Trans‐Vaginal Mesh Revision: A Comprehensive Review on Etiologies and Management Strategies with Emphasis on Postoperative Pain Outcomes

The use of polypropylene mesh to augment surgery aimed to correct pelvic organ prolapse and stress urinary incontinence stems largely from the high recurrence rates of native tissue repairs. While objective outcomes were improved, mesh related complications began to emerge that included mesh exposures, extrusions, dyspareunia and other pain issues. However, the indication for and benefit of surgical intervention(s) to address these complications are lacking. We aim to review to current literature regarding postoperative pain outcomes following vaginal mesh revision. Evidence based literature indicates that mesh complications are not rare and surgery that aims to address them generally have an overall benefit. However, studies available are generally small case series of a retrospective nature with short follow up. Some themes are evident: there is a long lag period from mesh insertion to removal; there is a lack of a true denominator of total mesh insertions making it hard to gauge the real scope of the problem; mesh material found not along the expected trocar path or coursing close to neurovascular structures thus raises the possibility of technical errors during insertion. Transvaginal mesh revision(s) for mesh complications generally have a positive effect on pain outcomes, but better controlled studies are needed. Additionally, since technical issues may be a factor in the development of mesh complications, rigorous training and sufficient surgical case volume should be emphasized.     

Prevention of Parastomal Hernia by Placement of a Polypropylene Mesh at the Primary Operation

Introduction Parastomal hernias occur frequently after placement of a permanent colostomy. Preliminary reports have shown a beneficial effect of placing a mesh at the primary operation to prevent the formation of a parastomal hernia. We studied the safety and prophylactic effect of placing a newly designed polypropylene mesh in an onlay position at the primary operation. Methods This was a prospective study that included 25 patients scheduled for elective colorectal surgery. Risk factors for development of parastomal hernia were recorded before surgery. A prepared lasercut polypropylene mesh with six “arms” was placed in an onlay position. Immediate and long-term complications were evaluated by an experienced stoma nurse and a surgeon. Abdominal ultrasound was performed at 6 and 12 months follow-up. Parastomal hernia was defined as both clinical and ultrasonographic signs of protrusion in the vicinity of the stoma. Results The median follow-up time was 12 (range, 2–26) months. One patient died eight days after surgery. Of the 24 patients included, none had infections or immediate complications after surgery. Two patients had minor complications necessitating a local revision of one of the mesh arms. No other long-term complication was found. Two patients had signs of parastomal hernia at 6 and 12 months follow-up, respectively. Conclusions Placement of a polypropylene mesh in an onlay position at the primary operation is a safe procedure and probably results in a low risk of parastomal hernia occurrence. The mesh materials were provided free of charge by StomaMesh A/S, Svendborg, Denmark. Presented at the meeting of the Danish Surgical Society, Copenhagen, Denmark, April 7 and 8, 2005.     

Ellipsoid bounding region-based ChainMail algorithm for soft tissue deformation in surgical simulation

Real-time modelling of force interaction with soft tissues is of great importance for interactive surgical simulation. This paper presents a new ChainMail algorithm for real-time modelling of soft tissue deformation under force interaction. Unlike traditional ChainMails using a box-shaped bounding region, the proposed method defines an ellipsoid-shaped bounding region according to the concept of principal strains in continuum mechanics to control the movement of chain elements. Based on this ellipsoid-shaped bounding region, new position adjustment rules are developed and further integrated with temporal-domain model dynamics for dynamic simulation of soft tissue deformation. Haptic interaction with soft tissues is achieved via force input, soft tissue deformation, and force feedback. Experimental results demonstrate that the proposed ChainMail can simulate soft tissue mechanical behaviours, accommodate isotropic and homogeneous, anisotropic and heterogeneous materials, and handle large deformation. The proposed ChainMail also requires only small computational time, capable of achieving real-time computational performance.     

