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Prevention of Adhesion to Prosthetic Mesh: Comparison of Different Barriers Using an Incisional Hernia Model
Abstract
Objective: To assess whether use of antiadhesive liquids or coatings could prevent adhesion formation to prosthetic mesh. Summary Background Data: Incisional hernia repair frequently involves the use of prosthetic mesh. However, concern exists about development of adhesions between viscera and the mesh, predisposing to intestinal obstruction or enterocutaneous fistulas. Methods: In 91 rats, a defect in the muscular abdominal wall was created, and mesh was fixed intraperitoneally to cover the defect. Rats were divided in five groups: polypropylene mesh only (control group), addition of Sepracoat or Icodextrin solution to polypropylene mesh, Sepramesh (polypropylene mesh with Seprafilm coating), and Parietex composite mesh (polyester mesh with collagen coating). Seven and 30 days postoperatively, adhesions were assessed and wound healing was studied by microscopy. Results: Intraperitoneal placement of polypropylene mesh was followed by bowel adhesions to the mesh in 50% of the cases. A mean of 74% of the mesh surface was covered by adhesions after 7 days, and 48% after 30 days. Administration of Sepracoat or Icodextrin solution had no influence on adhesion formation. Coated meshes (Sepramesh and Parietex composite mesh) had no bowel adhesions. Sepramesh was associated with a significant reduction of the mesh surface covered by adhesions after 7 and 30 days. Infection was more prevalent with Parietex composite mesh, with concurrent increased mesh surface covered by adhesions after 30 days (78%). Conclusions: Sepramesh significantly reduced mesh surface covered by adhesions and prevented bowel adhesion to the mesh. Parietex composite mesh prevented bowel adhesions as well but increased infection rates in the current model. Incisional hernias occur in 5% to 20% of patients after abdominal surgery. 1–4 In incisional hernia repair, the introduction of tension-free techniques by using prosthetic material has reduced recurrence rates from up to 50% to less than 24%. 5–9 However, foreign materials, such as prosthetic mesh, represent a strong stimulus for the development of permanent adhesions. 10 Particularly if the mesh is placed intraperitoneally, concern exists about development of adhesions between bowel and mesh. These adhesions can cause serious complications, such as intestinal obstruction and enterocutaneous fistulas. 11–14 The aim of the present study was to assess whether adhesions due to intraperitoneal mesh can be prevented by the use of physical barriers that can be applied laparoscopically. For this purpose, we assessed if intraperitoneal administration of liquid physical barriers composed of hyaluronic acid (Sepracoat, HAL-C; Genzyme Corp., Cambridge, MA) or Icodextrin solution (Extraneal, Baxter Healthcare Inc.) could prevent adhesions to a polypropylene mesh without interfering with wound healing and tissue incorporation of the mesh. In addition, we studied the ability of specifically coated meshes, Sepramesh (Genzyme) and Parietex composite mesh (Sofradim, France), to prevent adhesions.
... [6,7] Dense fibrous tissue forms within and around the mesh material, which can lead to complications such as bowel obstruction, perforation, infertility, and chronic discomfort. [8,9] Since the proportion of surgical procedures performed via laparoscopy increased during the past ten years, efforts of developing intraperitoneal repair mesh on the basis of polypropylene material had been constantly undertaken to satisfy clinical requirement. [10][11][12] For example, surface modifications were used to enhance the hydrophilicity and biocompatibility of lightweight PP meshes. ...
... [11,13,14] However, the fabrication of polypropylene-based composite meshes usually requires complicated coating procedures including physical adsorption and covalent crosslinking; [2,15] and the use of the PP composite meshes still caused many mesh related complications, such as infection, seroma, migration, and adhesion, leading to severe consequence or even reoperation. [8,9] Therefore, it remains a big challenge to develop lightweight intraperitoneal repair meshes that exhibit highly permeable, biocompatible, and antiadhesive properties. ...
... Further investigation indicated that PCO mesh, one of the synthetic meshes, had more complications of infection and recurrence than other meshes. [8,33] Moreover, it was demonstrated that expanded polytetrafluoroethylene (ePTFE) hernia mesh still induced infection, seroma, and shrinkage due to its masked and blocked pores and inflammatory response of the body to foreign materials. [33,34] If mesh with disappeared pores become nonpermeable, the inflammatory cell cannot go through the mesh freely and may be weak to endure infection. ...
Ventral hernia is a public health issue and millions of meshes are used to repair abdominal wall defects every year. Polypropylene‐based composite meshes represent an important class of materials for intraperitoneal repair, but the meshes generally give rise to infection, seroma, migration, and adhesion, leading to severe consequence or even reoperation. Here, a facile and versatile one‐way fabrication of lightweight, highly permeable, and biocompatible composite meshes with superior antiadhesion properties is proposed by modifying polypropylene meshes with well‐defined polydopamine nanocoating. The resulting composite meshes are found to significantly enhance the biocompatibility and antiadhesion effect in rat model. The scalable production and excellent biomedical properties of composite meshes make them a promising candidate for future‐generation ventral hernia repair materials. A facile and versatile one‐way fabrication of lightweight, highly permeable, and biocompatible composite meshes with superior antiadhesion properties is proposed by modifying polypropylene meshes with well‐defined polydopamine nanocoating. The resulting composite meshes are found to significantly enhance the biocompatibility and antiadhesion effect in rat model. Such excellent biomedical properties of composite meshes make them promising candidates for future‐generation ventral hernia repair.
... Burger et al. 6 reported that after 10 years of postoperative follow-up, 63% of patients with fascial repair had hernia recurrence, while with the use of meshes, 32% of patients had the same problem. Hence, the use of surgical meshes for correction of abdominal hernias was strengthened due to its lower recurrence rates [6][7][8][9][10][11][12][13][14] . ...
... With the advent of laparoscopic surgery and the placement of intraperitoneal meshes, major adhesion formation was highlighted 2,7,[14][15][16][17][18][19] . The composite meshes -which have the surface facing the viscera made of absorbable and microporous material and the surface facing the muscles made of synthetic macroporous material -are the ones with the best results 20,21 . ...
... Ditzel et al. 28 compared, in rats, Parietex composite® and polypropylene meshes, among others, and observed a smaller adhesion formation area with Parietex composite®, 30 days after mesh implantation. The same result was observed in the studies by Burger et al. 4 , van't Riet et al. 6 , Schreinemacher et al. 14 and Lamber et al. 19 , with the analysis in the last one being performed 21 days after implantation. Ditzel et al. 6 and Burger et al. 28 also noted that Parietex composite® showed better incorporation to the abdominal wall. ...
Purpose:
To compare the polypropylene mesh (Marlex®) to Vicryl®, Parietex composite® and Ultrapro® meshes to assess the occurrence of adhesions in the intraperitoneal implantation.
Methods:
Sixty Wistar rats were allocated into three groups: PP+V, in which all the animals received a polypropylene and a Vicryl® mesh; PP+PC, with the implantation of polypropylene and Parietex composite® meshes and PP+UP, in which there was implantation of polypropylene and Ultrapro®. Macroscopic analysis was performed 28 days later to assess the percentage of mesh area affected by adhesion.
Results:
in the PP+ V group, the Vicryl® mesh showed lower adhesion formation (p=0.013). In the PP+PC, there were no differences between polypropylene and Parietex composite® (p=0.765). In the PP+UP group, Ultrapro® and polypropylene meshes were equivalent (p=0.198) .
Conclusion:
All the four meshes led to adhesions, with the Vicryl® mesh showing the least potential for its formation.
... The visceral contact component may be absorbable or non-absorbable. When nonabsorbable, this component is known as a physical barrier [110][111][112] and when absorbable as a chemical barrier [113][114][115][116][117][118][119][120][121][122][123][124][125][126] (Figure 5). ...
... The visceral contact component may be absorbable or non-absorbable. When nonabsorbable, this component is known as a physical barrier [110][111][112] and when absorbable as a chemical barrier [113][114][115][116][117][118][119][120][121][122][123][124][125][126] (Figure 5). The barriers used for visceral contact have always shared the structural characteristic of their smooth surface. ...
Biomaterials and their applications are perhaps among the most dynamic areas of research within the field of biomedicine. Any advance in this topic translates to an improved quality of life for recipient patients. One application of a biomaterial is the repair of an abdominal wall defect whether congenital or acquired. In the great majority of cases requiring surgery, the defect takes the form of a hernia. Over the past few years, biomaterials designed with this purpose in mind have been gradually evolving in parallel with new developments in the different surgical techniques. In consequence, the classic polymer prosthetic materials have been the starting point for structural modifications or new prototypes that have always strived to accommodate patients’ needs. This evolving process has pursued both improvements in the wound repair process depending on the implant interface in the host and in the material’s mechanical properties at the repair site. This last factor is important considering that this site—the abdominal wall—is a dynamic structure subjected to considerable mechanical demands. This review aims to provide a narrative overview of the different biomaterials that have been gradually introduced over the years, along with their modifications as new surgical techniques have unfolded.
... DOI: 10.1002/anbr.202200111 ...
Biomedical device‐associated infection (BAI) is a common symptom in hospitals. To solve this problem, the biomedical device needs fast, efficient, and safe antibacterial methods to prevent infection. Herein, a strategy for surface antibacterial functionalization is proposed, using mild photothermal effect and quaternary ammonium salt to common sterilize. Au nanorods (NRs) and quaternized N,N′‐dimethylethylenediamine (QDED) (quaternary ammonium salt) are modified on the surface of polyurethane (PU) to fabricate PU‐Au‐QDED. First of all, stable and recyclable mild photothermal radiation is achieved by low‐power near‐infrared (NIR) light irradiation, and then in a shorter time of NIR irradiation, mild photothermal effect promotes the disturbance of the alkyl chain of quaternary ammonium salt to destroy the bacterial membrane, together with quaternary ammonium salt QDED that has fast and efficient antibacterial property, especially against multidrug‐resistant bacteria. Meanwhile, mild photothermal effects, together with quaternary ammonium salt QDED, have good biocompatibility. Among all of the samples, PU‐Au‐Q5 demonstrates fast, efficient, and safe antibacterial performances. At the same time, the antibacterial mechanisms are further studied. Finally, the in vivo antibacterial properties are verified by the subcutaneous implantation animal model. The present work provides a facile and promising approach to develop high‐performance antibacterial biomedical devices. A hybrid nanocoating with rapid bactericidal property and high biocompatibility is developed based on Au nanorods and quaternary ammonium salts.
... Prolonged hospitalization, with a possible intensive care stay, the development of further complications such as pneumonia, delirium or re-operations due to recurrences can be the consequence [5][6][7]. In addition, incisional hernias were found in up to 70% of cases within 10 years after FD treatment [3,[8][9][10]. ...
Introduction
Acute fascia dehiscence (FD) is a threatening complication occurring in 0.4–3.5% of cases after abdominal surgery. Prolonged hospital stay, increased mortality and increased rate of incisional hernias could be following consequences. Several risk factors are controversially discussed. Even though surgical infection is a known, indisputable risk factor, it is still not proven if a special spectrum of pathogens is responsible. In this study, we investigated if a specific spectrum of microbial pathogens is associated with FD.
Methods
We performed a retrospective matched pair analysis of 53 consecutive patients with an FD after abdominal surgery in 2010–2016. Matching criteria were gender, age, primary procedure and surgeon. The primary endpoint was the frequency of pathogens detected intraoperatively, the secondary endpoint was the occurrence of risk factors in patients with (FD) and without (nFD) FD.
Results
Intraabdominal pathogens were detected more often in the FD group ( p = 0.039), with a higher number of Gram-positive pathogens. Enterococci were the most common pathogen ( p = 0.002), not covered in 73% (FD group) compared to 22% (nFD group) by the given antibiotic therapy. Multivariable analysis showed detection of Gram-positive pathogens, detection of enterococci in primary laparotomy beside chronic lung disease, surgical site infections and continuous steroid therapy as independent risk factors.
