Ventral Hernias Flashcards
What are OVHR 5 techniques?
Tissue to Tissue Onlay Retro-muscular Pre-peritoneal Intra-abdominal
Advantages of tissue-to-tissue repair
Simple
Inexpensive
No foreign body introduced
Disadvantages of tissue-to-tissue technique?
Tension on suture line
Can’t see other defects
Not suitable for large defects
Advantages of onlay technique?
Simple
Inexpensive
Disadvantages of onlay technique?
Numerous sutures to secure mesh
Inability to see other defects
Infection - mesh too close to skin
Lateral dissection - increased seroma - increase time required
Advantages of retro-muscular/pre-peritoneal repair?
Pascal’s law
Less risk of infection - mesh further away from skin
Disadvantages of retro-muscular/pre-peritoneal repair?
Lateral dissection - increased seroma - increased time
Potential issues with suture placement
Inability to see other defects
Best OVHR technique?
Intra-abdominal placement
Advantages of intra-abdominal technique?
Pascal’s law
Less risk of mesh becoming infected - furthest away from skin
Can locate additional defects***
Disadvantages of intra-abdominal repair?
Increased risk of bowel injury***
Must compromise the peritoneum
Advantages of LVHR?
Deep placement - Pascal’s Law
Quicker recovery
Minimally invasive
Quicker recovery
Disadvantages of Lap repair technique?
Technically challenging
Expensive
Adhesiolysis - increases time
Risk of intra-abdominal injury
Why is it important to have an adhesion barrier for mesh placed in the intra-abdominal cavity?
To protect the bowel from adhering to the mesh until the peritoneum grows back.
What is Davol’s permanent adhesion barrier
ePTFE
What is Davol’s absorbable adhesion barrier?
Sepra technology
What are the disadvantages of using 100% ePTFE products?
?
What benefit does the original Composix offer?
.
Composix EX Advantages
Rapid tissue in-growth - due to monofilament polypropylene
Prevents bowel adhesions with ePTFE barrier
Overlap prevents adhesions to the edge of polypropylene with ePTFE barrier
Composix LP advantages
- Rapid tissue in-growth with uncoated monofilament polypropylene
- LOW PROFILE enables all sizes to be inserted into a trocar / large pore mesh
- prevents bowel adhesions with ePTFE barrier
Why was Composix LP developed?
Surgeons wanted mesh to fit through trocar easier.
Surgeons are interested in lighter weight, large pore mesh.
What is the benefit of Composix LP over Composix EX?
Comes with an introducer tool to assist with rolling and introducing mesh through trocar
What are the key differences between Composix EX and LP?
LP has 15% larger pores and 50% lighter weight.
Describe technique for Composix EX and LP.
11 steps
- Place ports
- ID defect
- Reduce hernia and take down adhesions
- Measure defect and determine proper mesh size
- Pre place center stitch
- Roll mesh 7. Deploy through trocar
- Position mesh 9. Fixate in opposing corners
- Fixate perimeter 11. Fixate double crown
What is the benefit of PGA fibers?
Provides added strength to repair during incorporation into abdominal wall.
Describe features and benefits of hydrogel barrier.
Minimizes tissue attachment to prosthesis
Allows complete peritoneal growth over mesh
Advantages of Ventralight ST
Rapid tissue in-growth with monofilament polypropylene
Provides added strength to repair with PGA fibers
Prevents bowel adhesions with Sepra Technology
Proven Sepra brand
Features and benefits of SepraMesh IP
1 layer of uncoated monofilament polypropylene for rapid tissue in-growth
PGA fibers bind polypropylene to Sepra barrier to provide added strength to repair
Proven Sepra technology prevents bowel adhesions and absorbs in 30 days
Materials used in SepraMesh IP and Ventralight ST
1 layer of uncoated monofilament polypropylene
PGA fibers
Sepra technology with hydrogel barrier
Describe lap technique for using Ventralight ST and SepraMesh IP
12 steps
- Place ports 2. ID defect
- Reduce hernia and take down adhesions
- Measure defect and determine proper mesh size
- Hydrate mesh 6. Roll mesh
- Insert mesh through trocar
- Position mesh below defect
- Fixate in opposing corners 10. Fixate permimeter
- Fixate double crown
- Deflate and close
What is the difference between SepraMesh IP and Ventralight ST?
50% lighter weight
15% larger pore size
Lighter color
Describe Echo PS positioning system
Low profile, thermoplastic polyurethane (TPU) coated nylon balloon pre-attached to Ventralight ST or Composix LP
Which 2 products can come attached to Echo PS?
Ventralight ST and Composix LP
What purpose Echo PS serve in LVHR
Serves as 3rd arm of doctors. Reduces the frustration involved in placing the mesh.
What is the surgeon targeting strategy for Echo PS?
Go to your current customers first who are satisfied with Ventralight mesh
Once you have practiced and perfected your pitch, go after competition.
Describe the technique for using Echo PS.