Lessons Learned from Mesh Litigation for Prolapse and Incontinence

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can cause significant impairment in quality of life and lead many women to seek surgical correction. These procedures are often performed using polypropylene mesh. The Food and Drug Administration (FDA) issued a Public Health Notification to inform patients of adverse events related to the use of mesh placed in these repairs. Since this time, there have been almost 50,000 legal proceedings related to complications of polypropylene mesh in the urogynecology setting. Currently, the FDA is conducting further studies to evaluate the safety and efficacy of polypropylene mesh, but it is still available for use in the repair of SUI and POP. Thus, patients should be carefully selected and counseled appropriately regarding conservative management options and alternative surgical therapies prior to mesh placement. As a result of the FDA recommendations, researchers are currently trying to develop a treatment alternative to mesh.     

Transperineal repair of recurrent rectocele using polypropylene mesh

The aim of this study was to review our experience in patients with recurrent rectoceles using polypropylene mesh for operative repair. The study comprised six women, median age 56 (range 46–68) years. Patients were selected for recurrent rectocele mesh repair between 1996–1998. The rectovaginal septum was repaired with polypropylene mesh (ATRIUM) through a perineal approach. The median follow-up period was 11 months. All of the six women achieved successful evacuation after surgery without the need for vaginal digitation and without recurrences. Five (83%) were very satisfied. This technique is bloodless, easy to perform, and effective as far as relief of symptoms. The time required for repair of the recurrent rectocele is approximately 8 min. In conclusion, operative mesh repair of the rectovaginal septum removes the need for vaginal digitation in all women with recurrent rectoceles and appears to have advantages over the transrectal, vaginal or other techniques and seems the method of choice for the repair of recurrent rectocele. Received: 16 August 1998 / Accepted in revised form: 18 November 1998     

Softening Effects in Biological Tissues and NiTi Knitwear during Cyclic Loading

Samples of skin, tendons, muscles, and knitwear composed of NiTi wire are studied by uniaxial cyclic tension and stretching to rupture. The metal knitted mesh behaves similar to a superelastic material when stretched, similar to soft biological tissues. The superelasticity effect was found in NiTi wire, but not in the mesh composed of it. A softening effect similar to biological tissues is observed during the cyclic stretching of the mesh. The mechanical behavior of the NiTi mesh is similar to the biomechanical behavior of biological tissues. The discovered superelastic effects allow developing criteria for the selection and evaluation of mesh materials composed of titanium nickelide for soft tissue reconstructive surgery.     

Evaluation of postoperative adhesions in rats submitted to peritoneostomy with polypropylene mesh associated to nitrofurazone

BACKGROUND: Peritoneal injuries, common in per and postoperative, lead to the formation of adhesions. The use of polypropylene mesh increases the postoperative adhesions incidence. Based on the fact of nitrofurazone accelerates the healing process, a possible action on peritoneal adhesions was cogitated. AIM: To evaluate postoperative adhesions in rats submitted to peritoneostomy with polypropylene mesh fixation associated to nitrofurazone. METHODS: Thirty-three Wistar rats were separated into three groups of eleven animals each one. In group I was performed the laparotomy with exposition of the abdominal cavity followed by the laparotomy suture; in group II was performed the resection of a abdominal wall fragment followed by polypropylene mesh fixation on the gap and in group III was performed the same done in group II, but the mesh was previously impregnated with nitrofurazone. After 45 days the animals were sacrificed and necropsied. RESULTS: Seven animals of group I had no adhesions (degree 0), two had degree 1 adhesions and two had degree 2. In group II, one animal was classificated as degree 3 and ten as degree 4. In group III, one had degree 0, eight had degree 3 and one had degree 4 (one animal died before 45 days). All adhesions found involved the abdominal wall; ten animals had adhesions involving only omentum (group I = 4; group II = 1 and group III = 5); eleven animals had adhesions involving omentum, small bowel and other abdominal organs (group II = 10; group III = 1); three animals had adhesions involving only small bowel, all belonged to group III. Fourteen animals had adhesions involving small bowel, of these ten belonged to group II (nine with more than one fixation point) and four belonged to group III (three with just one fixation point). CONCLUSION: The association of nitrofurazone with polypropylene mesh did not reduce significantly the postoperative adhesions incidence in rats, but reduced the intensity and severity of these adhesions.     

