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Restoring Abdominal Wall Function: The Holy Grail?

Restoring Abdominal Wall Function: The Holy Grail?. Brian Jacob MD FACS. Disclosures. Consultant / Teaching/Research Grant: Covidien. Principles for the repair of incisional ventral hernia. Reapproximate the rectus muscles along the midline for ventral hernia repairs to the extent possible

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Restoring Abdominal Wall Function: The Holy Grail?

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  1. Restoring Abdominal Wall Function: The Holy Grail? Brian Jacob MD FACS

  2. Disclosures • Consultant / Teaching/Research Grant: Covidien

  3. Principles for the repair of incisionalventral hernia • Reapproximate the rectus muscles along the midline for ventral hernia repairs to the extent possible • Attempt to restore the functional, innervated abdominal wall and create a true dynamic repair without undue tension. • The abdominal wall is a load-bearing structure and reacts dynamically to internal and external forces • (hence the need for a ‘‘dynamic repair’’) Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair The Ventral Hernia Working Group: Karl Breuing, MD, Charles E. Butler, MD Stephen Ferzoco, MD, Michael Franz, MD, Charles S. Hultman, MD, MBA, Joshua F. Kilbridge, Michael Rosen, MD,Ronald P. Silverman, MD, , and Daniel Vargo, MD Surgery: 148, 544-558, 2010

  4. “ ” J Gastrointest Surg. 2010. 14:175

  5. Abdominal Wall Hernia Repair: typical outcome measures • Intraop morbidity • Recurrence rates • Infection rates • Acute and Chronic Pain • Seroma / Hematoma • Ileus and obstruction • Cost

  6. Laparoscopic Ventral Hernia Repair: 9 Year Experience in 850 Patients Heniford BT, Park A, Ramshaw B, Voeller G. Ann Surg, 2003 Complications

  7. Abdominal Wall Hernia Repair: typical patient goals • Reduction of strangulation risk • Resolution of an unsightly bulge • Relief from discomfort / pain • Healing of ulcerated or excess skin • Improvement of abdominal wall function by restoration of abdominal domain?

  8. “Abdominal Wall Function”:what is it and why? • Patient – related endpoint • Coordinated ability, and abdominal wall strength, used to perform all routine activities • Includes breathing, lifting, coughing, bending, working, exercise, etc • Quantify results of the many patient -, technique -, and material – specific variables that can modify hernia outcomes

  9. “Abdominal Wall Function”:why not? • Abdominal Wall Function • Poorly defined • Rarely used • Difficult to assess objectively • Lack assessment tool • May not be relevant

  10. April 2009 SP Bowers

  11. New terms • Functional abdominal wall • Dynamic abdominal wall

  12. What is a dynamic abdominal wall?

  13. Definition of dynamic abd wall

  14. Measuring abdominal wall function: not actually such a new concept • Between 1991 and 1999, 235 patients received polypropylene meshes in a sublay position for incisional hernia repair: • 115 patients were implanted with a Marlex heavy-weight mesh (Mhw mesh), • 37 patients with an Atrium heavy-weight mesh (Ahw mesh) and • 83 with a Vypro low-weight mesh (Vlw mesh). • Measured abdominal wall function with 3D stereography • “Data suggested that the use of low-weight large-pore meshes is advantageous for abdominal wall function.” Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Welty G, Klinge U, Klostemalfen B etal. 2001. Hernia.

  15. Current standard measure in 2012:

  16. What is an adynamic(or poorly functioning) abdominal wall? Using the term “abdominal wall function” as an outcome metric has yet to be accepted

  17. What we don’t want: • Bowel can adhere to polyester surface • Inadequate overlap • Inadequate fixation

  18. What we don’t want

  19. What we don’t want

  20. Abdominal Wall Function:Not just about closing the defect

  21. Pathophysiology

  22. Wound Healing: Midline or Defect Closure Mesh / Tissue Interface “The main challenge for surgery is to find the best technique in a given situation (patient, hernia, anatomy), which provides the best overlap…” Uwe Klinge, Aachen, Germany 2011

