1. Guy Voeller, MD, FACS Professor of Surgery, University of Tennessee Past President, The American Hernia Society

17. SUTURE FIXATION Van’t Riet 2002 Pig model using PPM Used sutures vs tacks (1-5/7cm mesh) Tensile strength 67N vs 28N for single fixation(p<0.001) 115N vs 42N for double(p<0.001) 150N vs 82N for 5 fixation points(p<0.05)

18. SUTURE FIXATION Increasing fixation > 3 per 7cm did not improve TS (every 1.8cm) The TS is up to 2.5 times greater when sutures are used instead of tacks Sutures are preferable for LVH repair

21. Evaluation of Mesh Fixation Strength Time ControlTitanium Spiral Tacks 15.4NNitinolAnchors 7.4 N PolypropyleneSuture 39.1 N Polyglactin 910 Suture Suture 40.0 N Funded – Society of American Gastrointestinal Endoscopic Surgeons

22. Normal Intraabdominal Pressure Stand Valsalva 5 N/cm (3.9-6.8) Stand cough 15 N/cm (7.5-18.1) Jumping 15 N/cm (8.5-19.1) Sitting 2 N/cm (1.3-2.3) Stairs 4.8 N/cm (4.0-5.7) Squat 2.3 N/cm (1.2-2.9) * CMC “normals” study*

24. PIONEERS LeBlanc (Louisiana) Toy and Smoot (Delaware) Gagner, Park and Pomp (Canada) Franklin (Texas) and Ramshaw (Atlanta) Voeller and Mangiante (Memphis)

25. LeBlanc Surg Laparosc Endosc 1993 5 cases; ePTFE 5 trocars Staples only; no sutures Extension of his IPOM technique

26. Toy and Smoot Extension of their IPOM for inguinal Developed mesh spreader Developed suture passer Used ePTFE

27. Franklin Surg Laparosc Endosc 1998 176 patients from 1991-1998 ePTFE and PPM; sutures and staples First to try to close defect if possible F/U 1-84 months 1.1% recurrence No mention of % f/u

28. Voeller and Mangiante First case in 1993 with staples only Recurred 6 months later Mangiante taught Rives repair by George Wantz Realized mimic Rives was critical First to use 5mm tacking device First to do with all 5mm ports Introduced Ioban® as part of procedure First course in the world in 1995 in Memphis

29. Park, Gagner and Pomp 1996 Surg Laparosc Endosc 30 cases ePTFE and PPM; sutures One recurrence at 18 mo f/u Minimal morbidity

30. Prospective, Multicenter Study of Laparoscopic Ventral Hernioplasty. Preliminary Results Toy, Bailey, Carey, Chappius, Gagner, Josephs, Mangiante, Park, Pomp, Smoot, Uddo, Voeller Surg Endosc 1998 Hernias > 4 cm 2 - ePTFE; sutures and staples (tacks) 144 patients over first 2 years Mean OR time was 120 min Mean f/u was 355 days with 95% f/u 4.2% RR; D/C at mean of 2.3 days Return to normal activity at 15 days

31. RAMSHAW Am Surg 1999 Retrospective study of lap vs open 3 year period, 1995-1998 Mean f/u was 21 months 36 recurrences in open and 2 in the lap group Complications much less

32. VOELLER ACS 1999 Heniford, Park, Ramshaw, Voeller 407 repairs F/U 2-5 years RR 3.4% majority due to mesh removal for infection

33. PARK American Surgical Association Published AOS 2003 Heniford, Park, Ramshaw, Voeller 850 patients 13% morbidity Mean f/u was 20 months 4.7% RR

34. Conclusions LAP has fewer wound problems LAP has fewer mesh infections LAP has quicker return to activity LAP and OPEN same recurrence rate QOL is same after LAP and OPEN LAP does not reconstruct abdominal wall Need a study to see if lack of reconstruction matters

35. Abdominal Wall Function Rectus muscles act as stays to stabilize Linea alba is a larger area than a “line” Lateral muscles insert on midline via rectus sheath Length of muscle fibers are short in upper, long in the middle and nonexistent in lower

36. Incisional Hernia More than a hole in the abdominal wall Different from groin, epigastric or umbilical hernias Rives called it “eventration disease” Extent of eventration dictates for the most part what I do for incisional hernia

37. Eventration Disease Respiratory insufficiency Abdominal wall moves in and out during both inspiration and expiration Bowels are pushed out on inspiration and eventually the bowels lose their right of domain Back muscles are not counterbalanced by abdomen

38. Eventration Disease (cont.) Postural changes occur i.e. lordosis Lateral abd. muscles retract Muscles become fatty and fibrotic Lateral retraction makes defect larger Last changes are dermatologic - skin ischemia, ulcers

39. Components Separation Technique Ramirez O. Plast Reconstr Surg. 1990: 86:519) Utilizes overlapping redundant layers of abdominal wall for coverage; can gain 6 cm laterally from each side

40. COMPONENTS SEPARATION Bleichrodt the Netherlands JACS 2003 43 patients with ventral hernias Mean f/u of 15 months in 38 patients 17 with complications 12 of 38 (32%) with recurrence Best in contaminated situation where mesh should not be used

44. MIS Components Separation First group to do was Lowe PRS 2000 Maas and Bleichrodt used hernia balloon Rosen popularizing in USA Combine MIS CS with closure of the defect laparoscopically to “reconstruct” the abd. wall

45. Future SILS Notes Self-Adhering mesh Meshes impregnated with agents to fight infection Meshes impregnated with agents to decrease pain Abdominal wall transplant

46. ADHESIVE Ladurner, Eur J Med Res 2008 Cyanoacrylat glue vs tacks vs sutures Animal model of LVIH Glue equal to tacks in tensile strength

47. NOTES Fong, Endoscopy 2007 Transcolonic 5 pigs 2 x 3 cm pieces of mesh Used magnets Transfascial sutures All meshes intact and no infection at sacrifice

48. NOTES Surg Endosc, Miedema 2009 Transgastric; 5 pigs 13 x 15 cm Surgisis with sutures delivered Sacrificed at 2 weeks OR time 215 min Culture positive abscesses present in 3 of 5 meshes Adhesions varied from 2-100%

49. NOTES Jacobsen Hernia 2009 38 y.o. female Painful recurrent umbilical hernia Repaired transvaginally

50. NOTES Lomanto 2009 5 pigs Mesh placed and fixed transvaginally; fibrin glue Sacrificed at 2 weeks All meshes in place One subQ abscess

51. Self-Adhering Mesh Champault Hernia 2009 LW PPM; Adhesix® (Cousin Biotech, France) Coated with glue on one side Implanted laparoscopically in pigs Removal at 1 day, 1 week and 1 month post-op Excellent integration No migration or shrinkage

52. Thank you