开放式肠造口旁疝原位无张力修补术临床效果研究

目的探讨肠造口旁疝形成原因及开放式原位无张力疝补片修补术的临床应用。方法对2002年8月—2009年10月间共38例肠造口旁疝患者行开放式原位补片无张力疝修补术进行回顾分析。结果 38例手术均顺利完成,术后住院时间10~16d,无切口感染、皮下积液、肠坏死、肠梗阻等并发症,术后远期复发1例。结论腹外斜肌腱膜的破坏是造成造口旁疝形成的原因,利用聚丙烯单丝Prolene网片行开放式肠造口旁疝原位无张力修补术简单、有效,值得推广。     

Improving the reinforcement of parastomal tissues with marlex® mesh

PURPOSE: Parastomal hernia formation commonly complicates permanent stomas and represents a significant and frequently recurrent management problem, regardless of the method of repair. Prosthetic material reinforcement of parastomal tissues offers the best results. However, problems with unravelling of mesh fibers along cut margins leading to aperture enlargement and hernia recurrence may occur. Raised intra-abdominal pressure in the early postoperative period before incorporation of the mesh into surrounding tissues may result in hernia formation if the aperture size in the mesh increases. METHODS: Assessment of the physical properties of Marlex mesh was performed in a materials testing laboratory, using standardized tests to simulate the stresses imposed on in situ mesh. RESULTS: Holes cut in Marlex mesh were found to enlarge and distort at loads simulating intra-abdominal pressure changes. Reinforcement with a polypropylene pursestring suture was found to stabilize the periaperture mesh fibers and maintain the original area throughout tensions at least double maximal intra-abdominal pressures. Distensibility of intact sheets of mesh was found to vary by up to 100 percent, depending on the direction of the applied tension, and thus, mesh orientation in hernia repair has major implications. CONCLUSION: We propose that if mesh is used to reinforce abdominal wall tissues and is cut or fashioned to size, then the cut margins must be reinforced if the intended dimensions and functional integrity of the mesh are to be maintained.     

Correction of rectal procidentia by use of polypropylene mesh (Marlex)

Summary and Conclusions A simple rapid method for the correction of rectal procidentia by the use of polypropylene mesh (Marlex) is described. The excellent results of this procedure make it preferable to any other. The material used gives the impression that an external sphincter is present immediately postoperatively. It is hoped that this technic will permit treatment of the elderly patient without the need for extensive surgical procedures.     

Polyacylurethanes as Novel Degradable Cell Carrier Materials for Tissue Engineering

Polycaprolactone (PCL) polyester and segmented aliphatic polyester urethanes based on PCL soft segment have been thoroughly investigated as biodegradable scaffolds for tissue engineering. Although proven beneficial as long term implants, these materials degrade very slowly and are therefore not suitable in applications in which scaffold support is needed for a shorter time. A recently developed class of polyacylurethanes (PAUs) is expected to fulfill such requirements. Our aim was to assess in vitro the degradation of PAUs and evaluate their suitability as temporary scaffold materials to support soft tissue repair. With both a mass loss of 2.5–3.0% and a decrease in molar mass of approx. 35% over a period of 80 days, PAUs were shown to degrade via both bulk and surface erosion mechanisms. Fourier Transform Infra Red (FTIR) spectroscopy was successfully applied to study the extent of PAUs microphase separation during in vitro degradation. The microphase separated morphology of PAU1000 (molar mass of the oligocaprolactone soft segment = 1000 g/mol) provided this polymer with mechano-physical characteristics that would render it a suitable material for constructs and devices. PAU1000 exhibited excellent haemocompatibility in vitro. In addition, PAU1000 supported both adhesion and proliferation of vascular endothelial cells and this could be further enhanced by pre-coating of PAU1000 with fibronectin (Fn). The contact angle of PAU1000 decreased both with in vitro degradation and by incubation in biological fluids. In endothelial cell culture medium the contact angle reached 60°, which is optimal for cell adhesion. Taken together, these results support the application of PAU1000 in the field of soft tissue repair as a temporary degradable scaffold.     

