrinkle or curl when placed in closed space,in retromuscular position,without suturing.3.heavy mesh protects from recurrence laying flat 3.heavy mesh protects from recurrence laying flat without tension,being hold in place by intra-without tension,being hold in place by intra-abdominal pressure and connective tissue infiltration.abdominal pressure and connective tissue infiltration.4.4.HeavyHeavy meshmesh withoutwithout suturessutures slidesslides on on posteriorposterior wallwall of of musclesmuscles fittingfitting toto differentdifferent pressurepressure whenwhen patientpatient wakewake up and up and movesmoves (SLIDING MESH)(SLIDING MESH)MAIN CONCEPTS SLIDING MESHWHEN YOU WHEN YOU SUTURESUTURE THE THE LIGHT MESHLIGHT MESH ALL ALL THE WAY AROUND,EVERY THE WAY AROUND,EVERY STITCH STITCH CREATES A TENSION POINTCREATES A TENSION POINT,BECAUSE IT IS,BECAUSE IT IS SUBMITTED TO THE SUBMITTED TO THE PULLING FORCES OF PULLING FORCES OF THE ABDOMINAL WALL MUSCLESTHE ABDOMINAL WALL MUSCLES:WHEN:WHEN THE PATIENT STAND UP AND WALKS THE THE PATIENT STAND UP AND WALKS THE MUSCLES CONTRACTS AND IN A DYNAMIC MUSCLES CONTRACTS AND IN A DYNAMIC ACTION ACTION PULL THE STITCHES APPLIED ON PULL THE STITCHES APPLIED ON THE MESHTHE MESH WHICH IS NOT ELASTIC,SO WHICH IS NOT ELASTIC,SO THAT IT CANT FOLLOW THE MUSCLE IN ITS THAT IT CANT FOLLOW THE MUSCLE IN ITS MOVMENT IN THAT WAY YOU HAVE MOVMENT IN THAT WAY YOU HAVE DAMAGE DAMAGE OF OF MUSCLEMUSCLES FIBERSS FIBERS PIERCED BY PIERCED BY SUTURES AND SUTURES AND PAIN FOR THE PATIENTPAIN FOR THE PATIENT WHO WHO HIS LIMITED IN MOVMENTS HIS LIMITED IN MOVMENTS MAIN CONCEPTS SLIDING MESHUSING A RIGID-HEAVY MESH-YOU DONT NEED TO PUT USING A RIGID-HEAVY MESH-YOU DONT NEED TO PUT STITCHES BECAUSE THE STITCHES BECAUSE THE RIGID MESH STAYS FLAT RIGID MESH STAYS FLAT WITHOUT ANY SUTURINGWITHOUT ANY SUTURING AND IT IS AND IT IS SECUREDSECURED IN THE IN THE RETROMUSCULAR POSITION RETROMUSCULAR POSITION BYBY THE THE INTRABDOMINALPRESSURE AND BY THE FIBROBLASTIES INTRABDOMINALPRESSURE AND BY THE FIBROBLASTIES PROLIFERATIONPROLIFERATION OVER TIME.THE OVER TIME.THE RIGID MESH FITSRIGID MESH FITS VERY VERY WELL WELL AT ANY CHANGE OF BODY POSITIONAT ANY CHANGE OF BODY POSITION AND FEETS TO AND FEETS TO THE MUSCULAR ACTIVITY THE MUSCULAR ACTIVITY SLIDING ALONG THE SLIDING ALONG THE ABDOMINAL WALLABDOMINAL WALL.THE MUSCULAR FORCES.THE MUSCULAR FORCES DISTRIBUTED UNIFORMLY ALL OVER THE RIGID MESH,DISTRIBUTED UNIFORMLY ALL OVER THE RIGID MESH,WITHOUT CREATING TENSION INSTEAD THE MUSCULAR WITHOUT CREATING TENSION INSTEAD THE MUSCULAR FORCES CONCENTRATE OVER ANY SINGLE STITCHFORCES CONCENTRATE OVER ANY SINGLE STITCH CREATING TENSION AND THEREFORE PAIN AND CREATING TENSION AND THEREFORE PAIN AND DISCONFORT FOR THE PATIENTDISCONFORT FOR THE PATIENTTension free suture less“SLIDING MESH”hernioplastyAfter few days mesh is colonized by fibroblasts and it is fixed without sutures in NO TENSION POSITION to the tissue,avoiding its dislocation o oMesh must have proper rigidity and flat shape memoryMesh must have proper rigidity and flat shape memoryo oMesh should be Mesh should be macroporousmacroporous,made of polypropylene,made of polypropylene,much bigger than defectmuch bigger than defecto oTest for rigidity:mesh held in upright position does not Test for rigidity:mesh held in upright position does not bendbend Clinical evaluation of the“Tension Free sutureless sliding mesh”Hernia Repair,where rigid mesh is applied without sutures,in a closed space156 patients(82 F,74M)156 patients(82 F,74M)BMI-mean 29.6 4.1 BMI-mean 29.6 4.1 Ventral hernia-defect 5cmVentral hernia-defect 5cmn nprimary defect primary defect 34(21%)34(21%)n nincisionalincisional hernia hernia 119(76%)119(76%)n npostraumaticpostraumatic defect defect 3 (2%)3 (2%)Ventral hernias (january 2003-january 2007)Primary defect Primary defect 34(21%)34(21%)o o18(11%)18(11%)umbilicalumbilical o o14(5%)epigastric 14(5%)epigastric o o 2(1,3%)Spigelian 2(1,3%)Spigelian Postraumatic Postraumatic 3(2,7%)3(2,7%)o o3(2,7%)damage of“3(2,7%)damage of“rectusrectus abdominisabdominis“muscle“muscle MaterialMaterialIncisionalIncisional hernia hernia 119(76%)119(76%)81(52%)midline 81(52%)midline incisionalincisionalo o 13(8%)-13(8%)-supraumbilicalsupraumbilical M1M1o o 18(11%)18(11%)-juxtaumbilicaljuxtaumbilical M2 M2 o o 18(11%)18(11%)-subumbilicalsubumbilical M3 M3 o o 12(7,6%)12(7,6%)-xiphoxipho-pubic-pubic M4M4 6(11%)6(11%)paramedialparamedial 4(7%)transverse 4(7%)transverse 3(5%)lumbar 3(5%)lumbar 11(5%)11(5%)paracolostomicparacolostomic hernia hernia 2(4%)after appendectomy 2(4%)after appendectomyUsed prosthetic