Conclusion
Risk factors are factors that reduce wound healing or increase intra-abdominal pressure. Furthermore detection of Gram-positive pathogens especially enterococci was detected as an independent risk factor and its empirical coverage could be advantageous for high-risk patients.
... Seprafilm consists of a solid sheet of biodegradable chemicallymodified sodium hyaluronate and carboxymethyl cellulose that physically separates tissue surfaces. It is one of the most studied and implemented anti-adhesion products [258] and has shown efficacy in reducing abdominal adhesions in various animal models [259][260][261][262][263][264][265][266][267][268][269][270][271]. Furthermore, Seprafilm has been explored in preclinical studies of pericardial [229,[272][273][274] and pleural adhesions [258]. ...
Post-operative adhesions affect patients undergoing all types of surgeries. They are associated with serious complications, including higher risk of morbidity and mortality. Given increased hospitalization, longer operative times, and longer length of hospital stay, post-surgical adhesions also pose a great financial burden. Although our knowledge of some of the underlying mechanisms driving adhesion formation has significantly improved over the past two decades, literature has yet to fully explain the pathogenesis and etiology of post-surgical adhesions. As a result, finding an ideal preventative strategy and leveraging appropriate tissue engineering strategies has proven to be difficult. Different products have been developed and enjoyed various levels of success along the translational tissue engineering research spectrum, but their clinical translation has been limited. Herein, we comprehensively review the agents and products that have been developed to mitigate post-operative adhesion formation. We also assess emerging strategies that aid in facilitating precision and personalized medicine to improve outcomes for patients and our healthcare system.
... The use of tension-free techniques with prosthetic materials for incisional hernia repairs has decreased recurrence rates from 50% to 24% [11]. The risk factors for recurrence following incisional hernia reconstruction have been identified as hernia diameter (> 10 cm), BMI (> 30 kg/m2), history of previous repair, chronic obstructive pulmonary disease and diabetes, smoking and postoperative wound site complications (surgical site infection, hematoma and seroma) [12,13] The present study also found that a history of previous repair, smoking and surgical site infection were statistically associated with recurrence development. ...
Objectives: The aim of this study is to compare the results of different surgical methods used in giant midline incision hernias. Methods: The records of 90 patients operated on for a midline abdominal incisional hernia were reviewed retrospectively. The patients were divided into three groups based on the surgical method used primary prosthetic repair (PPR), component separation with mesh (CSM) and component separation without mesh (CS). Two-year follow-up results were compared. Results: A statistically significant difference was noted between the groups in the transverse diameter measurement of the defect (p = 0.003). Subgroup analyses revealed that the median transverse diameter was higher in the CSM group than in the CS group (p = 0.003). There was also a statistically significant difference in the duration of surgery (p < 0.001), with a subgroup analysis revealing that the duration of surgery was longer in the CSM group than in the PPR and CS groups (PPR-CSM; p = 0.008, CSM-CS; p < 0.001). Recurrent incisional hernia, smoking and postoperative morbidity development were found to be statistically and significantly associated with recurrence (p = 0.005, p = 0.002, p < 0.001; respectively). Conclusions: The use of the CSM method for the repair of giant incisional hernias may reduce recurrence.
... Coated meshes, with a protective layer on the visceral side of the polypropelene meshes, have been introduced in surgery. The coating materials used were carboxy methyl cellulose-hyaluronate compound and bovine collagen extract (Riet et al., 2003) and recently ECM matrix digest (Wolf et al., 2014). But intraabdominal life time of these substance are questionable, as they are absorbed before the peritoneal repair. ...
Bioengineered scaffolds derived from the decellularized extracellular matrix (ECM) obtained from discarded animal organs and tissues are attractive candidates for regenerative medicine applications. Tailoring these scaffolds with stem cells enhances their regeneration potential making them a suitable platform for regenerating damaged tissues. Thus, the study was designed to investigate the potential of mesenchymal stem cells tailored acellular bubaline diaphragm and aortic ECM for the repair of full-thickness abdominal wall defects in a rabbit model. Tissues obtained from bubaline diaphragm and aorta were decellularized and bioengineered by seeding with rabbit bone marrow derived mesenchymal stem cells (r-BMSC). Full-thickness abdominal wall defects of 3 cm × 4 cm size were created in a rabbit model and repaired using five different prostheses namely; polypropylene sheet, non-seeded diaphragm ECM, non-seeded aorta ECM, r-BMSC bioengineered diaphragm ECM and r-BMSC bioengineered aorta ECM. Results from the study revealed that biological scaffolds are superior in comparison to synthetic polymer mesh for regeneration in terms of collagen deposition, maturation, neovascularization, as well as, lack of any significant(P>0.05) adhesions with the abdominal viscera. Seeding with r-BMSC significantly increased (P<0.05) the collagen deposition and biomechanical strength of the scaffolds. The bioengineered r-BMSC seeded acellular bubaline diaphragm showed even superior biomechanical strength as compared to synthetic polymer mesh. Tailoring of the scaffolds with the r-BMSC also resulted in significant reduction (P<0.01) in antibody and cell mediated immune reactions to the xenogeneic scaffolds in rabbit model.
... A recent audit of the Americas Hernia Society Quality Collaborative (AHSQC), a nationwide hernia-specific registry, revealed that some surgeons utilize barrier-coated mesh (CM) in the retromuscular space. Surgical dogma states that an anti-adhesive barrier coating is not required for mesh placed in the retrorectus space, because the abdominal viscera is separated from the mesh via the posterior rectus sheath and peritoneum [8,9]. Furthermore, the properties that make barrier-coated mesh well-suited for Hernia intraabdominal implantation are theoretically unfavorable in the retrorectus position. ...
PurposeThe outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space.Methods
Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI).Results3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group.Conclusion
Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.
... This is part of the natural immune response to any foreign material and is part of the healing process. Unfortunately, there is a chance that the mesh can become adhered to other layers inside the peritoneum space [7][8][9]. Depending on the mesh selected, the outcomes and chance of problematic adhesion can vary [10][11][12][13]. The severity of adhesions can manifest in symptoms ranging from patient discomfort to emergency surgery for complex cases [9,11,14]. ...
Hernia repair outcomes have improved with more robust material options for surgeons and optimized surgical techniques. However, ventral hernia repairs remain challenging with an inherent risk of post-surgical adhesions in the peritoneal space which can occur regardless of interventional material or its surgical placement. Herein, amino acid-based poly(ester urea)s (PEUs) with varied amount of an allyl ether side chains were modified post polymerization modification with the zwitterionic sulfnate group (3-((3-((3-mercaptopropanoyl)oxy)propyl) dimethylammonio)propane-1-sulfonate) to promote anti-adhesive properties. These alloc-PEUs were processed using roll-to-roll fabrication methods to afford films that were amenable to surface functionalization via a zwitterion-thiol. Functional group availability on the surface was confirmed via fluorescence microscopy, x-ray photoelectron spectroscopy (XPS), and quartz crystal microbalance (QCM) measurements. Zwitterionic treated PEUs exhibited reduced fibrinogen adsorption in vitro when compared to unfunctionalized control polymer. A rat intrabdominal cecal abrasion adhesion model was used to assess the extent and tenacity of adhesion formation in the presence of the PEUs. The 10% alloc-PEU zwitterion functionalized material was found to reduce the extent and tenacity of adhesions when compared to adhesion controls and the unfunctionalized PEU controls.
... However synthetic meshes are generally not recommended on such situations [5]. The persistent inflammatory response may induce local side effects such as adhesions, erosions, and fistula formation, particularly when mesh is directly in contact with viscera [6][7][8]. Moreover in the presence of bacterial contamination, their use could result in a larger number of complications such as mesh infection and the need for mesh removal with related morbidity and mortality [9]. Among difficulties in the management of the open abdomen, there is the bacterial contamination. ...
No definitive evidences exist on the biological prosthesis in abdominal wall reconstruction after open abdomen; dedicated studies are needed.
... reaction [13,62], larger mesh shrinkage [3] and adhesion formation to adjacent viscera [54,84] that ultimately affected the healing process [17,18]. However, symptoms varied for several reasons in character and severity from patient to patient. ...
For pelvic floor disorders that cannot be treated with non-surgical procedures, minimally invasive surgery has become a more frequent and safer repair procedure. More than 20 million prosthetic meshes are implanted each year worldwide. The simple selection of a single synthetic mesh construction for any level and type of pelvic floor dysfunctions without adopting the design to specific requirements increase the risks for mesh related complications. Adverse events are closely related to chronic foreign body reaction, with enhanced formation of scar tissue around the surgical meshes, manifested as pain, mesh erosion in adjacent structures (with organ tissue cut), mesh shrinkage, mesh rejection and eventually recurrence. Such events, especially scar formation depend on effective porosity of the mesh, which decreases discontinuously at a critical stretch when pore areas decrease making the surgical reconstruction ineffective that further augments the re-operation costs. The extent of fibrotic reaction is increased with higher amount of foreign body material, larger surface, small pore size or with inadequate textile elasticity. Standardized studies of different meshes are essential to evaluate influencing factors for the failure and success of the reconstruction. Measurements of elasticity and tensile strength have to consider the mesh anisotropy as result of the textile structure. An appropriate mesh then should show some integration with limited scar reaction and preserved pores that are filled with local fat tissue. This chapter reviews various tissue reactions to different monofilament mesh implants that are used for incontinence and hernia repairs and study their mechanical behavior. This helps to predict the functional and biological outcomes after tissue reinforcement with meshes and permits further optimization of the meshes for the specific indications to improve the success of the surgical treatment.
... Several data exist regarding the abdominal wall closure after OA [104,105]. Non-absorbable synthetic materials (i.e., polypropylene mesh) in a bridging position (i.e., no linea alba closure), where no native tissue protect viscera, may induce several local side effects (adhesions, erosions, and fistula formation) [106][107][108][109][110][111]. Synthetic meshes in contaminated fields are not recommended by guidelines in emergency abdominal wall reconstruction [112]. ...
Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartmentsyndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangementsand multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinicalsituations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source ofinfection or the necessity to re-explore (as a“planned second-look”laparotomy) or complete previously initiateddamage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-traumapatients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuriesor critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consumingand represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only beconsidered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as thepatient can physiologically tolerate it. All precautions to minimize complications should be implemented.
... This new generation will have to show a better integration with the tissue of the abdominal wall, but no adhesions on the visceral side. Based on the ideas of van't Riet [68], Ebersole [69] and Xu [70], new alternatives rely broadly on surface mesh modification by novel coatings to existent meshes and/or integration of nanofiber based systems. ...
Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods.
... In general, non-absorbable synthetic materials (i.e., polypropylene mesh) reinforce any fascial repair through a combination of mechanical tension and intense inflammatory reaction, resulting in the entrapment of the mesh into scar tissue. However, in a bridging position, there is no native tissue to protect viscera from the mesh and thus, the persistent inflammatory response combined with the contaminated field may induce local side effects such as adhesions, erosions, and fistula formation [130][131][132][133][134][135]. International guidelines on emergency repair of abdominal wall hernia therefore do not recommend the use of synthetic meshes in contaminated fields [136]. ...
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
... In a large randomized controlled trial, ID showed significantly higher adhesion reduction compared with lactated Ringer's solution [22,23]. The ineffectiveness in the presence of a hernia mesh has also been described by van t' Riet et al. [24]. In this publication, the effect of hydroflotation might have been outweighed by a strong foreign body reaction triggered by the mesh material. ...
Background:
Adhesion formation remains an important issue in hernia surgery. Liquid agents were developed for easy and versatile application, especially in laparoscopy. The aim of this study was to compare the antiadhesive effect of fibrin sealant (FS, Artiss(®)), Icodextrin (ID, Adept(®)) and Polyethylene glycol (PEG, CoSeal(®)) alone and in combination and to evaluate the resulting effect on tissue integration of the mesh.
Methods:
A total of 56 Sprague-Dawley rats were operated in open IPOM technique. A middleweight polypropylene mesh of 2 × 2 cm size was implanted and covered with 1: FS, 2: ID, 3: PEG, 4: FS + ID, 5: FS + PEG, 6: PEG + ID, 7: control group, uncovered mesh (n = 8 per treatment/control). Observation period was 30 days. Macroscopic and histological evaluation was performed.