Repair of parastomal hernia with the use of polypropylene mesh extraperitoneally

Parastomal hernia is the most frequent complication of colostomy. Many surgical techniques have been postulated and prosthetic surgery seems to represents the first-choice treatment. The aim of this study is to report the surgical treatment of 4 patients that developed parastomal hernia, 3-10 months after abdominoperineal excision of the rectum and permanent sigmoidostomy due to carcinoma of the rectum. The repair was made with the use of polypropylene mesh extraperitoneally. One case of limited skin necrosis occurred without any serious consequences. No recurrence has been recorded among the patients, up to this day (follow-up period: 36 months). In conclusion, the suturing of fascial defect and the use of polypropylene mesh extraperitoneally is effective in the treatment of parastomal hernia.     

Imaging of osteomyelitis and musculoskeletal soft tissue infections: current concepts

The diagnostic imaging of osteomyelitis can require the confluence of multiple imaging technologies. Conventional radiography should always be the first imaging modality. Sonography is most useful in the diagnosis of fluid collections in a joint or in the extra-articular soft tissues but is not useful for evaluating presence of osseous infection. CT scan can be a useful method to detect early osseous erosion and to document the presence of sequestrum, foreign body, or gas formation but generally is less sensitive than other modalities for the detection of bone infection. Nuclear medicine and MRI are the most sensitive and most specific imaging modalities for the detection of osteomyelitis. Nuclear medicine is particularly useful in identifying multifocal involvement, which is common in children. MRI provides more accurate information of the local extent of the soft tissues and possible soft tissue abscess in patients with musculoskeletal infection.     

Application of Tissue Engineering to Pelvic Organ Prolapse and Stress Urinary Incontinence

Synthetic or biological materials can be used for the surgical repair of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). While non‐degradable synthetic mesh has a low failure rate, it is prone to complications such as infection and erosion, particularly in the urological/gynecological setting when subject to chronic influences of gravity and intermittent, repetitive strain. Biological materials have lower complication rates, although allografts and xenografts have a high risk of failure and the theoretical risk of infection. Autografts are used successfully for the treatment of SUI and are not associated with erosion; however, can lead to morbidity at the donor site. Tissue engineering has thus become the focus of interest in recent years as researchers seek an ideal tissue remodeling material for urogynecological repair. Herein, we review the directions of current and future research in this exciting field. Electrospun poly‐L‐lactic acid (PLA) and porcine small intestine submucosa (SIS) are two promising scaffold material candidates. Adipose‐derived stem cells (ADSCs) appear to be a suitable cell type for scaffold seeding, and cells grown on scaffolds when subjected to repetitive biaxial strain show more appropriate biomechanical properties for clinical implantation. After implantation, an appropriate level of acute inflammation is important to precipitate moderate fibrosis and encourage tissue strength. New research directions include the use of bioactive materials containing compounds that may help facilitate integration of the new tissue. More research with longer follow‐up is needed to ascertain the most successful and safe methods and materials for pelvic organ repair and SUI treatment.     

Synthetic sling options for stress urinary incontinence

Various materials have been used in the treatment of stress urinary incontinence. Autologous materials such as muscle and fascia were first used to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. We review the literature and describe different synthetic materials used for slings. We performed a comprehensive review of the literature on synthetic grafts used in slings using MEDLINE and resources cited in those peer-reviewed papers. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and lower complication rates than other mesh types due to their structure and composition. The success of the graft appears to be independent of the placement technique. The ideal graft provides structural integrity and durability with minimal adverse reaction by the host tissue. Certain synthetic grafts used in pubovaginal slings can provide durability with minimal complications.     

