1. Prosthetics in Complex Bariatric Abdominal Wall Reconstruction Garth R Jacobsen, M.D. Director UCSD Hernia Center Surgical Program Director Center for the Future of Surgery UC San Diego Department of Surgery

2. Bias? W.L. Gore: Honoraria: Speaking, Consulting, Writing, Proctering, Fellowship Support Ethicon Honoraria: Speaking, Consulting, Research Grants, Proctering, Fellowship Support USGI: Honoraria: Speaking, Consulting, Research Grants, Proctoring Covidien Honoraria: Speaking LifeCell: Honoraria: Speaking, Consulting Davol: Honorarium, Speaking MTF: Honorarium, Writing Novus: Honoraria; Consulting

3. Bariatric Surgery Obese patients more commonly have hernias Most obesity operations involve transection of the GI tract Well followed group

4. “If we could artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernias would be discovered” Theodore Billroth 1829-1894

5. “Throughout the body, contractile dynamic muscular tissue resists strain and stress better than fascia and ligaments” Ralph Ger 1983

6. Components Separation

7. Ramirez Operative Technique

8. Net Gain Release of external oblique 2 cm upper 4 cm mid 2 cm lower Release of the posterior rectus sheath 3 cm upper 5 cm mid 3 cm lower Total Gain 5 cm upper 9 cm mid 5 cm lower

9. Should We Reinforce? No large level 1 data sets exist Traditionally Expensive Anecdotal reports and small case series report recurrence rates from zero to 35% Onlay, Underlay, Lateral, Sandwich?

10. Factors associated with performance Raw Material and Design Polymer/tissue Strength Elasticity Architecture Pore Size Fiber Size Density Weave Bioreactivity

11. Synthetic Nonabsorbable Polymers

12. Polypropylene Polypropylene (Most Common) Hydrophobic Resistant to significant degradation Induces biologic reactivity Weight, filament size, pore size, and architecture

13. Polyester Polyethylene terephthalate (PET) Hydrophilic Inflamatory response similar to PP Subject to degradation over time Subject to contraction Brand Names Mersiline – Ethicon Parietex – Covidien

14. Polytetraflouroethylene ePTFE Good Biocompatibility Highly engineered (3 to 100 um pore sizes) Subject to contracture Adhesion Resistant

15. Coated Nonabsorbables Attenuate host response to the prosthetic Variations for both PP and PE Useful when prosthetic is exposed to viscera Examples: C-Qur (Atrium) Omega-3 FA 80 Days Proceed (Ethicon) Oxidized Regenerated Cellulose (ORC) Absorbable PDS (polydiaxanone) 14 days Physiomesh (Ethicon) Monocryl backing Parietex Composite Polyethlene Glycol, Glycerol 14 days

16. Partially Absorbable Reduce the density of the nonabsorbable polymer component Increase intra-operative handling characteristics Vypro II (Ethicon) PP and Polyglactin (Vicryl) Ultrapro (Ethicon) PP Poliglecaprone-25 (Monocryl)

17. Composite Multiple mesh types combined into one sheet

18. Light vs Heavy Most commonly utilized mesh in use today is heavy weight polypropylene Marlex, Prolene, Surgipro, 3D Max Good handling characteristics High surgeon satisfaction Mechanically over engineered 26 N/cm vs >50 N/cm Potentially higher rates of pain, fistula formation, infection and mesh contraction Less compliant abdominal wall

19. What is Lightweight? Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? Surg Clin North Am. Feb 2008;88(1):101-112, ix.

20. Lightweight Offerings Davol Bard 3dMax light Bard Composix LP Ethicon Ultrapro Gore Infinit

21. Biologic Prosthetics

22. Biologic Prosthetics Based on a collagen scaffold derived from a donor source Dermal sources Human, porcine and fetal Other sources Porcine small intestinal submucosa (layered) Bovine pericardium Decellularized to leave only organized collagen and extracellular ground tissue

23. Biologic Prosthetics Continued CrosslinkedvsNoncrosslinked Crosslinking resists collagenases Crosslinked meshes can last for years, uncrosslinked will be resorbed in 3 months Potential Advantages Potential for infection resistance Low adhesion formation*

24. Cost Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? SurgClin North Am. Feb 2008;88(1):101-112, ix.

25. Synthetic “biologics” Synthetic bioabsorbable (glycolide: trimethylene carbonate) copolymer Native collagen ingrowth Fully resorbable in 6 months

26. So Which One is Best? Complex decision with no clear answer Type of procedure being done Clinical situation Desired handling characteristics Products available at your institution Cost of the product

27. UCSD expierience Retrospective review of a prospectively collected database Inclusion: Ventral hernia operated upon with the goal to restore native anatomy with investigation of a novel bio absorbable buttress

28. Demographics

29. Operative Intervention

30. Wound Class

31. Reconstruction Technique

32. Mesh Placement

33. LOS and Complications

34. EO to EO onlay Reinforcement

35. Case Examples Infected crosslinked biologic mesh and 8 months post op BIOA EO to EO after complete components

36. Case Examples Infected synthetic mesh and 9 months post op BIOA EO to EO after anterior sheath release

37. Pet CT 3 months, anterior onlay

38. Case Examples Post operative infected seroma (proteus/enterococcus) day 15, treated with IR drainage and 8 months post op BIOA EO to EO after complete components

39. Case Examples 54 year old mail with large defect and infected mesh

41. Completed Components

42. Large Sheet Anterior Application

43. Complications Flap Necrosis Both identifiable at 1 week Both required intraoperative debridement and vac placement Pt 1: 66 yo female, bmi 30, 180 cm defect, repair 6, panniculectomy, onlay Bio-A, 1 year fu doing well Pt 2: 66 yo female, bmi 26, 6 cm defect, repair 3, panniculectomy, onlay Bio-A, 50 days post op, scheduled for scar revision

44. Tracheostomy 60 yo female with hx of repair x 7, infected biologic, and 900 sq cm defect. Release of Anterior and posterior sheath Onaly Bio A Butress ICU Paralytics for high Compartment pressures Trach day 8 Decannulated and discharged postoperative day 15 7 months out and doing well.

45. Seromas 3 total 1 did not require drainage and spontaneously resolved 1 drained in office x 1 1 Infected requiring IR drainage Initial operation was MRSA mesh excision

46. Conclusions There are many materials from which to choose from; surgeon knowledge of particular characteristics is key New classes of mesh may provide cost and patient advantage Bio Absorbable matrices are proving successful as a supportive adjuncts to complex abdominal wall restoration.

47. Thanks