work Flashcards
10 layers
- Skin
- Subcutaneous Fat- Sub Q
- Scarpus Fascia
- External Oblique Muscle
- Internal Oblique Muscle
- Transverse abdominal Muscle
- Transverse Fascia
- Pre Peritoneal Space
- Peritoneum
- Inta Abdominal Cavity
Onlay where does the mesh lye
Between Subcutaneous Fat (Sub Q) and Scarpas Fascia
Underlay same as intra abominably where does the mesh lye?
Btw Peritoneum and Intra Abdominal cavity
Retro Rectus where does the mesh lye
Btw Transverse Fascia and Pre Peritoneal Space
Superior and Cephald
Towards the Head
Inferior and Caudad
Towards the Feet
Anterior
front
Posterior
Back
Proximal
Near trunk- point of orgin
DIstal
Away from center of body
Ventral Hernia working Group
Grade 1- Cookie cutter. 77% of Hernias
Grade 2- Multi Co Morbidity- infection- diabetic. 4th Co morbidity= 67% infection
Grade 3- Potentially contaminated. Colostomy- removal of the colon. Illiostomy- large or small intestine coming out. 8%
Grade 4- Contaminate= outside of the body & infection= inside of your body. 4%
Modified Ventral Working Group
Grade 1- Same- cookie cutter. 77% —- products= Synthetic
Grade 2- Co morbid —- Products= Synthetic/Phasix
Grade 3&4- prior infection—- Products Phasix/Zen
Onlay Pros/Cons
Pro- Easiest Visualization, easiest technique, cheapest, 5cm each side of overlap
Cons- Closest to the skin= highest rate of infection
What is a biologic
100% resorbable. It goes away infection eats it up into the body
Underlay Pros/cons
Pro- Less Seroma on mesh
Negative- Cost, hard to do, Puts tension on the mesh
Retro Rectus Pros/Cons
Positive- Sutured to Muscle & Vasculization(Blood flow) on both sides
Con- Bowl injury
Anterior Component Separation what is it?
Rectus Abdominal Reconstruction
Anterior Release what is it?
Top Abdominal cut- Has a Sub Q flap- done onlay or underlay
eliminates tension
TAR what does it stand for & what is it?
Transverse Abdominoius
Puts Mesh in the Transverse Abdominous plane
*- No Sub Q Flaps & No Seroma
3 typers on Inguinal Hernias?
- Indirect
- Direct
- Femoral
What is an Indirect Inguinal Hernia?
They occur bc of a weakened internal Ring, which is the location where the spermatic cord exits the pelvis. These are also congenital and make up 70% of ___ Hernias
What is a Direct Inguinal Hernia?
Internal oblique and transverse abdominal muscle dont go all the way to the inguinal ligament. Make up 30% of ___ Hernias. Trasnverse Fasica called “ wear and tear” - caused by straining
What is a Femoral Inguinal Hernia?
Occur at the femoral space- below the inguinal ligament. Make up 5% of hernias in women. It is where the illiac vessels pass out of the pelvis and travel down the femor just below the inguinal ligament
The tissue layer where the spermatic cord exits the internal ring?
Internal Oblique Muscle
The tissue layer where the testicular vessels and Vas Deferens become the spermatic cord?
Transversalis fascia
Difference between tissue/muscle layers ventral vs groin/inguinal?
Posterior layer of the rectus fascia ends
What are the 4 products for complex abdominal wall repair?
1- XenAB
2- Xen Matrix
3- Phasix ST
4- Phasix Flat sheet
When is Synthetic not a good option?
When infection or contamination presents itself or for complex cases
What is XenAB and when is it used?
Complex Abdominal wall repair
- 1st antibacterial coated surgical graft for hernia reapir demonstraed to prevent the olonization of MRSA, E Coli, MRSE and E aerogenes in Pre Clinical models
- Orange sheet
What is Xen Matrix and when is it used?
Complex abdominal wall repair
- Regenerative collagen matrix, non cross linked, open collagen structure for hernia and abdominal wall repair
- early tissue remodeling
- since 2006
What is Phasic ST and when is it used?
Complex Abdominal wall reapir
- Fully resorbable biologically derived scafflod with an absorbable barrier based on Sepra technology
- Hydrogel barrier- repair strength of a synthetic
What is Phasix Flat sheet and when is it used?