Results:
Severe adhesions were found in group 2 (ID), group 6 (PEG + ID) and the controls. Best results were achieved with FS alone or FS + ID. Mesh integration in the treatment groups was reduced in comparison with the control group. This is a new finding possibly relevant for the outcome of intraperitoneal mesh repair. Group 6 (PEG + ID) showed an impairment of tissue integration with <50 % of the mesh surface in seven samples.
Conclusion:
FS alone and in combination with ID yielded excellent adhesion prevention. ID alone did not show significant adhesion prevention after 30 days. Tissue integration of FS-covered meshes was superior to ID or PEG alone or combined. PEG did show adhesion prevention comparable to FS but evoked impaired tissue integration. So Artiss(®) is among the most potent antiadhesive agents in IPOM repair.
... The Sepra Ò barrier technology is a hydrogel that has been optimized to swell upon rehydration to reduce the development of peritoneal tissue attachments to the underlying mesh. Preclinical studies have previously demonstrated the efficacy of this mesh coating absorbable barrier technology [21][22][23][24]. ...
Background:
The objective of this study was to evaluate the mechanical and histological properties of a fully absorbable poly-4-hydroxybutyrate/absorbable barrier composite mesh (Phasix™ ST) compared to partially absorbable (Ventralight™ ST), fully absorbable (Phasix™), and biologically derived (Strattice™) meshes in a porcine model of ventral hernia repair.
Methods:
Bilateral abdominal surgical defects were created in twenty-four Yucatan pigs, repaired with intraperitoneal (Phasix™ ST, Ventralight™ ST) or retromuscular (Phasix™, Strattice™) mesh, and evaluated at 12 and 24 weeks (n = 6 mesh/group/time point).
Results:
Prior to implantation, Strattice™ demonstrated significantly higher (p < 0.001) strength (636.6 ± 192.1 N) compared to Ventralight™ ST (324.3 ± 37.1 N), Phasix™ ST (206.9 ± 11.3 N), and Phasix™ (200.6 ± 25.2 N). At 12 and 24 weeks, mesh/repair strength was significantly greater than NAW (p < 0.01 in all cases), and no significant changes in strength were observed for any meshes between 12 and 24 weeks (p > 0.05). Phasix™ mesh/repair strength was significantly greater than Strattice™ (p < 0.001) at 12 and 24 weeks, and Ventralight™ ST mesh/repair strength was significantly greater than Phasix™ ST mesh (p < 0.05) at 24 weeks. At 12 and 24 weeks, Phasix™ ST and Ventralight™ ST were associated with mild inflammation and minimal-mild fibrosis/neovascularization, with no significant differences between groups. At both time points, Phasix™ was associated with minimal-mild inflammation/fibrosis and mild neovascularization. Strattice™ was associated with minimal inflammation/fibrosis, with minimal neovascularization at 12 weeks, which increased to mild by 24 weeks. Strattice™ exhibited significantly less neovascularization than Phasix™ at 12 weeks and significantly greater inflammation at 24 weeks due to remodeling.
Conclusions:
Phasix™ ST demonstrated mechanical and histological properties comparable to partially absorbable (Ventralight™ ST) and fully resorbable (Phasix™) meshes at 12 and 24 weeks in this model. Data also suggest that fully absorbable meshes with longer-term resorption profiles may provide improved mechanical and histological properties compared to biologically derived scaffolds.
... The only treatment option is surgery. Fascia healing is based on the same principle as wound healing and is closely related to tissue regeneration 20 . The tissue level of hydroxyproline one of the main ingredients of collagen and a good indicator of wound healing objectively reflects the amount of collagen synthesis in the wound. ...
... The only treatment option is surgery. Fascia healing is based on the same principle as wound healing and is closely related to tissue regeneration 20 . The tissue level of hydroxyproline one of the main ingredients of collagen and a good indicator of wound healing objectively reflects the amount of collagen synthesis in the wound. ...
Purpose ::
To evaluate the effects of platelet rich plasma (PRP) on the healing of fascia wherein peritonitis has been created.
Methods::
Twenty eight Wistar Albino rats were divided into four groups. Only a primary fascial repair following laparotomy was performed on Group 1, a primary fascial repair performed and PRP treatment applied following laparotomy on Group 2, and a fecal peritonitis created following laparotomy and a primary fascial repair carried out on Group 3. A fecal peritonitis was created following laparotomy and primary fascial repair and PRP treatment on the fascia was carried out on Group 4.
Results::
TNF-α was found to be significantly lower in the control group (Group 1). It was detected at the highest level in the group in which fecal peritonitis was created and PRP applied (Group 4). TGF-β was determined as being significantly higher only in Group 4. Histopathologically, the differences between the groups in terms of cell infiltration and collagen deposition were not found to be significant.
Conclusion::
When platelet rich plasma was given histologically and biochemicaly as wound healing parameters cellular infiltration, collagen accumulation, and tissue hydroxyiproline levels were not increased but neovascularization, fibroblast activation and TNF Alfa levels were increased and PRP accelerated wound healing.
... Parietex composite mesh is a nonabsorbable polyester mesh coated with an absorbable and hydrophilic film on the visceral side, which gets absorbed within 3 weeks, and a new peritoneal covering will be formed over the mesh with significant protection against bowel adhesion [14]. Unfortunately, the Parietex composite mesh is more easily infected than other meshes, resulting in an augmented inflammatory response [15]. ...
The management of abdominal wall repair continues to present a challenging problem, especially in the repair of major defects. Many abdominal wall defects can be repaired by primary closure; however, if the defect is large and there is a tension on the closure of the wound, the use of prosthetic materials becomes indispensable. Many studies have been performed with various materials and implant techniques, without the comparison of their degrees of success, based on sound meta-analysis and/or inclusive epidemiologic studies. This review covered the effectiveness of recent advances in prosthetic materials and implant procedures used in repair of abdominal wall, based on biomechanical properties and economic aspects of reconstructed large abdominal wall defects and hernias in animals. The presented results in this review helped to reach treatment algorithms that could maximize outcomes and minimize morbidity.
... Modified mesh with a barrier coating have been specifically designed to prevent adhesion, Sepramesh (Genzyme) has been successful in adhesion prevention but great caution needs to be taken in orientation of the mesh while intra-abdominal placement, reverse orientation may lead to severe adhesion [16]. Parietex composite mesh (Sofradim, France), is also effective but incidence of infection and inflammation has been reported to be high with Parietex [17]. Therefore, there is strong clinical demand to identify new agents to prevent post-operative adhesion. ...
Background:
Adhesion formation remains a major complication following hernia repair surgery. Physical barriers though effective for adhesion prevention in clinical settings are associated with major disadvantages, therefore, needs further investigation. This study evaluates silk fibroin hydrogel as a physical barrier on polypropylene mesh for the prevention of adhesion following ventral hernia repair.
Study design:
Peritoneal explants were cultured on silk fibroin scaffold to evaluate its support for mesothelial cell growth. Full thickness uniform sized defects were created on the ventral abdominal wall of rabbits, and the defects were covered either with silk hydrogel coated polypropylene mesh or with plain polypropylene mesh as a control. The animals were killed after 1 month, and the adhesion formation was graded; healing response of peritoneum was evaluated by immunohistochemistry with calretinin, collagen staining of peritoneal sections, and expression of PCNA, collagen-I, TNFα, IL6 by real time PCR; and its adverse effect if any was determined.
Results:
Silk fibroin scaffold showed excellent support for peritoneal cell growth in vitro and the cells expressed calretinin. A remarkable prevention of adhesion formation was observed in the animals implanted with silk hydrogel coated mesh compared to the control group; in these animals peritoneal healing was complete and predominantly by mesothelial cells with minimum fibrotic changes. Expression of inflammatory cytokines decreased compared to control animals, histology of abdominal organs, haematological and blood biochemical parameters remained normal.
Conclusion:
Therefore, silk hydrogel coating of polypropylene mesh can improve peritoneal healing, minimize adhesion formation, is safe and can augment the outcome of hernia surgery.
... Most barrier layers are absorbed over a period of 30-120 days. [70][71][72] The regeneration of the mesothelium lining the peritoneal cavity after injury occurs in 5-7 days. 73 Even if the time dynamics of adhesions formation has not been precisely defined, 74 it is likely that significant adhesions are not expected to form before most of the barrier layers are absorbed. ...
Surgical implants are commonly used in abdominal wall surgery for hernia repair. Many different prostheses are currently offered to surgeons, comprising permanent synthetic polymer meshes and biologic scaffolds. There is a wide range of synthetic meshes currently available on the market with differing chemical compositions, fiber conformations, and mesh textures. These chemical and structural characteristics determine a specific biochemical and mechanical behavior and play a crucial role in guaranteeing a successful post-operative outcome. Although an increasing number of studies report on the structural and mechanical properties of synthetic surgical meshes, nowadays there are no consistent guidelines for the evaluation of mechanical biocompatibility or common criteria for the selection of prostheses. The aim of this work is to review synthetic meshes by considering the extensive bibliography documentation of their use in abdominal wall surgery, taking into account their material and structural properties, in Part I, and their mechanical behavior, in Part II. The main materials available for the manufacture of polymeric meshes are described, including references to their chemical composition, fiber conformation, and textile structural properties. These characteristics are decisive for the evaluation of mesh-tissue interaction process, including foreign body response, mesh encapsulation, infection, and adhesion formation.
... Since the first synthetic materials described by Usher et al. at the end of the 1950s, [2][3][4][5], along with those later proposed by Lichtenstein for his method of tension-free repair [6], the use of a biomaterial for hernia repair has become standard procedure for this type of surgery. The benefits of prosthetic mesh implant over the traditional repair procedures of autoplasty or sutures include a substantial reduction in the incidence of hernia recurrence [7][8][9][10]. ...
Background:
The use of a prosthetic mesh to repair a tissue defect may produce a series of post-operative complications, among which infection is the most feared and one of the most devastating. When occurring, bacterial adherence and biofilm formation on the mesh surface affect the implant's tissue integration and host tissue regeneration, making preventive measures to control prosthetic infection a major goal of prosthetic mesh improvement.
Methods:
This article reviews the literature on the infection of prosthetic meshes used in hernia repair to describe the in vitro and in vivo models used to examine bacterial adherence and biofilm formation on the surface of different biomaterials. Also discussed are the prophylactic measures used to control implant infection ranging from meshes soaked in antibiotics to mesh coatings that release antimicrobial agents in a controlled manner.
Results:
Prosthetic architecture has a direct effect on bacterial adherence and biofilm formation. Absorbable synthetic materials are more prone to bacterial colonization than non-absorbable materials. The reported behavior of collagen biomeshes, also called xenografts, in a contaminated environment has been contradictory, and their use in this setting needs further clinical investigation. New prophylactic mesh designs include surface modifications with an anti-adhesive substance or pre-treatment with antibacterial agents or metal coatings.
Conclusions:
The use of polymer coatings that slowly release non-antibiotic drugs seems to be a good strategy to prevent implant contamination and reduce the onset of resistant bacterial strains. Even though the prophylactic designs described in this review are mainly focused on hernia repair meshes, these strategies can be extrapolated to other implantable devices, regardless of their design, shape or dimension.
... The management of pain during operation was obtained by intramuscular administration of 2.5 mg/kg morphine sulfate. In the postoperative period this same analgesic scheme was employed during the first three days followed by maintenance with paracetamol orally at a dose of 20 drops to 500 ml of consumed water [5][6][7][8][9][10][11][12] . ...
Objective:
To analyze the performance of two surgical meshes of different compositions during the defect healing process of the abdominal wall of rats.
