1. Materials for inguinal hernia repair: Mesh and Fixation
Bruce Ramshaw MD FACS
Consultant, Halifax Health
Daytona Beach, FL

2. Mesh Basics Multiple types of mesh Synthetic Biologic Alloderm
Polypropelene
PTFE
Polyester
Biologic
Alloderm
Surgisis
Permacol
Many others

3. Prosthetic Biomaterials
Metal Synthetic Biomaterials
Silver Wire
Germany
United States
Limited tensile strength
Limited pliability
Corrode/oxidize
Migrating fragments
Wound infections

4. Stainless Steel
Haas 1958

5. Prosthetic Biomaterials
Monofilament fibers
woven
Usher et al. Am Surg
24:969, 1958
knitted
Gained popularity during the Vietnam war
Most commonly used mesh worldwide
Francis Usher, MD

6. Prosthetic Biomaterials
Polypropylene Mesh
Marlex
(C.R. Bard, Murray Hill, NJ)
Initially woven - single strand
Knitted modification

7. Prosthetic Biomaterials
Prolene: double stranded polypropylene
(Ethicon)

8. Prosthetic Biomaterials
Surgipro
(United States Surgical Corp, Norwalk, CT)
multiple monofilaments polypropylene

9. Prosthetic Biomaterials
Polyester Fiber-
Hydrophilic
Europe s /
Rives and Stoppa
Thin, pliable, and elastic
Conform to the visceral sac
Rapid fibroblast ingrowth
(true ingrowth)

10. Prosthetic Biomaterials
Polytetrafluoroethylene (PTFE)
Solid PTFE - early poor results
Microporus PTFE ’s
Dual Mesh
two-sided: interstitial spacing
3 microns vs >100 microns
Dual Mesh Plus
antimicrobial additive

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

12. Mesh Contraction and Migration

13. Original size

14. Mesh Contraction- Recurrence

15. Mesh Contraction- Recurrence

20. Heavyweight Polypropylene
Hydrophobic
Chronic inflammatory reaction
Significant contraction
Poor compliance

21. Mesh Comparison

22. Heavyweight Polypropylene
Mesh Comparison
Polyester
Heavyweight Polypropylene

23. Mesh Comparison:
Eight 10 x 10 cm pieces of mesh implanted for three months
Two polypropylene mesh infections
PE mesh: /- 7 cm2
PP (Hvywt.) mesh: /- 14 cm2
Histology and mechanism of ingrowth are different
Tensile strength is less with PP (194N vs. 159N)

24. Cutaneous Nerve

26. Fixation

28. Fixation When Tacking, Where to Tack Trend toward limited tacks
Fixation for Inguinal Hernia
Fixation
When Tacking, Where to Tack
Trend toward limited tacks
Coopers ligament (inferior-medial)
Rectus Sheath (superior-medial)
Above ASIS (lateral)

29. Fixation To Tack or Not to Tack
Fixation for Inguinal Hernia
Fixation
To Tack or Not to Tack
Does fixation reduce risk of recurrence?
Does non-fixation reduce risk of post-op pain?
Moreno-Egea et al. RCT Fixation v. No Fixation in 170 patients. Archives Nov, No difference in recurrence or chronic pain.

30. Inguinodynia- Removing tack

31. Fixation Alternative to Tacking Absorbable Tacks
Fixation for Inguinal Hernia
Fixation
Alternative to Tacking
Absorbable Tacks
Good: Temporary Fixation (6 to 18 months)
Bad: may increase cost
5 mm available are inferior to the tacks (strength)

32. Absorbable Tack Fixation: Bard and Covidien

33. Fixation Alternatives to Tacking Fibrin Glue application
Fixation for Inguinal Hernia
Fixation
Alternatives to Tacking
Fibrin Glue application
Lau et al. RCT of Fibrin Glue v. Tack Fixation Annals Nov, Zero recurrences in both groups, 20% v. 13.5% chronic pain (p=0.4)
Good: Temporary mesh stabilization
Bad: may increase cost, cumbersome application device (though improving)

34. THANK YOU
Questions?