Complex Abdominal wall repair
- fully resorbable biologically 12- 18 month derived scaffold.
- Not intra abdominal
- In between Synthetic mesh and Biologic graft= this
What are the 4 synthetic abdominal ventral hernia repair products?? (OVHR)
- Ventrio
- Ventrio ST
- Ventralex
- Ventralex ST
What is Ventrio and when is it used?
Synthetic Abdominal VENTRAL hernia repair
Self expanding polypropylene and ePTFE patch for soft tissue reconstruction with SorbaFlex Memory Technology
Anterior= 2 layers form a pocket to assist w/ positioning and fixation.
Posterior- ePTFE w/ overlap- minimize chances of bowel adhesion
SorbaFelx memory technology ring- absorbs 6-8 week.
- Patch inserted through small incision, then pop open and lay flat
What is Ventrio ST and when is it used
Synthetic Abdominal Ventral Hernia Repair
Uncoated monofilament polyporpylene mesh with SobraFlex Memeory Technology and an absorbable barrier based on Sepra Technology.
Anterior= 2 layers form a pocket to assist w/ positioning and fixation.
Posterior- Absorbable = 30 days
Key Study Facts:
- key to a successful technique- pre tensioning
- Available in 9 sizes
- Can be placed intraperitonally (entering the Peritoneum) bc of the hydrogel barrier
- absorbs 6-8 months
- has a full pocket - competition only has a lateral skirt
- 1% reoccurrence rate
What is Ventralex and when is it used?
Synthetic Abdominal Ventral Hernia repair- used for umbilical repairs
Designed for ventral, incisional, umbilical and epigastric hernia rapair as well as the trocar site closure and features of sorbaflex memory technology
What is Ventralex ST and when is it used?
Synthetic Abdominal Ventral Hernia repair- used for UMBILICAL repairs
A clinically proven umbillical hernia repair solution with sorbaflex memory technology and an absorbable barrier featuring sepra technology
dissolves 30 days posterior
absorbable ring- dissolves 6-8 months
- has straps for easy use
Key Study facts:
- #1 umbilical patch sold in the market today
- 88 patients- 0 reocurrence rate
- Anterior- medium pore polyprop mesh
- SorbaFlex™ Memory Technology – Absorbable Recoil Ring (PDO) in 6-8 months
- 3 sizes
- clear space- twice the size of defect
- Surgeon must pull apart straps bc 2- they dont come seperated 2- gain acess to pocket
- Technigue to fixate U stiches in a minimum of 2 Quadrants for a small patch and 4 Quadrants for a medium or large patch
- Doesn’t need a barrier overelap bc it swells when hydrated minimizing attachment to the edge of the patch
- Designed to fit down a trocar
Indicated for repair of trocar site deficiencies
What are the 5 ventral Laparoscopic hernia repair products?? (LVHR)
- Composix EX
- Composix LP
- Echo PS
- Ventralight ST
- SepraMesh LP
What is Composix EX and when is it used??
- Ventral laprascopic Repair
Polpropylene/Posteriro- ePTFE prosthesis for laproscopic verntral hernia repair
What is Composix LP and when is it used??
- Ventral laprascopic repair
Low profile, large prore polypropelyne/ posterior ePTFE prothesis for laproscopic verntrla hernia reapir
lighter weight mesh- has an introducer tool- can come w/ echo PS positioning system compared to Composix EX
What is Echo PS positioning system and when is it used??
Ventral Lap Repair
pre attached low profile balloon to help facilitate deployment, placement and positioning in Lap ventral hernia
- 3rd hand for surgeon
- Comes pre attached to Compsix LP or Ventralight ST
- Balloon is removed from patient
Key Facts:
- The center of mesh is indicated by Bard logo
- Reduces frustration involving placing and positioning
- Roll & Deploy ( rotate 1/2 turn to relaseas- opposite direction)
- how to remove: grasping removal point to trocar and remove both simultaneously
- Makes learning curve easier for new surgeons
- 61% time saving for mesh positioning using
- how to deflate: cut the inflation tube as close to skin as possible
What is Ventralight ST and when is it used??