Methods:
thirty-three adult Wistar rats were anesthetized and subjected to removal of an area of 1.5 cm x 2 cm of the anterior abdominal wall, except for the skin; 17 animals had the defect corrected by edge-to-edge surgical suture of a mesh made of polypropylene + poliglecaprone (Group U - UltraproTM); 16 animals had the defect corrected with a surgical mesh made of polypropylene + polidioxanone + cellulose (Group P - ProceedTM). Each group was divided into two subgroups, according to the euthanasia moment (seven days or 28 days after the operation). Parameters analyzed were macroscopic (adherence), microscopic (quantification of mature and immature collagen) and tensiometric (maximum tension and maximum rupture strength).
Results
: there was an increase in collagen type I in the ProceedTM group from seven to 28 days, p = 0.047. Also, there was an increase in the rupture tension on both groups when comparing the two periods. There was a lower rupture tension and tissue deformity with ProceedTM mesh in seven days, becoming equal at day 28.
Conclusion
: the meshes retain similarities in the final result and more studies with larger numbers of animals must be carried for better assessment.
The development and evaluation of synthesis materials are crucial to reducing the morbidity and magnitude of post‐enterorrhaphy surgical complications. Despite the possibility of production, chitosan thread has not yet been used in enterorrhaphy, and its effects on intestinal healing have not been evaluated. Therefore, this study aimed to evaluate the effects of chitosan thread on the intestinal wall repair of rabbits submitted to cecorrhaphy. For this, 42 rabbits were allocated into two groups with 21 animals. One group was submitted to cecorrhaphy with chitosan suture thread (CG) and the other with poliglecaprone suture thread (PG). The occurrence of postoperative complications, the intensity of edema, cellular response, formation of granulation tissue, as well as the deposition and maturation of collagen fibers, and the intensity of vascular endothelial growth factor (VEGF‐α) expression, were evaluated during the intestinal wall repair process. The evaluations occurred on the 5th, 15th, and 25th postoperative (PO) days. The animals did not develop peritonitis, but adherence was observed in six animals from CG and seven from PG, with no difference between groups. The polymorphonuclear infiltrate showed higher intensity and higher amount of type III collagen fibers in CG on the 15th PO day. In contrast, a lower amount of type I collagen fibers was observed in CG samples on the 25th PO day. Therefore, the chitosan thread used for cecorrhaphy in rabbits results in minimal postoperative complications, presents biocompatibility, and bioactively assists the tissue repair process of the cecal wall, inducing minimal tissue reaction, stimulating the deposition of type III collagen fibers in the proliferative phase, with sustained VEGF‐α expression, but with reduced deposition of type I fibers, indicating a delay in collagen maturation.
Introduction:
The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis.
Methods:
Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula).
Results:
Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion.
Conclusion:
VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications.
Inguinal and incisional hernias are the two most common types of hernias caused by abdominal wall weakness and defects in connective tissue. The structure of the extracellular matrix, mainly collagen and metalloproteinases (MMPs), and their regulators have been studied extensively and found to play a significant role in the pathophysiology of hernias. One of the regulators of MMPs, tissue inhibitor metalloproteinases (TIMPs), bind to MMPs and inhibit its activity significantly shifting the balance towards collagen synthesis rather than degradation. Due to their importance in collagen metabolism, their metabolism might be significant in the aetiology of hernias. Our study used immunohistochemical techniques to investigate the possible effects of TIMP 1 and 2 on the samples taken from the abdominal walls of patients with inguinal and incisional hernias, compared them with control patients, and reviewed the literature. In this study, samples of 90 patients (30 patients from control, inguinal hernia, and incisional hernia groups) were taken and analysed. These samples were stained with TIMP‐1 Ab‐2 and TIMP2 Ab‐5 (Clone 3A4) antibodies and evaluated under ×100 magnification. The degree of staining was classified as (a): No staining (0), (b): Staining less than 10% (I), (c): Staining between 10% and 50% (II), (d): Staining more than 50% (III). Statistical analyses were done. No significant difference was found between groups in terms of patient demographics. Smoking and family history of hernia was not found to be associated with TIMP expression. TIMP1 expression was significantly higher in the incisional and inguinal hernia group than in the control group (P < .05), while the level of TIMP2 was higher in the control group. (P < .05). TIMP1 and TIMP2 levels did not significantly differ between incisional and inguinal hernia groups. We found significantly increased TIMP‐1 levels in tissue samples from patients with hernia supporting its suggested role in hernia pathophysiology. Local alterations in MMP and TIMP levels might play a role in the pathogenesis of hernias. Thus detection of TIMP in tissues can be important for clinical use after further validation studies. In the era of molecular medicine, detecting TIMP levels in hernia patients can impact clinical practice.
Implantable meshes used in tension-free repair operation facilitate treatment of internal soft tissue defect. However, clinical meshes fail to achieve anti-deformation, anti-adhesion and pro-healing properties simultaneously, leading to undesirable surgery outcomes. Herein, inspired by peritoneum, a novel biocompatible Janus porous PVA hydrogel (JPVA hydrogel) is developed to achieve efficient repair of internal soft tissue defect by the facile yet efficient strategy based on top-down solvent exchange. The densely porous and smooth bottom-surface of JPVA hydrogel minimizes adhesion of fibroblasts and does not trigger any visceral adhesion, and its loose extracellular matrix-like porous and rough top-surface can significantly improve fibroblast adhesion and tissue growth, leading to superior abdominal wall defect treatment to commercially available PP and PCO meshes. With unique anti-swelling property (swelling ratio: 6.4%), our JPVA hydrogel has long-lasting anti-deformation performance and maintains high mechanical strength after immersing in PBS for 14 days, enabling tolerance to the maximum abdominal pressure in internal wet environment. By integrating visceral anti-adhesion and defect pro-healing with anti-deformation, JPVA hydrogel patch shows great prospect for efficient internal soft tissue defect repair.
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Literature continues to be ambiguous on the type of mesh to be used in laparoscopic incisional and ventral hernia repair. This study presents non-randomised comparison of polypropylene and covered mesh in laparoscopic incisional and ventral hernia repair. Patients undergoing laparoscopic ventral hernia repair from 2004 to 2018 were divided into two groups, i.e. polypropylene or covered mesh. Laparoscopic ventral hernia repair was done following a standard protocol. Patient outcomes were measured in terms of re-exploration, wound/ mesh infection, seroma, subacute intestinal obstruction, fistula formation and recurrence. Patients were followed up regularly. Laparoscopic repair was performed in 527 patients. Conversion to open repair was done in 30 patients. Polypropylene mesh was used in 175 patients and covered mesh in 352 patients. Subacute intestinal obstruction was seen in 12 patients (6.9%) in polypropylene group and in 18 patients (5.1%) in covered mesh group. There were 28 recurrences, 11 (6.2%) in polypropylene group and 17 (4.8%) in covered mesh group. The median duration of recurrence was 2 years with a range of 16–48 months. Outcomes with polypropylene mesh were comparable to covered mesh for laparoscopic ventral hernia repair with regards to early and late post-operative outcomes. The incidence of fistulisation and obstruction was also similar between the two groups. It is safe to use polypropylene mesh in situations where covered mesh is not affordable or available especially in low resource countries.
The first edition of the World Society of Emergency Surgeons (WSES) guidelines on the indications and treatment of open abdomen in trauma as well as in non-trauma patients was published at the end of 2018. Publications from 1980 to 2017 were included in the evaluation. Based on the GRADE system each publication was checked for its evidence and evaluated in a Delphi process. In this article the aspects of the guidelines are presented and commented on.
ABSTRACT: Introduction: Laparoscopic sleeve gastrectomy is the most commonly applied bariatric surgical technique today. Incidental findings during routine bariatric surgery are a common occurance, and therefore prompt and effective intraoperative management is key to the prognosis of the patient.
Case Presentation: In this article, a case of accessory spleen that is fo-und incidentally after intraoperative bleeding in the gastric fundus posterior neighbor during laparoscopic sleeve gastrectomy is presented.
Conclusion: Accessory spleens tend to be asymptomatic. However, if undiagnosed, can lead to dangerous consequences.
Non recognition of anatomical alterations caused by surgery and placement of surgical prosthetic materials may cause misdiagnosis on medical imaging. This may lead to incorrect evaluation and unnecessary patient workup. Radiologists must be aware of common postoperative findings and their pitfalls. In this case report we present FDG PETCT appearance of hernia plug repair called 'plugoma' or 'meshoma'.
Abstract
BACKGROUND:
The use of surgical meshes in ventral hernia repair has significantly reduced hernia recurrence rates. However, when placed intraperitoneally prosthetic materials can trigger the development of peritoneal adhesions. The present experimental study evaluated the combined icodextrin 4% and dimetindene maleate treatment in preventing peritoneal adhesion formation to polypropylene and titanium-coated polypropylene meshes.
MATERIALS AND METHODS:
Sixty female white rabbits were divided into four groups. A 2 × 2 cm piece of mesh was fixed to intact peritoneum in all animals through a midline laparotomy. A lightweight polypropylene mesh was implanted in groups 1 and 2 and a titanium-coated polypropylene mesh in groups 3 and 4. Groups 2 and 4 were treated, intraoperatively, with intravenous dimetindene maleate (0.1 mg/kg) and intraperitoneal solution of icodextrin 4% (20 mL/kg) and for the next 6 d with dimetindene maleate intramuscularly. The observation period lasted 15 d. Adhesion scores, percentage of mesh affected surface, tissue hydroxyproline levels, and tissue histopathology were examined.
RESULTS:
All animals in group 1 and 57% of animals in group 3 presented postoperative adhesions. The combination of antiadhesives significantly reduced the extent and severity of adhesions as well as the hydroxyproline levels in groups 2 and 4 compared with groups 1 and 3. On microscopic evaluation, animals in group 1 exhibited higher inflammation scores compared with group 2, whereas animals in groups 2 and 4 had better mesotheliazation compared with groups 1 and 3.
CONCLUSIONS:
The combined administration of icodextrin 4% and dimetindene maleate reduces the extent and severity of adhesions and may be successfully used to prevent adhesion formation after mesh intraperitoneal placement.
OBJECTIVE: We aimed to present our experience of laparoscopic treatment of incarcerated abdominal wall hernia in our general surgery clinic. MATERIALS & METHODS: We retrospectively reviewed the patients who were treated with a laparoscopic approach to abdominal anterior wall hernia between January 2017 and January 2018 in our clinic. Patient data were obtained from computer records. Patients who were not able to access the data were excluded from the study. Laparoscopic intraperitoneal mesh technique was applied to all the patients to be studied. RESULTS: Thirteen patients were included in the study. All of the patients were female. The mean age was 55.8 (38-70) years and the duration of surgery was 60.4 (30-85) minutes. The mean diameter of the defect was 4.7 (3-6) cm and postoperative hospital stay was 2.1 (1-4) days. Complications were seroma in 3 patients. CONCLUSION: As a result; We aimed to show that using laparoscopic intraperitoneal repair technique using dual mesh is safe and convenient.
GİRİŞ Ön karın duvarı hernileri veya ventral herniler, parietal abdominal duvar fasiyasındaki ve kas dokusundan karın içi organların veya preperitoneal içeriğin dışarı taşmış olduğu defektlerdir. Tüm karın duvarı fıtıklarının yaklaşık % 5-6'sını oluşturan ventral herniler, konjenital veya kazanılmış olabilir. Genellikle en önemli belirti karın ön duvarında yer alan yatınca kendiliğinden ya da elle itilerek kaybolabilen şişliklerdir. Eğer kendi haliyle ya da elle yerine yerleştirilemezse inkarsere fıtıklar olarak tarif edilir. İnkarserasyon durumunda içeriğe göre ağrı, bulantı, kusma gibi şikayetler izlenebilir (1-3).
Medical textiles (MedTech), as the cross-point of (bio)polymer chemistry, textile technology, and medical science, represent the most emerging technical textile area, evidencing innovations far beyond the "classical." In that frame, a state of the art is presented for implantable MedTech products as the most demanding (by functionality and safety) among health care and hygiene materials, extracorporeal devices, and nonimplantable materials. Innovative processing and finishing technologies in combination with (bio)polymers and high standards applied for medium-to-high risk medical devices for soft and hard tissue regeneration, cardiovascular implants, or sutures are overviwed. Particular accent is given on authors' research topics, that is, hernia repair composites, vascular grafts, and orthopedic implants with emphasis on their acceptance from biomedical aspects: cells' adherence/growth, cytotoxicity, biocompatibility with the host, hemocompatibility, and biodegradation kinetic. Finally, recent regulations within directives are presented, covering the quality, safety, and reliability of medical devices. The adaption of textile manufacturing/finishing processes for development of smart and personalized textile implants are foreseen as future MedTech perspective.