- Verify all components
- Hydrate ST 3. Roll with introducer tool
- Deploy through trocar
- Pull inflation tube up through center of defect
- Assemble inflation device
- Inflate balloon 8. Position mesh over defect
- Initial fixation 10. Deflate by cutting inflation tube at skin level 11. Remove balloon from mesh
- Pull balloon up to trocar and remove both together 13. Finish fixation
Advantages of Echo PS
Easy insertion
Effortless placement
Positioning and assisted fixation
Describe design of Ventrio and Ventrio ST
2 layers of uncoated monofilament polypropylene forming positioning pocket
Absorbable PDO ring - causes patch to spring open and lie flat
ePTFE barrier
Advantages/ benefits of Ventrio/Ventrio ST
Provides the benefits of a lap repair through ease of an open approach
Time savings
Proven shorter patient recovery
Proven low complication and recurrence rate
Describe Ventrio ST technique
- Incision
- Id the defect 3. Reduce hernia
- Take down adhesions
- Clear area 5-7 cm and determine patch size
- Hydrate and roll (only for ST)
- Insert patch 8. Check patch popped open
- Pretension fascia 9. Fixate quadrants
- Fixate mesh perimeter 11. Suture bites in pocket 12. Close fascia. Close wound
What are the advantages of the Ventrio technique?
Provides the benefits of lap repair through ease of open approach
Describe the design of Ventralex and Ventralex ST
2 layers of uncoated monofilament polypropylene forming positioning pocket and straps (standard pore)
Permanent PET ring - causes to spring open
ePFTE barrier OR ST adhesion barrier
List features and advantages of Ventralex
Encourages rapid tissue in-growth with uncoated monofilament polypropylene
Facilitates proper placement, positioning and fixation with positioning pocket and straps
PDO ring allows patch to open and lay flat to maintain it’s shape
ePTFE minimizes tissue attach,net to mesh’s posterior
Proven #1 prosthetic for umbilical hernia repair on the market
Features and advantages of Ventralex ST.
Encourages rapid tissue in-growth with uncoated monofilament polypropylene
Facilitates proper placement, positioning and fixation with positioning pocket and straps
PDO ring allows patch to open and lay flat to maintain it’s shape
Proven Sepra Technology adhesion barrier
Proven #1 prosthetic for umbilical hernia repair on the market
What are the indications for using Ventralex
Open umbilical hernia repairs
Describe technique for using Ventralex
- Incision 2. Id defect 3. Excise and reduce
- Clear area 2x size of the defect
- Fold and insert
- Patch pops open, pull up on straps
- Ensure patch is laying flat 8. Pull straps apart
- Suture in quadrants
- Suture straps then cuts straps
- Close fascia
Describe Sepra Technology
Prevents bowel adhesions
Absorbs in 30 days or less
Hydrogel swells to protect adhesions to edge of mesh
Proven Sepra brand
Describe Ethicon Proceed surgical Mesh
(Thick cream mesh with blue stripes)
Polypropylene mesh
PDO encapsulates mesh and provides bonding agent to adhesion barrier
ORC - absorbable adhesion barrier
Weaknesses of Ethicon Proceed
List 3
- PDO Bonds mesh to ORC (adhesion barrier) and also Inhibits tissue growth
***ORC - states should not be used in presence of blood
No design to help with open repairs
Davol product to position against Ethicon Proceed
Ventrio ST
Describe Ethicon Proceed Ventral Patch PVP
(Thick cream round mesh with blue stitching)
Multi-filament polyester
Vicryl mesh encapsulated in PDO
Inner rings PDO
Straps and posterior Proceed
Weaknesses/Disadvantages of Ethicon PVP
Limited clinic data
Contains proceed
Only 2 sizes - no large
Lacks design features like Ventralex
Davol product to position against Ethicon PVP
Ventralex ST
Describe Ethicon Physiomesh
(Lightweight, large pore with stripe down middle)
Layers Monocryl, PDS, Monocryl
Polypropylene mesh
Describe Ethicon Physiomesh weaknesses
No data
Monocryl on both sides
No adhesion barrier overlap
Lacks design features to open repair
May be too lightweight
Davol product to position against Ethicon Physiomesh
Ventralight ST
Covidien Parietex Composite mesh
Weaknesses/disadvantages
…
Davol products to position against Covidien Parietex Composite mesh
Ventralex ST with Echo PS
Describe Covidien Parietex Composite
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Describe Covidien Parietex OS mesh
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Describe Covidien Parietex OS mesh
Weaknesses
…
Covidien Parietex Composite Ventral Patch
Describe
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Covidien Parietex Composite Ventral Patch
Weaknesses
…
Covidien Accusmesh positioning system
Describe
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Covidien Accumesh PS
Weaknesses
…
Davol product to sell against Covidien Parietex Composite Ventral Patch
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Davol product to sell against Covidien Parietex OS
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Covidien Symbotex
Describe
(White large pore, blue tear drop)
Monofilament polyester
Covidien Symbotex
Weaknesses
…
Davol product to sell against Covidien Symbotex
Ventralight ST
SepraMesh IP
Iannitti white paper - strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model
Results - 74% of tissue in-growth occurs within first 2 weeks after surgery
Uses - casts doubt on competitive products where interstices are covered - how much in-growth is achieved
Iannitti - techniques and outcomes of abdominal incisional hernia repair using synthetic mesh - report of 455 cases
R - low recurrence rate, low early infection rate
Uses - defend ePTFE - clinical data showing good outcomes
Ventrio/ ST open technique
Relating product design to technique to good outcomes
Burger white paper - evaluation of new prosthetic meshes for ventral hernia repair
R- SepraMesh and panetex are best options
U - positioning Sepra against competition
Voeller white paper - Ventralex Mesh in umbilical/epigastric hernia repairs
U - clinical proof of efficacy of Ventralex
- positioning and defending Ventralex
Gilliam white paper
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Archer Poster - single arm, single center, retrospective study with prospective follow-up of LVHR utilizing SepraMesh
U - proves efficacy of SepraMesh
