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INGUINAL HERNIA REPAIR THE CASE OF ABSORBABLE MESH

INGUINAL HERNIA REPAIR THE CASE OF ABSORBABLE MESH. Salvador Morales-Conde Associate Professor Departament of Surgery. University of Sevilla University Hospital “Virgen Macarena” Spain. INGUINAL HERNIAS. EVOLUTION. NO MESH. MESH. MESH AND PLUG. (lichtenstein). tension. No tension.

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INGUINAL HERNIA REPAIR THE CASE OF ABSORBABLE MESH

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  1. INGUINAL HERNIA REPAIR THE CASE OF ABSORBABLE MESH Salvador Morales-Conde Associate Professor Departament of Surgery. University of Sevilla University Hospital “Virgen Macarena” Spain

  2. INGUINAL HERNIAS EVOLUTION NO MESH MESH MESH AND PLUG (lichtenstein) tension No tension Less tension recurrences lower recurrences Same recurrences Less pain Less pain pain PROBLEMS RELATED TO THE PLUG

  3. INGUINAL HERNIAS EVOLUTION MESH AND PLUG Less tension Same recurrences Less pain PROBLEMS RELATED TO THE PLUG

  4. NON-ABSORBABLE PLUG ABSORBABLE PLUG INGUINAL HERNIAS EVOLUTION MESH AND PLUG Less tension PGA/TMC POLYPROPYLENE Same recurrences Less pain PROBLEMS RELATED TO THE PLUG

  5. A Bioabsorbable hernia plug should provide the benefits of reduction of the hernia, while the onlay mesh incorporation occurs, without the long-term complications associated with permanent polypropylene plugs.

  6. ABSORBABLE vs NON-ABSORBABLE PLUGS FOR INGUINAL HERNIAS. EXPERIMENTAL STUDY Salvador Morales-Conde Associate Professor Departament of Surgery. University of Sevilla University Hospital “Virgen Macarena” Spain

  7. NON-ABSORBABLE PLUG INGUINAL HERNIAS EXPERIMENTAL STUDY polypropylene

  8. ABSORBABLE PLUG INGUINAL HERNIAS EXPERIMENTAL STUDY PGA/TMC

  9. pig METHOD general anesthesia operating room

  10. pig METHOD bilateral inguinal incision general anesthesia Identificaction inguinal ring operating room

  11. pig METHOD bilateral inguinal incision plug general anesthesia Identificaction inguinal ring operating room Absorbable

  12. METHOD plug Non-Absorbable

  13. METHOD plug Absorbable

  14. METHOD plug Absorbable

  15. METHOD plug Absorbable

  16. METHOD plug Non-Absorbable Absorbable

  17. pigs 6 pigs 6 pigs 6 months 3 months explants METHOD EVALUATION OF THE RESULTS

  18. RESULTS

  19. RESULTS - II MACROSCOPIC EVALUATION 4/10 CASES (40%) (polypropylene) ADHESIONS TO THE BLADDER 0/10 CASES (0%) (PGA/TMC)

  20. RESULTS - II MACROSCOPIC EVALUATION

  21. RESULTS - II MACROSCOPIC EVALUATION 4/10 CASES (40%) (polypropylene) INGUINAL RING WAS OPEN 0/10 CASES (0%) (PGA/TMC)

  22. RESULTS - II MACROSCOPIC EVALUATION

  23. RESULTS - II MACROSCOPIC EVALUATION

  24. RESULTS - II MACROSCOPIC EVALUATION

  25. RESULTS - II MACROSCOPIC EVALUATION

  26. 6 month retrieval Fixed in 10% neutral buffered formalin, serial sections black arrow - GORE plug yellow arrow - inguinal canal GORE Plug Polypropylene black arrow - polypropylene plug red arrow - peritoneal surface yellow arrow - inguinal canal

  27. RESULTS - III HISTOLOGICAL ANALYSIS

  28. RESULTS - III COLLAGEN/MATERIAL

  29. GORE Plug 3 months 6 months Polarized light microscopy illustrates loss of crystallinity as the GORE plug bioabsorbs. The polypropylene fibers (black arrows) are much larger 10x Polypropylene

  30. Total area collagen material Polypropylene plug

  31. Total Area collagen material GORE Hernia Plug

  32. RESULTS - III MICROSCOPIC EVALUATION Image Analysis % colagen

  33. RESULTS - III MICROSCOPIC EVALUATION Image Analysis % material

  34. RESULTS - III TYPE OF CELLS

  35. 6 month tissue response GORE hernia plug - arrows indicate bioabsorbing fragments of PGA/TMC - predominantly macrophages, foreign body giant cells and fibroblasts. Blood vessels are observed within the PGA/TMC material H&E 25x Polypropylene plug (P), encapsulated by inflammatory cells - predominantly macrophages, foreign body giant cells, fibroblasts and lymphocytes P P H&E 25x

  36. RESULTS - III HISTOLOGICAL EVALUATION Inflammation

  37. RESULTS - III EROSION OF STRUCTURTES

  38. GORE Plug 6 months black arrow illustrates spermatic cord and the red arrow illustrates remnants of resorbable plug Milligan’s trichrome 2.5x Polypropylene Black arrow illustrates spermatic cord, red arrow illustrates polypropylene fibers. Plug is adhered to the cord blue color - collagen

  39. 3 month tissue response Adhesion to the cord structure (black arrow) by the polypropylene plug (PP), with compression of the canal. PP Milligan’s trichrome 10x The advancing fibrosis from the polypropylene plug (PP) entraps (black arrows) the nerve fibers. The stiff polypropylene fibers impinge (red arrow) on the nerve bundle. PP PP n n Milligan’s trichrome 25x

  40. Polypropylene plug P 3 months 6 months P P yellow arrow - erosion into blood vessels with hematoma into surrounding soft tissue black arrow - wall of vein

  41. CONCLUSIONS

  42. WITH POLYPROPYLENE THERE IS a) erosion into peritoneum, muscle, blood vessels and adipose tissues, b) adhesions to cord structures and bladder and c) impingement and entrapment of nerve fibers HISTOLOGICAL FINDINGS

  43. material present • persistent inflammation • persistent foreign body response • protrudes through inguinal canal, with erosion into adjacent structures (nerve, muscle, cord,…) • space filled with collagen and foreign body • material resorbs • inflammation subsides • foreign body response subsides • maintains tissue architecture • space filled with collagen HISTOLOGICAL FINDINGS PGA/TMC vs Polypropylene

  44. PGA/TMC plugs restore posterior inguinal wall while closing the inguinal canal, by subtituting its material for collagen and new tissue Polypropylene plugs mantain open the inguinal canal in most cases, exposing the plug to the abdominal cavity creating adhesions to different structures MACROSCOPIC FINDINGS

  45. Based on this study the PGA/TMC PLUG WILL PLAY AN IMPORTANT ROLE IN INGUINAL HERNIA REPAIR IN THE NEAR FUTURE CLINICAL APLICATION

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