Hernia incidence has been observed since ancient time. Advancement in the medical textile industry came up with the variety of mesh materials to repair hernia, but none of them are without complications including recurrence of hernia. Therefore individuals once developed with the hernia could not lead a healthy and comfortable life. This drawn attention of surgeons, patients, researchers and industry to know the exact mechanism behind its development, complications and recurrence. Recent investigations highlighted the role of genetic factors and connective tissue disorders being the reason for the development of hernia apart from the abnormal pressure that is known to develop during other disease conditions. This review discusses different mesh materials, their advantages and disadvantages and their biological response after its implantation.
Abdominal wall reconstruction (AWR) requires a coordinated effort between general surgeons and plastic surgeons to re-establish and restore the boundaries of the abdominal cavity. Given the nature of the patient population and disease states that require AWR there is an inherent deficiency of healthy and robust tissue to support the abdominal viscera without herniation. As a result, mesh materials are often sought to enhance the structural integrity of the abdominal wall. The type of mesh material and plane of mesh placement are at the discretion of the surgeon. Surgical techniques have evolved to enable improved outcomes in AWR. Component separation through open or minimally invasive techniques provides the ability to re-approximate the rectus muscles bundles in the midline allowing a second layer of dynamic reconstruction to the underlying mesh construct. These techniques avoid bridging mesh repairs which have a greater risk of hernia recurrence. By optimizing patient selection criteria, mesh selection, and surgical technique as outlined in this chapter, superior outcomes can be achieved in even the most challenging abdominal wall reconstructions.
Background:
The present animal study was conducted to comparably investigate the performance of four different fixation techniques of intraperitoneally implanted meshes.
Materials and methods:
Fifteen New Zealand white rabbits were used. In each animal, four abdominal wall defects were created and repaired with four pieces of intraperitoneal mesh (Parietex Composite), fixed with nonabsorbable (titanium) spiral tacks (group A), absorbable (lactic and glycolic acid co-polymer) screw-type tacks (group B), transfascial polypropylene sutures (group C), or fibrin glue (group D). Adhesion formation, mesh shrinkage, tensile strength, and host tissue response were evaluated at 90 d.
Results:
Adhesions were observed in all groups, and differences were not significant. The percentage of shrinkage was higher in group C (26.91%), lower in group D (12%), whereas in groups A and B, the mean shrinkage was 20.17% and 23.33%, respectively (P = 0.032). The incorporation of mesh fixation element to the abdominal wall was 9.18 ± 3.91 N, 6.96 ± 3.0 N, 13.68 ± 5.38 N, and 2.57 ± 1.29 N, in groups A, B, C, and D, respectively (P < 0.001). Regarding local inflammatory response and foreign body reaction, no difference was observed between groups. However, with respect to fibrous tissue presence, its quantity was clearly less in group D compared with the other groups (P < 0.001).
Conclusions:
None of the examined fixation techniques proved to be ideal. Probably, the best way to fixate an intraperitoneally implanted mesh may be achieved using a combination of the studied materials. Prospective randomized trials are needed to confirm the superiority of the combined use of different fixation devices in clinical practice.
Background: Adhesions to intraperitoneally implanted meshes (IPOM) are a common problem following hernia surgery and may cause severe complications. Recently, we showed that missing peritoneal coverage of the intestine is a decisive factor for adhesion formation and 4DryField® PH (4DF) gel significantly prevents intestine-to-mesh adhesions even with use of uncoated Ultrapro® polypropylene mesh (UPM). The present study investigates adhesion prevention capability of coated Parietex® mesh (PTM) and Proceed® mesh (PCM) in comparison to 4DF treated UPM.
Methods: 20 rats were randomized into two groups. A 1.5 x 2 cm patch of PTM or PCM was attached to the abdominal wall and the cecum was depleted from peritoneum by abrasion. After seven days incidence of intestine-to-mesh adhesions was evaluated using Lauder and Hoffmann adhesion scores. Histological specimens were evaluated; statistics were performed using student's t-test. The data were compared with recently published data of 4DF treated uncoated UPM.
Results: Use of PTM or PCM did not significantly diminish development of intestine-to-mesh adhesions (adhesion reduction rate PTM: 29%, p = 0.069 and PCM: 25%, p = 0.078). Histological results confirmed macroscopic finding of agglutination of intestine and abdominal wall with the mesh in between. Compared to these data, the use of UPM combined with 4DF gel reveals significantly better adhesion prevention capability (p < 0.0001) as shown in earlier studies. However, in clinical situation interindividual differences in adhesion induction mechanisms cannot be excluded by this experimental approach as healing responses towards the different materials might vary.
Conclusion: This study shows that in case of impaired intestinal peritoneum coated PTM and PCM do not provide significant adhesion prevention. In contrast, use of UPM combined with 4DF gel achieved a significant reduction of adhesions. Hence, in case of injury of the visceral peritoneum, application of a polysaccharide barrier device such as 4DF gel might be considered more effective in reducing intestine-to-mesh adhesions than coated mesh devices.
A woman in her 80s visited our hospital with severe abdominal pain and hematemesis. An emergent gastrofiberscopy was performed, and she was diagnosed with gastroesophageal reflux. However, she continued to have severe abdominal pain, rebound tenderness and muscular defense. An abdominal CT scan was performed and indicated strangulated bowel obstruction. Because of hypovolemic shock and acute renal failure, conservative therapy with fluid replacement and insertion of a long decompression tube was initiated. On the third day of hospitalization, the patientʼs general condition improved and an operation was performed. The operative findings were massive hemorrhagic ascites and intestinal necrosis. The Kugel patch had adhered to the omentum, trapping the small intestine into an adhesive band around the prosthesis. This Kugel patch had been inserted 5 years previously. Recently, several complications involving prostheses have been reported, including infection, ileus and perforation, but there have been few cases of strangulated bowel obstruction caused by adhesion of a direct Kugel patch. Therefore, we chose to report this case along with a review of the literature.
Pneumatosis intestinalis (PI) is generally regarded as a worrying sign due to its relatively frequent association with serious conditions such as acute gastrointestinal necrosis. While PI can also be associated with a wide spectrum of benign conditions, its diagnosis as benign is usually accepted with the exclusion of gangrenous bowel, even in the absence of other clinical signs suggesting ischemia. We report a case of extensive PI in a patient with celiac disease and discuss its management and the role of diagnostic laparoscopy in this condition with emphasis on the different etiologies of PI.
doi:10.4021/jmc63w
Hernia repair is one of the most commonly performed surgical procedures worldwide, with a multi-billion dollar global market. Implant design remains a critical challenge for the successful repair and prevention of recurrent hernias, and despite significant progress, there is no ideal mesh for every surgery. This review summarizes the evolution of prostheses design toward successful hernia repair beginning with a description of the anatomy of the disease and the classifications of hernias. Next, the major milestones in implant design are discussed. Commonly encountered complications and strategies to minimize these adverse effects are described, followed by a thorough description of the implant characteristics necessary for successful repair. Finally, available implants are categorized and their advantages and limitations are elucidated, including non-absorbable and absorbable (synthetic and biologically derived) prostheses, composite prostheses, and coated prostheses. This review not only summarizes the state of the art in hernia repair, but also suggests future research directions toward improved hernia repair utilizing novel materials and fabrication methods.
Purpose:
To evaluate the tissue integration of a double-sided mesh after fixation in diaphragm and to study the diaphragmatic mobility by ultrasound.
Methods:
Twenty male Wistar rats were used. The animals were assigned into two equal groups according to the day of euthanasia. The animals were anesthetized and a 1.5 x 1.5 cm of double-layer mesh was inserted between the diaphragm and the liver. For the evaluation of the diaphragm mobility a sonographic method was used. Measurements on specific breathing parameters were taking place. Pathological evaluation took place after the animal's euthanasia.
Results:
Extra-hepatic granuloma was not differentiated overtime, (χ2=0.04, p>0.05). Neither fibrosis was significantly differentiated, (χ2=0.04, p>0.05). Intra-hepatic granuloma was significantly differentiated overtime, (χ2=10.21, p<0.05). Concerning Te parameter, means were significantly differentiated over time, F (3, 30) = 5.12, (p<0.01). Ttot parameter, it was differentiated over time, F (3, 8)=4.79, (p<0.05). IR parameter was also longitudinally differentiated, F (3, 30)=3.73, (p<0.05).
Conclusion:
The measurements suggest a transient malfunction of diaphragmatic mobility despite the fact that inflammatory reaction, fibrosis and extra-hepatic granuloma were not significantly differentiated with the passage of time.
Surgical planning in complex abdominal wall reconstruction requires the combined efforts of plastic surgeons and general surgeons. To achieve the goals of reestablishing the integrity of the musculofascial unit and providing cutaneous coverage of the abdominal wall defect, surgeons must take into consideration local wound conditions, optimize the utility of remaining tissues, reinforce the abdominal wall with mesh, and provide durable skin replacement. To minimize hernia recurrences and maximize preservation of function, this type of complex abdominal wall reconstruction should be attempted only by teams of highly experienced surgeons.
Adhesions can be defined as fibro-collageneous tissue loops within the abdominal cavity. They can develop between all organs and/or to the abdominal wall and can lead to long-lasting complications such as intestinal obstruction, strangulation and fistula formation. They are the most common reason for an ileus and are responsible for this in over 50% [34].
The use of glue compositions to attach synthetic endoprostheses (meshes) to abdominal wall tissues in tension-free repair refers to a new and prospective branch of herniology.
The aim of the investigation was to assess the capabilities of abdominal wall plasty with glue fixation of synthetic endoprostheses in experiment.
Materials and Methods. We carried out an experimental controlled study on rabbits.
The basic group (n=34) was operated using IPOM (intraperitoneal onlay mesh) technique with synthetic endoprostheses fixation by cyanoacrylate adhesive “Sulfacrylate”, with no sutures used. In the control group (n=69) there was performed IPOM plasty with mesh fixation using traditional methods — by suturing. The distribution of endoprosthesis types in the groups was comparable. The mаcroscopic changes were observed on day 14, 21, 28, 90 after the implantation.
Results. The strength of mesh fixation to the abdominal wall in both groups was sufficient: 2.625 and 2.725 scores according to a modified Vanderbilt scale, p=0.936. The intensity of adhesive process was 2.125 and 3.823 scores, respectively, p=0.009. The colon was involved in adhesive process in 6.25% of cases in the main group, in the control group — in 33.3%, p=0.049.
Conclusion. Glue fixation provides firm and reliable mesh fixation to tissues. The technique significantly decreases the intensity of adhesive process in the abdominal cavity.
Increasingly, bioprosthetic materials are being used for a variety of surgical applications. In general surgery, for example, surgical techniques for hernia repair have been influenced directly by the development of different prosthetic meshes. As the field of biomaterial science advances, new insight into the physiological response to materials guides the development of newer classes of biomaterials including synthetic, partially synthetic, and natural tissue derivatives. This chapter, the first of three parts on materials for hernia repair, outlines historical aspects of bioprosthetic materials, details experimental (often animal) and clinical evidence for use of current materials, and establishes a framework for understanding the principles used for development of new prostheses. Although hernias serve as the model disease, the fundamentals of bio-prostheses interactions are applicable to many different genres in medicine.
OBJECTIVE: To study the age and sex incidence, various factors leading to incisional
hernia, methods to control them and various types of surgical repair by mesh and their complications.
