Materials for abdominal wall reconstruction:

from chemistry to biology

Domenico D’UGOFull Professor of Surgery

Catholic University - Rome

History of Prosthetic Hernia Repair

Direct Direct approximationapproximation

Prostethic repair

Autogenous Graft

Fascia Lata

Metals

Stainless steel

Silver

Tantalum

1910 1930

Mesh

Syntethic

filaments of

carbon polymer

late 50’s

PROSTHETIC

TENSION-FREE REPAIR

Sutured tissue strength

late 70’s 2000’sOverwhelming evidence of mesh superiority1900

Mesh concept

Monofilamented Polypropylene

(heavyweight)

Marlex ®

Monofilamented Polypropylene

(midweight)

Prolene Soft ® Parietene ®

Polysoft ® Evolution ®

Polypropylene + Poliglecaprone or Polilactic acid

(lightweight / partially absorbable)

Ultrapro ®

Evolution of prosthetic materials

Inertness

Permanence

Rapid fibrinous fixation

Ideal prosthesisIdeal prosthesis Amid, 1995Amid, 1995

Host tissue incorporation

1.

2.

3.

4.

Foreign body reaction

Fibroblast ingrowth

Heavyweight Marlex ® 90 - 95 0.6 - 0.9

Texture Type Examples Weight(g/m2)

Pore size (mm)

MidweightProlene Soft ®

Parietene ® Polysoft ® Evolution ®

45 - 75 1.5 - 3.0

Lightweightpartially absorbable

Ultrapro ® 28 - 40 2.0 - 4.0

Evolution of prosthetic materials

Cobb WS et al. J Surg Res, 2006

Physical features A new concept of “host reaction”

Cobb WS et al. J Surg Res, 2006

Physical features A new concept of “host reaction”

HeavyweightMidweightLightweight Native fascia

Cobb WS et al., 2006

Physical featuresPhysical features

Burst loadBurst load

Ideal Ideal syntheticsynthetic mesh: Has it arrived? mesh: Has it arrived?

No contraction

Durable tensile strength

Hypoallergenic

Resistance to infection

1.

2.

3.

4.

Effective tissue ingrowth (without excessive inflammation or foreign body reaction)

5.

6. Cost effectiveness

Novitsky YW, SAGES 2008

Biocompatibility

Proceed ®

New solutions for biocompatibilityNew solutions for biocompatibility Prolene Soft + PDS + Oxidized Regenerated CelluloseProlene Soft + PDS + Oxidized Regenerated Cellulose

Double layer biocompatible meshesDouble layer biocompatible meshes

Many products, many manufacturersMany products, many manufacturers

Mesh Manufacturer Permanent Barrier

Parietex CompositeTM Covidien Polyester Atelocollagen Type 1, polyethylene

glycol, glycerol

C-QurTM Atrium PP Omega-3 fatty acid

PROCEEDTM Ethicon PP Oxygenated regenerated cellulose +

polydioxanone (PDS)

SeprameshTM Davol PP Seprafilm

DualmeshTM Gore PTFE -

Surgimesh WNTM Aspide PP Silicone

New solutions for biocompatibilityNew solutions for biocompatibility

Polytetrafluoroethylene (PTFE)Polytetrafluoroethylene (PTFE)

Gore Infinit Mesh ®

reconstructiondegradation

STRE

NG

TH

TIME

Bio-ImplantNative Fascia Burst Strenght

Ideal prosthesisIdeal prosthesis

Next level biomaterialsNext level biomaterials

Ideal prosthesisIdeal prosthesis

Next level biomaterialsNext level biomaterials

2000’s1980

138 PubMed items(1980-2000)

272 PubMed items(2000-2008)

History of Biomaterials

Gaertner B et al, J Gastrointest Surg 2007

Why use Biomaterials ?

“Ideal” for a contaminated field (infection “tolerant”)

Vascular ingrowth allows for clearance of bacteria

…for who ?

Infected/exposed mesh

Complex recurrence

Gaertner B et al, J Gastrointest Surg 2007

BiomaterialsBiomaterials Physical features

Biomaterials PTFE Polypropylene

B = Biomaterials P = PTFE F = Fascia

B-F P-F B-B F-F

BiomaterialsBiomaterials

Many products, many manufacturersMany products, many manufacturers

Biomesh Type Products, Manufacturers

Human acellular dermis AlloDerm®, LifeCell

Flex HDTM, J&J

AlloMaxTM, Davol

Xenogenic acellular dermis PermacolTM (porcine), Tissue Science Laboratories

SurgiMendTM (bovine,calf), TEI Biosciences

CollaMendTM (porcine), Davol

XenMatriX® (porcine), Brennen Medical LLC; Brennenmed.com

StratticeTM, LifeCell

Porcine small intestine submucosa Surgisis®, Cook Medical

FortaGen®, Organogenesis

Bovine pericardium Peri-Guard® and Veritas®, Synovis Surgical Innovations

Alloderm ®

BiomaterialsBiomaterials

Human Cadaver-DerivedHuman Cadaver-Derived

Più pubblicato, più costoso, di più piccole dimensioni

Veritas ®

BiomaterialsBiomaterials

Bovine-DerivedBovine-Derived

Permacol ®

BiomaterialsBiomaterials

Porcine-DerivedPorcine-Derived

Surgisis ®

LiteratureLiterature

Minimal long-term follow-up

True prospective data are scarce

No published clinical data for many of the biologics on the market

Nanotechnology

Future perspectivesFuture perspectives

Tissue EngineeringTissue Engineering

Cell adhesion on biomimetic scaffold“Evolution offer

maximum mechanical integrity and stability

and mimes the mechanical features

of the abdominal wall”

Ciardelli G, 2008Dpt. of Mechanics - Industrial Bioengineering

Polytechnic University of Turin

Inert, Inactive, Permanent Materials

Viable, Cellular, Differentiable Materials

Whole Organ Regenerates

Bioactive, Conductive, Remodelable Materials

Biocomplexity

Biocomplexity