material20(36%)20(36%)HertraHertra 0*0*size-30cm size-30cm lenghtlenght-30 cm -30 cm widthwidth 28(50%)28(50%)OvalOval Patch*-18x14 cm Patch*-18x14 cm6(11%)6(11%)OvalOval Patch*-14x 11cm Patch*-14x 11cm2 (3%)2 (3%)OvalOval Patch*-12x 8 cm Patch*-12x 8 cm(HerniameshHerniamesh,ItalyItaly)*)*Ventral herniaGeneral anesthesia General anesthesia Antibiotics prophylaxisAntibiotics prophylaxisThromboembolicThromboembolic disease prophylaxis disease prophylaxisEarly mobilizationEarly mobilizationSurgical technique Ventral hernia(main point)1.1.ExcisionExcision of the of the herniahernia sacsac2.2.Closure of the peritoneum and posterior fascia with Closure of the peritoneum and posterior fascia with running suture running suture 3 3Placement of rigid mesh in retromuscular position or in Placement of rigid mesh in retromuscular position or in preperitoneal space preperitoneal space withoutwithout suture suture 4 4FibrinFibrin glueglue nebulizednebulized on on meshmesh 5 5ClosureClosure of of anterioranterior fascia with running suture fascia with running suture5 5 Relaxing incisions of anterior fascia,Relaxing incisions of anterior fascia,if if necessarynecessary6 6 RedonRedon drainage drainageSurgical techniqueSurgical technique1.1.ExcisionExcision of the of the herniahernia sacsac Surgical techniqueSurgical technique2.2.ClosureClosure of the of the peritoneumperitoneum and and posteriorposterior fascia fascia withwith runningrunning suture suture3 3.P Placementlacement of the of the rigidrigid meshmesh in in preperitonealpreperitoneal space or space or retromuscularretromuscular position position withoutwithout suture sutureSurgical techniqueSurgical techniqueSurgical techniqueSurgical technique4.suction drainage4.suction drainage Surgical technique Surgical technique 5.Closure of 5.Closure of anterioranterior fascia fascia withwith runningrunning suture suture6.Relaxing incisions,when necessary to reduce 6.Relaxing incisions,when necessary to reduce tensiontensionUmbilical hernialarge size(10 cm)Umbilical hernialarge size(10 cm)Umbilical hernia large size(10 cm)Umbilical hernialarge size(10 cm)NextNext,anterioranterior fascia fascia is is closedclosedUmbilical hernialarge size(10 cm)After seven monthsbeforeafterUmbilical hernialarge size 10 cmafter seven monthsbeforeafterResection of rectus abdominis muscle due to endomethriosis tumor.Mesh replaced the muscleIntramuscular pathologyEndomethriosis in left rectus abdominis muscleResection of rectus abdominis muscle due to endomethriosis tumor.Mesh replaced the muscleAfter one After one yearyearResection of rectus abdominis muscle due to endomethriosis tumor.Mesh replaced the muscleTransverse incisional hernia upper right quadrantTransverse incisional hernia upper right quadrantTransverse incisional hernia upper right quadrant Transverse incisional hernia upper right quadrant1YEAR AFTER NO PAIN-NO LIMITATION PHYSICAL ACTIVITIESNO RECURRENCELumbar incisional herniaLumbar incisional herniaLumbar incisional herniaMeso-ipogastric ventral herniaRetromuscular mesh+lipectomybeforeafterUnder ribs right incisional herniabeforeafterUnder ribs right incisional herniaafterbeforeUpper right incisional herniabeforeafterbeforeafterEpi-meso-ipo recurrente incisional herniabeforeafterEpi-meso-ipo recurrente incisional herniabeforeafterResultsTypeType of repair:of repair:n n114(73%)cases-114(73%)cases-meshmesh in in retromuscularretromuscular position position n n 42(26%)42(26%)cases-cases-meshmesh in in preperitonealpreperitoneal space spaceTime hospitalization-4 days(2-6)Time hospitalization-4 days(2-6)No need for surgical intervention due No need for surgical intervention due toto seromaseroma,woundwound infectioninfection or or haematomahaematoma18 18 monthsmonths(6-482)(6-482)follow-upfollow-up 1 recurrence in suprapubic 1 recurrence in suprapubic regionregion becausebecause of insufficent of insufficent preparation due to presence of preparation due to presence of bladder-cutaneusbladder-cutaneus fistula fistulaNo chronic pain,no No chronic pain,no physicalphysical activityactivity limitationlimitation due due toto rigidrigid meshmesh implantationimplantationConclusionImplantation of the rigid mesh was safe and effective in treatment of ventral hernia full full assessmentassessment of the of the techniquetechnique willwill bebe basedbased on the on the resultsresults of the of the multicentermulticenter,prospectiveprospective studystudy beingbeing actuallyactually conductedconducted in in EuropeanEuropean hospitalshospitals and in Columbia and in Columbia University-U.S.A.University-U.S.A.Thank youXie Xiefrancescoabbonantetin.itfrancescoabbonantetin.it