BACKGROUND DATA: Incisional hernia is a common surgical condition with a reported incidence of
5-11% of patients subjected to abdominal operations. Many factors are associated with incisional
hernia like age, sex, obesity, chest infections, type of suture material, type of incision and most
important wound infection. All of them present a challenging problem to the surgeon. So this study
has been undertaken to assess the magnitude of this condition and different modalities in surgical
repair by mesh in our setup. MATERIALS & METHODS: This is a prospective study of 70 cases of
incisional hernia who attended to OPD and emergency department of Sri B. M. Patil medical college
Hospital & Research Centre from March 2012 to March 2014. Data were collected from the patients
ie, clinical history, examination and appropriate investigations. Documentations of patients which
include identification, history, clinical finding, investigative tests, operation findings, operative
procedures and complications during the stay in hospital and during subsequent follow up period,
were all recorded in a proforma specially prepared. RESULTS: In our series of 70 patients, clinical
details of 70 patients were available. Females (80%, n=48) out- numbered males (20%, n=12) and
the highest incidence was in the age group of 30 to 60 years with mean age of 45 years. Gynecological
operation accounted for 73.3% (n=50) of the index operations, with lower midline incision resulting
in 53.3%(n=44) of the incisional hernias. The polypropylene mesh placed overlay or inlay method. All
patients attended our follow up ranging from 3 months to 2 year. Two recurrences were noticed in
inlay mesh repair group. CONCLUSION: Based on our analysis, we believe that overlay mesh repair is
superior to inlay mesh repair for incisional hernia repair. There are however, very few publications
covering this technique of repair.
A series of 68 primary midline incisional hernias with a vertical Mayo repair was evaluated retrospectively. Patients without documented hernia recurrence following this repair were invited for physical examination. Life-table methods were used for statistical analysis. The 1-, 3-, 5-, and 10-year cumulative recurrence rates were 35%, 46%, 48%, and 54%, respectively. Also, generally accepted risk factors were studied. Multivariate analysis identified the size of the hernia (p = 0.02) and the use of steroids (p = 0.04) as the most important independent risk factors of first time recurrent incisional hernia. Considering the high recurrence rates found, the results of this study strongly suggest that the vest-over-pants repair should no longer be used for closure of midline incisional hernias.
To determine whether the type of prosthetic material and technique of placement influenced long-term complications after repair of incisional hernias.
Retrospective cohort analytic study.
University-affiliated hospital.
Two hundred patients undergoing open repair of abdominal incisional hernias with prosthetic material between 1985 and 1994.
Four types of prosthetic material were used and placed either as an onlay, underlay, sandwich, or finger interdigitation technique. The materials were monofilamented polypropylene mesh (Marlex, Davol Inc, Cranston, RI), double-filamented mesh (Prolene, Ethicon Inc, Somerville, NJ), expanded polytetrafluroethylene patch (Gore-Tex, WL Gore & Associates, Phoenix, Ariz) or multifilamented polyester mesh (Mersilene, Ethicon Inc).
The incidence of recurrence and complications such as enterocutaneous fistula, bowel obstruction, and infection with each type of material and technique of repair were compared with univariate and multivariate analysis.
On univariate analysis, multifilamented polyester mesh had a significantly higher mean number of complications per patient (4.7 vs 1.4-2.3; P<.002), a higher incidence of fistula formation (16% vs 0%-2%; P<.001), a greater number of infections (16% vs 0%-6%; P<.05), and more recurrent hernias (34% vs 10%-14%; P<.05) than the other materials used. The additional mean length of stay to treat complications was also significantly longer (30 vs 3-7 days; P<.001) when polyester mesh was used. The deleterious effect of polyester mesh on long-term complications was confirmed on multiple logistic regression (P=.002). The technique of placement had no influence on outcome.
Polyester mesh should no longer be used for incisional hernia repair.
Incisional hernia is an important complication of abdominal surgery. Procedures for the repair of these hernias with sutures and with mesh have been reported, but there is no consensus about which type of procedure is best.
Between March 1992 and February 1998, we performed a multicenter trial in which we randomly assigned to suture repair or mesh repair 200 patients who were scheduled to undergo repair of a primary hernia or a first recurrence of hernia at the site of a vertical midline incision of the abdomen of less than 6 cm in length or width. The patients were followed up by physical examination at 1, 6, 12, 18, 24, and 36 months. Recurrence rates and potential risk factors for recurrent incisional hernia were analyzed with the use of life-table methods.
Among the 154 patients with primary hernias and the 27 patients with first-time recurrent hernias who were eligible for the study, 56 had recurrences during the follow-up period. The three-year cumulative rates of recurrence among patients who had suture repair and those who had mesh repair were 43 percent and 24 percent, respectively, with repair of a primary hernia (P=0.02; difference, 19 percentage points; 95 percent confidence interval, 3 to 35 percentage points). The recurrence rates were 58 percent and 20 percent with repair of a first recurrence of hernia (P=0.10; difference, 38 percentage points; 95 percent confidence interval, -1 to 78 percentage points). The risk factors for recurrence were suture repair, infection, prostatism (in men), and previous surgery for abdominal aortic aneurysm. The size of the hernia did not affect the rate of recurrence.
Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia.
Background: Polypropylene mesh (PPM) is an effective material for the repair of abdominal wall defects, but has a tendency to induce dense adhesions when in contact with viscera. Seprafilm (Genzyme Corp, Cambridge, MA), a bioresorbable membrane, has been shown to reduce adhesion formation after midline closures in humans and to PPM in animals. Given the increased inflammatory response expected with surgical trauma, its efficacy under surgical conditions has been questioned.Study Design: A prospective, randomized, blinded study was conducted using a rabbit model. Standardized abdominal wall defects were created in three groups of New Zealand white rabbits. The cecum was deserosalized to simulate the effects of trauma. The abdominal defect was then repaired with PPM. In the control group, no Seprafilm was used. In the first experimental group Seprafilm was placed between the mesh and the abdominal viscera. In the second experimental group Seprafilm was placed over the deserosalized area and between the mesh and abdominal viscera. Animals were sacrificed at 30 days and adhesions were categorized and quantified using digital image analysis of inked specimens. The strength of incorporation was also determined.Results: The formation of adhesions between the viscera and mesh repair was dramatically reduced in both experimental groups compared with the control group. The incidence of visceral adhesions was reduced by 80% in the single film group (p = 0.0004) and 90% in the double film group (p = 0.00008). The reduction in surface area of adhesions was 96.4% in the single film group (p = 0.000019) and 99.4% in the double film group (p = 0.00002). Omental adhesions were reduced by 30% but this did not achieve statistical significance. Strength of incorporation was not adversely affected in either group.Conclusions: Seprafilm is highly effective in preventing adhesions to PPM. This effect was not diminished by the presence of visceral trauma and its resultant inflammatory response. The use of Seprafilm does not adversely affect tissue incorporation. Clinical trials are warranted to determine if the protective effects of Seprafilm demonstrated in this study are applicable in the clinical setting.
Objective: To assess the efficacy and safety of Sepracoat (HAL-C; Genzyme Corporation, Cambridge, MA) solution in reducing the incidence, severity, and extent of de novo adhesion formation at sites without direct surgical trauma or adhesiolysis at the time of gynecologic laparotomy.Design: Prospective, randomized, blinded, placebo-controlled multicenter study. Patients underwent gynecologic procedures via laparotomy; approximately 40 days later, surgeons assessed their adhesions during second-look laparoscopy.Setting: Twenty-three North American institutions.Patient(s): Two hundred seventy-seven women for safety evaluations; 245 women for efficacy studies.Intervention(s): Intraoperative serosal coating with Sepracoat (treatment) or phosphate-buffered saline (placebo) after opening of the abdominal cavity, after irrigation or every 30 minutes during surgery, and at the completion of surgery.Main Outcome Measure(s): Incidence, severity, and extent of de novo adhesions to 23 intraabdominal sites.Result(s): The Sepracoat group had a significantly lower incidence of de novo adhesions than the placebo group as assessed by the proportion of sites involved (0.23 ± 0.02 versus 0.30 ± 0.02, respectively) and the percentage of patients without de novo adhesions (13.1% versus 4.6%, respectively), as well as significantly reduced adhesion extent and severity. Sepracoat was well tolerated, with a safety profile nearly identical to that of the placebo.Conclusion(s): Sepracoat was significantly more effective than placebo and was safe in reducing the incidence, extent, and severity of de novo adhesions to multiple sites indirectly traumatized by gynecologic surgery via laparotomy.
Abdominal wall defects were repaired in 75 Sprague-Dawley rats with either Marlex mesh (25 rats), expanded polytetrafluoroethylene (PTFE) patch or polyglycolic acid (PGA) mesh (25 rats). Adhesion formation and peritoneal healing on these materials were serially investigated from one to 22 weeks after implantation. Adhesions to expanded PTFE were significantly less dense than to either Marlex or PGA mesh (p<0.05). A further 30 rats underwent abdominal wall repair with Marlex mesh (15 rats) or expanded PTFE patch (15 rats) in the presence of a staphylococcus aureus wound infection. One week after implantation, adhesions to expanded PTFE patch were significantly less than to Marlex mesh (p<0.05), but thereafter maximum adhesions were seen on both materials. Peritoneal healing was complete on expanded PTFE patch, but was scanty on Marlex and PGE meshes and was inhibited in the presence of a wound infection.
Five hundred and sixty-four patients reviewed 1 year after major abdominal surgery have been studied prospectively by a single observer for 10 years to determine the incidence and significance of incisional hernia. Of 337 (60 per cent) patients completing the 10 year follow-up 37 (11 per cent) developed an incisional hernia and 13 (35 per cent) of these first appeared at 5 years or later. One in three hernias caused symptoms. The late appearing hernias were smaller than the early ones, and caused little trouble. Of the 18 patients who consulted their general practitioner, 11 had symptoms and of these six (55 per cent) were referred for surgical opinion. Many hernias were diagnosed at routine outpatient follow-up and were likely to receive treatment from the surgeon. Most symptomatic patients were offered surgery with the remainder usually being offered a corset. In about half our patients (mainly those without symptoms) surgery was refused or advised against although the patients would have accepted it. Recurrence is common after surgical repair (40 per cent) but seems to be related to surgical technique. The possibility of complications occurring from an incisional hernia does not appear to be discussed with patients although obstruction occurred in 14 per cent of our patients with troublesome hernia.
The repair of inguinal or incisional hernias may occasionally require the placement of an intraabdominal mesh to reinforce parietal wall defects or weaknesses. An original composite mesh, consisting of a conventional polyester mesh combined with a coated hydrophilic and absorbable membrane designed to prevent intraperitoneal adhesions was evaluated. The efficacy of the product was tested through three experiments. The first carefully examined the absorption properties of the hydrophilic film as well as the biocompatibility of the patch after subcutaneous implantation. The second experiment was designed to evaluate adhesion formation in an animal model, comparing the mesh to two other commercially available membranes and to a control. In the third experiment, the product was tested in a porcine model. This was done in order to better evaluate the performance of the mesh in a model closer to human dimensions. These three experimental procedures demonstrated the biocompatibility of the membrane, the dramatically superior performance of the patch compared to other commercially available ones and to controls, and the validity of the concept in large animals. The composite mesh made of polyester and coated hydrogel fulfils the conditions for human evaluation.
PIP
Male albino rats were used in this experimental study designed to determine the physiological basis for the formation of peritoneal adhesions postoperatively, and hence to discover a physiological basis for adhesion-free healing after abdominal surgery. Recent evidence had shown that failure of the peritoneal fibrinolytic system may be the important etiological factor in postoperative adhesion formation; hence, the working hypothesis was that adhesion formation could be explained by alterations of intrinsic peritoneal fibrinolytic mechanisms. All rats underwent repeated biopsy to obtain control determinations of plasminogen activator activity (PAA), and then 70 animals had 2 by 2 cm areas of parietal peritonium resected to a thin layer of adherent underlying muscle on the abdominal wall on both sides of the original midline incision. On 1 side, the perioneal patch was immediately sutured back in place as an avascular, free graft. On the other, the raw peritoneal defect was left unrepaired. In 40 of these 70 rats, polyethylene patches were used to cover the peritoneal graft and defect. Animals were sacrificed in groups of 10 at various intervals postoperation to determine PAA and adhesion formation. 24 hours postoperatively, mean graft PAA had decreased to one-sixth the control value (P .001). Similar wide discrepancies were seen through 96 hours postoperation (all statistically significant at P .001). PAA was unchanged in controls. 96 hours postoperation, adhesions to the parietal defects had completely disappeared in 8 of 10 animals, yet all of the grafts remained covered by dense adhesions. By 2 weeks, all deperitonealized wounds showed complete absence of adhesions, compared with dense adhesions on the graft wound.