Ventral Lap Repair
Uncoated Lightweight monofilament polyprop mesh on the anterior side with an absorbable hydrogel barrier base on sepra technology on the posterior for lap repair
What two products can come with Echos PS Postioning system already pre attached??
Ventralight ST mech or Composix LP
What is SepraMesh LP and when is it used??
Ventral Lap repair
Combines the strength of polyprop mesh with an absorbable hydrogel barrier based on sepra technology for verntrla hernia repair
Hydrogel barrier- absorbs in 30 days
PGA fibers- absorbs in 50-80 days
what are the 6 Inguinal hernia repair products??
1- PerFix Plug 2- Per Fix Plug Light 3- OnFlex 4- Phasix Plus & Patch 5- 3D Max 6- 3D max light
What is PerFix Plug and when is it used??
Inguinal Hernia Reapir
Plug ad patch designed for use in a tension free open inguinal hernia repair
Top selling. Fluted outer cone- expands and contracts for a tension free repair
- Customizable
- plant A- Traumatic tip- wont pierce peritoneum
- Onlay Patch- helps prevent hernia in adjacent areas
- 4-5cm incision
- Mean time for operation is 28 minutes- study by Keith Millikan
- Tension Free
- 4 million inplants worldwide= .15% reocurrence rate & .5% cronic pain
-
What is On Flex and when is it used??
Inguinal Hernia Repair
Self- expanding light weight mesh for open preperitoneal inguinal hernia repair with sorbaflex memory technology
- pocket design helps w/ placement
- Anatomical shape designed to cover the myopectinela artifice
- absorbs in 6-8 months
- medium weight
- uncoated monofil polyprop
- pocket= positioning and placement
- The SorbaFlex™ PDO monofilament absorbs via
hydrolysis in 6-8 months
- Technique can be performed through one small
4-6 cm incision
What is SorbaFlex Memory Technology??
helps to avoid
buckling and folding of the mesh, which helps the
mesh lay flat and conform to the anatomy in the
preperitoneal space
What is Phasix Plug and Patch and when is it used??
Inguinal hernia repair
Lighter weight version- used when a reduced amount of material is indicated & Fully resorbable biosynthetic implant for soft tissue reconstruction
What is 3D Max and when is it used??
Inguinal Hernia repair- ONLY Lap
Unique 3 dimensional polyprop mesh for lap inguinal hernia repair
- doesnt require fixation
- notch for illiac vessels
- crest to go over inguinal ligament
- clinically proven w/ out fixation
- Mesh Burst Stength- 75 vs medtronic ProGrip 19 - EThican UltiPro- 16
Study Facts:
- Crest of 3D corresponds w inguinal ligament
- notch corresponds w illiac vessel
- m in 3d max stands for medial
- purpose of reinforced edge= adds memory for patch to pop open
What is 3D Max Light and when is it used??
Inguinal Hernia repair- ONLY Lap
Lighter weight version of 3D Max, featuring a large pore knit design. Has Unique 3 dimensional polyprop mesh for lap inguinal hernia repair
- doesnt require fixation
- notch for illiac vessels
- crest to go over inguinal ligament
- 49% less than medtronic Pro Grip
- Mesh Burst strength= 30 vs medtronic ProGrip 19 & Ethican UltiPro- 16
What are the 3 Fixation products??
1- Optifix
2- SorbaFIx
3- Capsure
What is OptiFix and when is it used??
When Fixation is needed- Absorbable PDLLA fasteners available in both a 15 & 30 count configuration delivered via a disposable 5 mm stored energy delivery system.
- spring loaded
- longest on the market
What is SorbaFix and when is it used??
When fixation is needed- Absorbable PDLLA fasteners available in both a 15 and 30 count configuration deliverd via a disposable 5 mm delivery system.
Main difference- fastener- threaded hallow core= tissue ingrowth
What is CapSure and when is it used??
Only Perminant fixation tool
- Permanent 136L stainless steel helical coil fastener with a smooth cap available in both a 15 and 30 count configuration via a disposable 5mm delivery system
- Capsure Fastener- MRI Conditional
- Capsures cap made of PEEK
What is the MK Hernia Technique and what product is it used on??
*- Allows for additional posterior coverage of the defect vs classic technique
hernia repair technique is a minimally
invasive, tension-free technique that can be completed
through a small 4-6 cm incision and minimal requirement of fixation. It is a preperitoneal repair performed through an open, anterior approach that can be completed using local or regional anesthesia.