  23. Matrix deposition: the fibroblast Collagen FIBRILS then bond to form FIBERS

  24. Type I / III Collagen Ratio • Type I: tensile strength (mature collagen) • Type III: thinner diameter, aka immature collagen • Quality of a wound is based on a high type I/III ratio • Reduced ratio (higher proportion of type III) • Reduced stability of connective tissue Junge K, Klinge U, Rosch R etal. (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prosthesis

  25. Type I / III • N = 78; 50 M 28 F • Primary inguinal 25 • Recurrent inguinal 18 • Primary incisional 11 • Recurrent incisional 24 Junge K, Klinge U, Rosch R etal. (2004) Decreased collagen type I/III ratio in patiens with recurring hernia after implantation of alloplastic prosthesis

  26. Type I / III ratio and indication for mesh removal N= 78 explants N=46 N=18 N=14 Junge K, Klinge U, Rosch R etal. (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prosthesis

  27. Type I / III Collagen Ratio • Reduced in patients with recurrent hernias • Provides new possibilities for future research • If I/III could be optimized, perhaps we would create better abdominal wall function Junge K, Klinge U, Rosch R etal. (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prosthesis

  28. N= 24 rabbits • Onlay • Anterior fascia and subcutanous tissue • Sublay (Underlay) • Posterior fascia and rectus • Type I/III ratio assessed • BETTER quality in Sublay position for both mesh materials Hernia. 2010

  29. Poor ingrowth = expensive hernia sac Video clip of shrunken mesh

  30. Poor abdominal wall function

  31. Collagen Fiber Crosslinking:Wound Strength Increases • Stabilizes the collagen fibers • Resists collagen breakdown by enzymes • Reaches up to 90% strength • Cellular turnover stops Wound Strength 7 14 21 28 35 42 49 56 63 DAYS

  32. Material are not all equal • Ongoing inflammatory processes can last at least a year.  • This poor biocompatibility may lead to poor mesh compliance.  Ki-67 Novitsky YW, Cristiano JA, Harrell AG, Newcomb W, Norton JH, Kercher KW, Heniford BT. (2008) Immunohistochemical analysis of host reaction to heavyweight-, reduced-weight, and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations.  Surg Endosc. 22: 1070-76

  33. Protein coagulum Platelet adherence Chemoattractant release PMN influx Macrophage, fibroblasts Collagen secretion Connective tissue 80% original strength Why does the material matter? Tissue Ingrowth

  34. Mesh after IPOM fixation

  35. ? Leads to better abdominal wall function ?

  36. Rosen et al. JACS 2007

  37. Surgeons can use pathophysiology to reduce the risk of recurrences • Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrences • Bridged mesh does not get incorporated • Wide Overlap in some situations may not be enough Junge K, Klinge U, Rosch R etal. (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prosthesis Kinge U, Prescher A, Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects. Chirurg 293.

  38. Hypothetical defect 10 cm 5cm x 10cm defect [50 cm2]

  39. Mesh with 5cm overlap (20 x 15)

  40. 20 x 15 mesh (5cm overlap) [mesh = 300 cm2]

  41. Ingrowth = 250 cm 2 (300-50)

  42. Closing the defect increases the surface area for tissue ingrowth By adding 50 cm2 of ingrowth, surface area is increased by 20% (50/250)

  43. LVHR: IPOM bridged – wide overlap may not be enough

  44. “Minilaparotomy” to close defect during LVHR

  45. Current Trends • Evaluating defect size • < 5cm • 5-10cm • >10cm • Using information about the patient to make preoperative AND intraoperative decisions on technique and materials • Not all defects should be treated with a standard laparoscopic IPOM

  46. Outcomes and defect size • Multivariate analysis of 310 consecutive patients with incisional hernias larger than 5cm • Overall recurrence rate was 6% after an average follow-up of 60 months. • A defect size greater than 10 cm is strongly predictive of recurrence after laparoscopic incisional hernia repair • Conclusion: • Defects larger than 10 cm may require a modified laparoscopic technique to increase the mesh / tissue interface Moreno-Egea A, Carrillo-Alcaraz A, Aguayo-Albasini JL. Is the outcome of laparoscopic incisional hernia repair affected by defect size? A prospective study. Am J Surg. 2012;203:87-94

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