Four techniques to close the fascia after midline laparotomy were compared in a prospective randomized multicentre trial. The four techniques were: interrupted closure with polyglactin; continuous closure with polyglactin; continuous closure with polydioxanone-s, and continuous closure with nylon. The early postoperative results in 1491 patients revealed an incidence of wound infection of 8.6 per cent and of wound dehiscence of 2.3 per cent with no statistically significant differences between the four techniques. We reviewed 1156 patients after 1 year. Wound pain was present in 9.7 per cent of the patients, statistically significantly more in the group closed with nylon (16.7 per cent). Suture sinuses developed in 3.5 per cent of the patients, statistically significantly more frequently in the nylon group (7.7 per cent). The total number of incisional hernias detected 1 year postoperatively was high (15.2 per cent) (interrupted polyglactin 16.9 per cent, continuous polyglactin 20.6 per cent, continuous polydioxanone 13.2 per cent and continuous nylon 10.3 per cent). The difference between nylon and continuous polyglactin is statistically significant. The results of this trial indicate that although nylon has the lowest incidence of incisional hernia it also is associated with more wound pain and suture sinuses.
A large abdominal wall hernia, not amenable to primary closure, may require insertion of a prosthesis. The ideal prosthesis maintains strength, is incorporated by surrounding tissues, and does not stimulate adhesions. These qualities vary among available synthetic prostheses. We tested tensile strength, bursting strength, and adhesion formation in response to six materials used in repair of abdominal wall hernias. Adult Sprague-Dawley rats (196) were randomly divided into a control group and six experimental groups. A 4 by 4 cm full-thickness resection of abdominal wall was closed with patches of polypropylene mesh (Marlex), polyglactin 910 mesh (Vicryl), expanded polytetrafluoroethylene (Gore-tex), Dacron-reinforced silicone rubber (Silastic), preserved human dura (PHD), or polypropylene mesh overlying gelatin film (Marlex and Gelfilm, respectively). In controls the 4 cm longitudinal full-thickness incisions were closed primarily. Seven rats randomly selected from each group were sacrificed after 1, 2, 4, and 8 weeks; bursting and tensile strength (tensiometer) and adhesion formation were assessed. There were no differences in bursting strength among the experimental groups at each testing period. Although bursting strength increased linearly with time it was significantly weaker than in controls at 1 and 8 weeks (P less than 0.05). Tensiometric data were inconclusive due to wide variability within the experimental groups. Adhesion formation was moderate to maximal at all evaluation periods for Marlex and Gore-tex. Early adhesion formation was minimal to moderate for both PHD and Vicryl, but later increased with PHD and decreased with Vicryl as this prosthesis was absorbed. No adhesions formed with Marlex and Gelfilm until the gelatin dissolved (1 week), after which the adhesion response was similar to that with Marlex alone. No adhesions formed after Silastic implantation, but graft extrusion and evisceration were common (75%). Controls had no adhesions at all evaluation periods. Wound strength was similar for all prosthetic materials. Absorbable prosthetic Vicryl provided the best long-term protection against adhesions.
A gastric leak with perigastric abscesses developed after a revision gastroplasty reinforced with Marlex, performed on a 34-year-old, morbidly obese woman. The site of the leak and the abscesses were drained but the Marlex could not be excised. The woman remained on long-term enteral nutrition at home and her fistula healed despite the presence of the Marlex mesh. She continued to lose weight and was well 8 months after the fistula had healed.
Marlex mesh is an excellent prosthetic material for closure of major abdominal defects. Most of its complications are seroma and infections. We have used Marlex mesh intraperitoneally for closure of burst abdomen in a patient who had a gastrectomy for recurrent duodenal ulcer. A year and a half later, this patient developed a fecal fistula to the skin due to incorporation of the Marlex mesh into the splenic flexure of the COLON. The patient underwent a second operation during which the fistula was resected and the Marlex removed. We concluded that intraperitoneal placement of Marlex mesh is not recommended.
Recurrent incisional hernia remains a major problem for the general surgeon. The rate of recurrence of hernia repaired by primary closure using nylon sutures or with knitted monofilament polypropylene (Marlex) mesh was studied. A total of 102 repairs were performed over a 19-year period. Marlex mesh was used in 49 cases and primary closure in 53. All except two patients were followed from 1 to 15 (mean 7.6) years or to death. The incidence of recurrence was 8 per cent when Marlex was used and 25 per cent after primary closure. In both groups the majority of the recurrences were in the first 16 months after repair. The use of Marlex mesh should be considered in the management of recurrent incisional hernia.
Incisional hernia is a serious complication of abdominal surgery. We compared incisional hernia frequency following gastric bypass (GBP) for morbid obesity versus total abdominal colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. A prefascial polypropylene mesh repair was also evaluated.
All patients had midline incisions, xiphoid to umbilicus in GBP patients and midepigastrium to pubis in IPAA patients. Fascia were closed with running No. 2 polyglycolic acid suture. Ninety-eight patients underwent prefascial polypropylene mesh repair; 80 were GBP patients, 46 had 1 previous repair, and 17 had 2 to 9 previous repairs (6 with properitoneal mesh).
Incisional hernia occurred in 20% (198/968) of GBP patients (19% without versus 41% with a previous hernia, P < 0.001) versus 4% (7/171) of the IPAA patients (P < 0.001), of whom 102 (60%) were taking prednisone (32 +/- 2 mg/d) and 5 were quite obese (body mass index > or = 30 kg/m2). Additional risk factors for hernia in GBP patients included wound infection, diabetes, sleep apnea, and obesity hypoventilation. For the 98 patients who underwent prefascial polypropylene mesh repair, the mean follow-up was 20 +/- 2 months (range 6 to 104), and complications occurred in 35% of patients, including minor wound infection (12%), major wound infection (5%), seroma (5%), hematoma (3%), chronic pain (6%), and recurrent hernia (4%).
Severe obesity is a greater risk factor for incisional hernia and hernia recurrence than chronic steroid use in nonobese colitis patients. A prefascial polypropylene mesh repair minimizes recurrence.
The authors determined the prevalence of foreign body granulomas in intra-abdominal adhesions in patients with a history of abdominal surgery.
In a cross-sectional, multicenter, multinational study, adult patients with a history of one or more previous abdominal operations and scheduled for laparotomy between 1991 and 1993 were examined during surgery. Patients in whom adhesions were present were selected for study. Quantity, distribution, and quality of adhesions were scored, and adhesion samples were taken for histologic examination.
In 448 studied patients, the adhesions were most frequently attached to the omentum (68%) and the small bowel (67%). The amount of adhesions was significantly smaller in patients with a history of only one minor operation or one major operation, compared with those with multiple laparotomies (p < 0.001). Significantly more adhesions were found in patients with a history of adhesions at previous laparotomy (p < 0.001), with presence of abdominal abscess, hematoma, and intestinal leakage as complications after former surgery (p = 0.01, p = 0.002, and p < 0.001, respectively), and with a history of an unoperated inflammatory process (p = 0.04). Granulomas were found in 26% of all patients. Suture granulomas were found in 25% of the patients. Starch granulomas were present in 5% of the operated patients whose surgeons wore starch-containing gloves. When suture granulomas were present, the median interval between the present and the most recent previous laparotomy was 13 months. When suture granulomas were absent, this interval was significantly longer--i.e., 30 months (p = 0.002). The percentage of patients with suture granulomas decreased gradually from 37% if the previous laparotomy had occurred up to 6 months before the present operation, to 18% if the previous laparotomy had occurred more than 2 years ago (p < 0.001).
The number of adhesions found at laparotomy was significantly larger in patients with a history of multiple laparotomies, unoperated intra-abdominal inflammatory disease, and previous postoperative intra-abdominal complications, and when adhesions were already present at previous laparotomy. In recent adhesions, suture granulomas occurred in a large percentage. This suggests that the intra-abdominal presence of foreign material is an important cause of adhesion formation. Therefore intra-abdominal contamination with foreign material should be minimized.
Objective:
To assess the safety and efficacy of Seprafilm (HAL-F), Bioresorbable Membrane, (Genzyme Corporation, Cambridge, MA) in reducing the incidence, severity, extent, and area of uterine adhesions after myomectomy.
Design:
Prospective, randomized, blinded, multicenter study. Adhesion reduction was assessed by an independent, blinded, gynecologic surgeon who reviewed videotapes of each patient's second-look laparoscopy.
Setting:
Nineteen institutions across the United States.
Patient(s):
One hundred twenty-seven women undergoing uterine myomectomy with at least one posterior uterine incision > or = 1 cm in length.
Intervention(s):
Patients were randomized to treatment with Seprafilm or to no treatment at the completion of the myomectomy.
Main outcome measure(s):
The incidence, severity, extent, and area of uterine adhesions at second-look laparoscopy.
Result(s):
The incidence, measured as the mean number of sites adherent to the uterine surface, was significantly less in treated patients (4.98 +/- 0.52 [mean +/- SEM] sites) than in no treatment patients (7.88 +/- 0.48 sites) as were the mean uterine adhesion severity scores (1.94 +/- 0.14 versus 2.43 +/- 0.10; treatment versus no treatment, respectively), mean extent scores (1.23 +/- 0.12 versus 1.68 +/- 0.10), and mean area of adhesions (13.2 +/- 1.67 versus 18.7 +/- 1.66 cm2). No adverse events occurred that were judged to be related to the use of Seprafilm.
Conclusion(s):
In this multicenter study, treatment of patients after myomectomy with Seprafilm significantly reduced the incidence, severity, extent, and area of postoperative uterine adhesions. Additionally, Seprafilm treatment was not associated with an increase in postoperative complications.
Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction, accounting for more than 40% of all cases and 60% to 70% of those involving the small bowel. This contrasts with earlier experience in the Western World and current practice in the Third World, where abdominal operations are infrequent, hernias remain untreated, and strangulated hernia is common. These are among the findings of prospective and retrospective studies on adhesions conducted at the Westminster Medical School, University of London, London, UK, and of other published studies on the clinical consequences of postoperative intra-abdominal adhesions and resultant intestinal obstruction. In an analysis of 210 patients who had undergone at least one previous abdominal operation, 92.9% had postsurgical adhesions. This is not surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation. Problems resulting from postsurgical adhesions create a considerable workload. At Westminster Hospital over 24 years, intestinal obstruction accounted for 0.9% of all admissions, 3.3% of major laparotomies and 28.8% of cases of large or small bowel obstructions. A 1992 British survey reported an annual total of 12,000 to 14,400 cases of adhesive intestinal obstruction. In 1988 in the United States, admissions for adhesiolysis accounted for nearly 950,000 days of inpatient care. Risk factors, such as type of surgery and site of adhesions, as well as timing and recurrence rate of adhesive obstruction, remain unpredictable or poorly understood. The type of surgery most frequently leading to adhesive obstruction includes colonic, and especially rectal surgery, appendicectomy, and gynecological procedures. Laparoscopy does not seem to eliminate the risk of adhesions and adhesive obstruction. Adhesions involving the small intestine occur less frequently than those involving the omentum, but are more likely to become obstructive. Follow-up of over 2,000 laparotomies at the Westminster Hospital demonstrated that 1% of patients developed adhesive obstruction within one year of surgery, and half of these occurred within the first postoperative month. However, obstruction may occur at any time, and some 20% of cases appeared more than 10 years later. Recurrent obstruction following adhesiolysis is common, but actuarial tables still need to be constructed. Adhesive obstruction is clinically challenging, since there is no simple way to differentiate between adhesive and strangulated obstructions. Mortality rates escalate from 3% for simple obstructions to 30% when the bowel becomes necrotic or perforated.