Used for OnFlex
What Onlay Patch requires no fixation and doesnt need to be sutured to fascia??
PerFIx Plug
29 more minutes to place Pro Grib than??? Clinical Data
3D Max
3D Max vs Ethicon Prolene
- Reduced length in hospital
- decrease in incident of post peroperative urinary retention
3D Max vs ProGrip Medtronic
Premier Database (Insurance collected by hosptials) 5,000 cases
- cases w pro grip cost on avg $1,975 more than 3DMax
- cases w pro grip on avg take 29 mins longer than 3D Max
- ProGrip more pain in 48 Hours
- ProGrip made of polyester and hard to place
What tissue is the surgeon generally placing 3D Max on?
Pre Peritoneal
Basic Hernia repair steps??
- Incision to gain access
- Identify and push/reduce hernia
- Reair 1- mesh 2- tissue to tissue
4- close wound and skin
How does the body react to mesh??
1- Inflammatory response is the intial phase of normal healing process that occurs when tissue is injured
- cells sent to help heal
- mesh reinforcing the area
2- bodys fibrotic response:
- fomration of collegen at a wound site builds a matrix= scar is formed
- new tissue takes over the monofilamnet ( mesh material) & evntually envelopes the mesh
How does mesh work in the body??
Mesh allows new tissue to grow in place/ strengthen area
tissue ingrowth = strength of repair
4 stages of hernias??
- Incisional- resulting from an incision
- Umbilical - belly button
- Inguinal- inner groin- Most common
- Ventral- bulge of tissue through abdominal wall
Advantages and disadvantages of using mesh?? When might mesh be contraindicated?
Contraindicated: mesh not suitable for children- where future in growth is compromised by use of mesh. Not suitable for places where infection exists.
Disadvantage: Simply no foreign body - expensive- infection is at a high risk- a DR teaches/knows anatomy well
Advanatages: Less pain, less tension on suture(row of stiches), lower reocurrence rate
Advantages and disadvantages of Tissue to Tissue??
Adv: Simply no foreign body - inexpensive- infection is at a high risk- a DR teaches/knows anatomy well
DisAdv: Extensive dissection of body, high occurrence, patient pain- row of stiches (Suture), not suitable for large defects
Advantages and disadvantages of Onlay??
Placed between Sub Q and scarpas fascia
Adv: easiest visualization, cheapest, easiest technique
DisAdv: closest to skin- highest infection rate, cant see other defects
Advantages and disadvantages of Retro Muscular??
Between Trasnverse Fascia and Pre Peritoneal Space
Adv: suture to muscle, Vasculirization on both sideds(Blow Flow), further from skin
DisAdv: Bowl Injury, increased seroma, time required, damages healthy tissue
Advantages and disadvantages of Preperitoneal??
Between Pre Peritoneal Space and Peritoneum
ADv: Pascals law- less risk of mesh becoming involved in infection- further from skin
DisAdv: Increased seroma, time required, damages healthy tissue, Bowl Injury
Advantages and Disadvantages of Intra- Abdominal Same as Underlay??
Strongest Mesh placement!
ADv: Pascals Law, less risk of infection, further from skin, seroma less likely, no lateral dissection needed
DisADv: Bowl Injury, Must compromise Peritoneum
Advantages and Disadvantages of LVHR?? And what does LVHR stand for??
Lap Ventral Hernia
Adv: Deep placement(Pascals Law), Minimal invasive, reduced infection risk, quick recovery
DisAdv: technically challenging, expensive, increased time for Adhesiolysis, Risk of intra abdominal injury
What is Pascals Law??
Tire pressure patch spred evenly out.
Why is it important to have an adhestion barrier for mesh placed in the intra abdominal cavity??
- Minimizes risk for surgeon, as well as keeps mesh from contacting with the bowel
What are Davol’s Adhesion barrier options??
- Perminate Barrier- ePTFE. All of Davol’s composite (Animal and plat material) products have Submicronic ePTFE
2- Absorbable - Ex Bard Ventralight ST mesh. Great for against bowel. Absorbs in 30 days.
What are the advanatages of PGA Fibers? What do they do?
Bioresorbable PGA fibers reinforce
the integrity of the hydrogel barrier by
binding it to the polypropylene mesh.
What is the Inguinal canal??
It is superior and parallel to the inguinal ligament. The canal serves as a pathway by which structures can pass from the abdominal wall to the external genitalia
What structure makes up Hasselbach’s Triangle??
- lateral border of the rectus muscle
- inferior epigastric artery
- inguinal ligament
What structures join at the internal ring?
anterior superior iliac spine and the pubic symphysis
Optifix key facts
- 39 cm cannula length- superior reach vs AbsorbaTack
- Optifix maintains 100% of its strength for the 1st 8 weeks well beyond critical healing period
- essentially resorbed at 52 weeks
- Optifix cant be put on consignment
- angled tip for smooth penetration
- Hollow Core- to promote tissue ingrowth
- Large smooth head 1- clinical study suggests may help minimize tissue attachment 2- large head easily visible laproscopically 3- superior surface area under the head- lightens blow as the fastener connects w/ mesh to help fastener from over driving deep into tissue
What landmark should the surgeon plan to fire Optifix just superior of and toward the medial aspect of in a LIHR??
Coopers ligament
While fixating in the pocket the surgeon should??
1-pre tension the fascia
2- Angled up so they are deploying away from the bowel and towards the rectus sheath
3- Assuring they are 1-2 cm from ring
Doctors should never fixate in these areas in inguinal hernia??
1- Triangle of doo (Illia Vessels)
2- Triangle of pain ( Femral branch- femral nerve and lateral nerve)
6 Selling Points against Ethican - SecureStrap
1-* 14% fastener site trama vs OptiFix 1.6% fastener trama
2- Pre Clinical studies indicate- MORE bleeding at point of fixation vs OptiFix
3- 5X Less surface area mesh coverage compared to OptiFix
4- Poor Visualization Lap bc surface are of strap
5- No tissue in growth through fasteners bc no hallow core like OptiFix
6- Only 12/25 straps vs 15/30 optifix
* Claims absorbs after 12 months
5 selling points against Covidian- AbsorbaTack (Blind Survey of Doctors at an International Conference)
1- Ratcheted deployment system- clunky
2- *Pre Clinical studies indicate it is fully resorbed at 6 months * claims to absorb after 12 months
3- *Depth of purchase 4.1 mm vs 5.9 mm OptiFix
4- Solid Core- doesn’t get tissue ingrowth through fastener
5- Older Technology- been around since 2007
- *Has absrbable tackers of 15,20 &30
When targeting SecureStrap what should you focus on?
1- Fastener site Trama
2- Device Price= neutral
3- Account Standardization (Absorb able & Perminate)
4- Current at risk SorbaFix Accounts
5- Fastener count difference 15&30 vs 12 & 25
Initial targets for OptiFix
1- Existing Mesh Accts
2- SecureStrap Accts w/ over 12 months
3- Current at risk SorbaFIx accts
Optifix vs SecureStrip pricing?
Neutral
Optifix vs AbsorbaTac Pricing?
Priced Competitive
Capsure Vs Protack (Covidian)??
- 4 revolutions vs 2 1/2
- Covidien overal market leader for fixation
- stainless stell fastener vs titanium
- Capsure fastener has a 2.15X greater mesh surface area coverage than ProTack Fastener
- Cpasure 14% single shear strength vs Protack
- Capsure out performed the ProTack fixation system in a Preclinical study at 2 weeks and 6 weeks
- More favorable fastener seating results
What are the clinical concerns with ProTack (Covidian)?
- Device reliability issues
- Design leaves exposed sharp point
- Difficulties securing large pore mesh
OptiFix Open vs OptiFix Differences??
- available in 20 count only
- Inverted Handle and trigger
- Cannula length 27 cm vs 39 cm
- curved vs straight
- Distial Tip- smooth and broad vs textured
Guide wire is 304s vs 316
Upside down vs Gun up
Where is the Line of Douglas (LOD)??
Landmark halfway between pubic bone and umbilicus
Above the LOD ventral hernias,
Below groin and femoral hernias.
What is Phasix made of??
P4HB- resorbable polymer derived from Biologic Fermentation. Naturally broken down/degrades from Hydrolisis. The structure of the mesh is open mono filament