Adhesion formation, which is almost inevitable following incisional hernia repair with prosthetic mesh, may lead to intestinal obstruction and enterocutaneous fistulae. Physical barriers, namely carboxymethylcellulose and hyaluronic acid, have been reported to lessen the intra-abdominal adhesions. To evaluate the effects of Seprafilm (Genzyme Corp., Cambridge, MA), a bioresorbable, translucent membrane composed of carboxymethylcellulose and hyaluronic acid, in the presence of a foreign body such as polypropylene mesh, an incisional hernia model in rats was used. Twenty-four male rats were divided into two groups: control (12) and Seprafilm (12). A defect, measuring 1.5 x 2.5 cm, was created in each animal. Control animals had the polypropylene mesh sutured to the defect, whereas in the other group, two membranes of Seprafilm were laid over the abdominal viscera before repair with polypropylene mesh. Half of the animals from each group were killed at postoperative day 7 and remaining half at day 30 for adhesion scoring and histological evaluation of wound healing. Seprafilm animals had fewer adhesions compared with control animals (P = 0.0008). Seprafilm had no adverse effect on wound healing. This membrane seems to have the potential to lessen the adhesion-related morbidity following incisional hernia repair.
To assess the efficacy and safety of Sepracoat (HAL-C; Genzyme Corporation, Cambridge, MA) solution in reducing the incidence, severity, and extent of de novo adhesion formation at sites without direct surgical trauma or adhesiolysis at the time of gynecologic laparotomy.
Prospective, randomized, blinded, placebo-controlled multicenter study. Patients underwent gynecologic procedures via laparotomy; approximately 40 days later, surgeons assessed their adhesions during second-look laparoscopy.
Twenty-three North American institutions.
Two hundred seventy-seven women for safety evaluations; 245 women for efficacy studies.
Intraoperative serosal coating with Sepracoat (treatment) or phosphate-buffered saline (placebo) after opening of the abdominal cavity, after irrigation or every 30 minutes during surgery, and at the completion of surgery.
Incidence, severity, and extent of de novo adhesions to 23 intraabdominal sites.
The Sepracoat group had a significantly lower incidence of de novo adhesions than the placebo group as assessed by the proportion of sites involved (0.23 +/- 0.02 versus 0.30 +/- 0.02, respectively) and the percentage of patients without de novo adhesions (13.1% versus 4.6%, respectively), as well as significantly reduced adhesion extent and severity. Sepracoat was well tolerated, with a safety profile nearly identical to that of the placebo.
Sepracoat was significantly more effective than placebo and was safe in reducing the incidence, extent, and severity of de novo adhesions to multiple sites indirectly traumatized by gynecologic surgery via laparotomy.
To evaluate the current practice of incisional hernia repair in Germany and analysis of the results of the Mayo duplication technique done in our hospital over a 10-year period.
Nationwide survey, retrospective analysis.
University department, Germany.
Survey of most surgical departments and of 114 patients with 135 incisional hernias in our unit.
Mayo duplication repair incisional hernias.
Common practice, recurrence rates, quality of life.
The Mayo overlap is the preferred technique in most surgical departments. The estimated failure rates (12% or less) in general practice are grossly underestimated. In our hospital the recurrence rate after Mayo duplication repair was 61/114 (54%) during a follow up time of 5.7 years with a follow-up-rate of 84%. Univariate and multivariate analyses failed to identify any predisposing factors. All patients with incisional hernias had limitations their physical function.
The widely used Mayo procedure leads to unacceptable results for repair of incisional hernias and other techniques should be evaluated and used more often. Repair of an incisional hernia does not improve overall quality of life.
There is a high incidence of adhesions after ventral hernia repair with polypropylene mesh. Hyaluronic acid (HA)-based membrane has been shown to reduce the incidence of adhesions in the absence of prosthetic mesh. The purpose of this study was to determine the effect of HA membrane on the quantity and grade of adhesions and its effect on strength of repair after abdominal wall repair with polypropylene mesh.
In 61 rats a full-thickness abdominal wall defect (excluding skin) was created, and a section of small bowel was abraded. The animals were randomized, receiving either HA membrane to cover the viscera or no membrane. The fascial defect was repaired with polypropylene mesh. Equal numbers of animals from each group were killed at 4 weeks and 8 weeks after surgery. Adhesion severity and percentage of mesh surface covered with adhesions were estimated. Tensile strength between mesh and muscle from each animal was measured. Sections of the mesh-muscle interface were examined histologically and measured for thickness and graded for inflammation and fibrosis.
Fifty-five animals survived until the end point. Animals in the HA membrane group had a significant reduction in (1) grade of adhesions between small bowel and mesh at 4 weeks (P = .009) and 8 weeks (P = .000001), (2) grade of adhesions between colon and mesh at 8 weeks (P = .00003), and (3) percentage of mesh covered with adhesions at 4 weeks (P = .01) and 8 weeks (P = .0000002). There was no difference between the 2 groups in tensile strength of the repairs, tissue thickness, degree of inflammation, or degree of fibrosis.
HA membrane reduces the quantity and grade of adhesions of both small and large bowel, to polypropylene mesh in a rat model of ventral hernia repair, without compromising strength of the repair.
Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures.
We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people.
1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions.
Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.
To evaluate the ability of collagen film, collagen gel, sodium hyaluronate/carboxymethylcellulose film, and fibrin glue to prevent adhesion formation.
Randomized trial using a rat model of a standardized abdominal wound and cecal wound.
University research laboratory.
Sprague-Dawley female rats.
Resorbable barriers or no barrier (controls) were placed between an abdominal wall wound (1 cm x 2 cm) and a similarly sized cecal wound.
Adhesion formation between wounds was assessed and quantitated 7 days after surgery.
Without treatment, 34 of 35 untreated rats (97%) developed adhesions. Treatment with collagen gel (3 of 33 rats), collagen film (3 of 10 rats), or sodium hyaluronate/carboxymethylcellulose film (2 of 10 rats) significantly reduced the incidence of adhesion formation. Treatment with fibrin sealant resulted in 9 of 10 animals having adherent wounds 7 days after surgery.
Resorbable barriers of collagen gel, collagen films and sodium hyaluronate/carboxymethylcellulose film were effective in significantly reducing adhesion formation. Fibrin sealant at 7 days had an incidence of adhesion formation similar to that in untreated control animals.
Adhesions to polypropylene mesh used for abdominal wall hernia repair may eventuate in intestinal obstruction or enterocutaneous fistula. A Seprafilm Bioresorbable Membrane translucent adhesion barrier has been shown to inhibit adhesions. This investigation was designed to determine if Seprafilm alters abdominal visceral adhesions to polypropylene mesh.
A 2.5-cm square abdominal muscle peritoneal defect was created and corrected with polypropylene mesh. Mesh alone was used in 17 rats. In another 17, the Seprafilm membrane was applied between the viscera and the mesh. Five animals had the bioresorbable membrane placed in the subcutaneous space and between the mesh and the viscera. Laparoscopy was performed 7, 14, and 28 days later to evaluate adhesions as a percentage of mesh surface involved.
Polypropylene mesh alone was associated with adhesions in every rat. The average area involved was 90%, the minimum was 75%. Adhesions were present within 24 hours and progressed up to 7 days with no change thereafter. When the Seprafilm barrier was used, the mean area involved was 50%. In 16 such rats, the area involved was smaller than any control animal. No adhesions formed in 5 animals. Scanning electron microscopy demonstrated a mesothelial cell layer covering the mesh after 4 weeks.
The use of the Seprafilm adhesion barrier resulted in a significant reduction of adhesion formation to polypropylene mesh (P <.001).
Intra-abdominal adhesion formation causes significant post-operative morbidity. Controlled studies using animal models have
been carried out to assess the tolerability and preventive efficacy of icodextrin solution (a biodegradable, biocompatible,
glucose polymer). Reduction of adhesion formation was first evaluated in a rabbit double uterine horn model, applying 10–75
ml of 7.5 and 20%, or 50 ml of 2.5–20% icodextrin solution post-operatively. Significant increases in adhesion free sites
(P < 0.005) were observed with volumes ≥25 ml, and at concentrations ≥4%. Efficacy of 50 ml 4 and 20% icodextrin was then evaluated
both during and after surgery, demonstrating significant reductions in adhesion formation (P < 0.002). In one study, intra- plus post-operative use of 4% icodextrin produced the greatest reduction of non-surgical site
adhesions; in others, the post-operative effect was predominant. Post-surgical administration of 50 ml 4% icodextrin in a
rabbit sidewall model also resulted in more adhesion-free animals, and a significant reduction (P < 0.001) in areas of adhesion formation and reformation. In a rat infection potentiation model, 4% icodextrin produced no
difference in mortality, abscess formation or overall abscess score. These data suggest that 4% icodextrin offers a well-tolerated
and effective means of reducing post-surgical adhesion formation.
Polypropylene mesh (PPM) is an effective material for the repair of abdominal wall defects, but has a tendency to induce dense adhesions when in contact with viscera. Seprafilm (Genzyme Corp, Cambridge, MA), a bioresorbable membrane, has been shown to reduce adhesion formation after midline closures in humans and to PPM in animals. Given the increased inflammatory response expected with surgical trauma, its efficacy under surgical conditions has been questioned.
A prospective, randomized, blinded study was conducted using a rabbit model. Standardized abdominal wall defects were created in three groups of New Zealand white rabbits. The cecum was deserosalized to simulate the effects of trauma. The abdominal defect was then repaired with PPM. In the control group, no Seprafilm was used. In the first experimental group Seprafilm was placed between the mesh and the abdominal viscera. In the second experimental group Seprafilm was placed over the deserosalized area and between the mesh and abdominal viscera. Animals were sacrificed at 30 days and adhesions were categorized and quantified using digital image analysis of inked specimens. The strength of incorporation was also determined.
The formation of adhesions between the viscera and mesh repair was dramatically reduced in both experimental groups compared with the control group. The incidence of visceral adhesions was reduced by 80% in the single film group (p = 0.0004) and 90% in the double film group (p = 0.00008). The reduction in surface area of adhesions was 96.4% in the single film group (p = 0.000019) and 99.4% in the double film group (p = 0.00002). Omental adhesions were reduced by 30% but this did not achieve statistical significance. Strength of incorporation was not adversely affected in either group.
Seprafilm is highly effective in preventing adhesions to PPM. This effect was not diminished by the presence of visceral trauma and its resultant inflammatory response. The use of Seprafilm does not adversely affect tissue incorporation. Clinical trials are warranted to determine if the protective effects of Seprafilm demonstrated in this study are applicable in the clinical setting.
It has been hypothesized that peritoneal hypofibrinolysis is of importance in the formation of postoperative adhesions, but results from experiments with fibrinolytic modulators are conflicting. We tested this hypothesis in a controlled prospective study in rabbits, comparing the effects of fibrinolytic inhibition (tranexamic acid) to fibrinolysis enhancement by local instillation of gel containing tissue-type plasminogen activator. Adhesion formation was measured after 1 week in a strictly standardized way and is presented as a percentage of an induced lesion that was covered by adhesions. Fibrinolytic inhibition significantly increased adhesion formation, both to the parietal peritoneum (34.2%+/- 3.2%) compared with untreated control (19.7%+/- 3.3%, p < 0.01) and to the bowel (76.3%+/- 5.8%) compared with untreated control (51.2%+/- 8.7%, p < 0.05). Control gel significantly increased adhesions to the parietal peritoneum (35.6%+/- 4.6%) versus untreated control (19.7%+/- 3.3%, p < 0.05), whereas gel containing tissue-type plasminogen activator significantly reduced the amount of adhesions to the parietal peritoneum (4.9%+/- 1.7%) compared with untreated control (19.7%+/- 3.3%, p < 0.01) and abolished adhesion formation to the injured bowel. The fibrinolytic system thus seems to be intimately involved in the early formation of intraabdominal adhesions.
- Hooker