The development and potential of acoustic radiation force impulse (ARFI) imaging for carotid artery plaque characterization

Stroke is the third leading cause of death and long-term disability in the USA. Currently, surgical intervention decisions in asymptomatic patients are based upon the degree of carotid artery stenosis. While there is a clear benefit of endarterectomy for patients with severe (> 70%) stenosis, in those with high/moderate (50-69%) stenosis the evidence is less clear. Evidence suggests ischemic stroke is associated less with calcified and fibrous plaques than with those containing softer tissue, especially when accompanied by a thin fibrous cap. A reliable mechanism for the identification of individuals with atherosclerotic plaques which confer the highest risk for stroke is fundamental to the selection of patients for vascular interventions. Acoustic radiation force impulse (ARFI) imaging is a new ultrasonic-based imaging method that characterizes the mechanical properties of tissue by measuring displacement resulting from the application of acoustic radiation force. These displacements provide information about the local stiffness of tissue and can differentiate between soft and hard areas. Because arterial walls, soft tissue, atheromas, and calcifications have a wide range in their stiffness properties, they represent excellent candidates for ARFI imaging. We present information from early phantom experiments and excised human limb studies to in vivo carotid artery scans and provide evidence for the ability of ARFI to provide high-quality images which highlight mechanical differences in tissue stiffness not readily apparent in matched B-mode images. This allows ARFI to identify soft from hard plaques and differentiate characteristics associated with plaque vulnerability or stability.     

The Soft and High Actuation Response of Graphene Oxide/Gelatin Soft Gel

The high actuation response of soft gel from a graphene oxide/gelatin composite was prepared as an alternative material in soft robotics applications. Graphene oxide (GO) was selected as the electroresponsive (ER) particle. GO was synthesized by modifying Hummer’s method at various ratios of graphite (GP) to potassium permanganate (KMnO₄). To study the effect of ER particles on electromechanical properties, GO was blended with gelatin hydrogel (GEL) at various concentrations. The electrical properties of the ER particles (GO and GP) and matrix (GEL) were measured. The capacitance (C), resistance (R), and dielectric constant of the GO/GEL composite were lower than those of the GO particles but higher than those of the GEL and GP/GEL composite at the given number of particles. The effects of external electric field strength and the distance between electrodes on the degree of bending and the dielectrophoresis force (F_d) were investigated. When the external electric field was applied, the composite bent toward electrode, because the electric field polarized the functional group of polymer molecules. Under applied 400 V/mm, the GO/GEL composite (5% w/w) showed the highest deflection angle (θ = 82.88°) and dielectrophoresis force (7.36 N). From the results, we conclude that the GO/GEL composite can be an alternative candidate material for electromechanical actuator applications.     

An experimental assessment of suture techniques using Lapra-ty clips through the laparoscope and a case report: laparoscopic closure using Lapra-ty for a perforation of the sigmoid colon

BACKGROUND/AIMS: As endoscopic procedures become various and complicated, it becomes necessary to develop alternative techniques for tissue suture and ligation. We have developed a new suture technique intracorporeal knotting. METHODOLOGY: An 8-cm suture material having a knot on the other side of a needle, was used in laparoscopic surgery. Furthermore, a 5-mm2 Vicryl mesh was pierced as a buttress. The Lapra-ty was used to secure the tissue. Under laparotomy, the forestomach of a male Donryu rat at 6 weeks of age was incised and sutured with 3-0 Vicryl. 3-0 Vicryl was secured with the knot substitute (group A) or three-throw knot (group B) under Nembutal anesthesia. The animals were sacrificed 7 days after operation. Specimens were taken from the forestomach. Those were fixed with 10% formalin and stained with hematoxylin eosin and Elastica Wangieson methods. The histological findings were compared between group A and group B. A successful laparoscopic closure using Lapra-ty is reported in a patient with a perforation of the sigmoid colon. RESULTS: Microscopically, in this method, neither erosion, ulcer nor microabscess is evidenced. This method may make an intracorporeal knot easy. Also we treated a patient who had a perforation of the sigmoid colon using Lapra-ty. The patient recovered without any trouble. CONCLUSIONS: This method could make ligation technique much easier and the operating time shorter.     

Covered metallic stents in the management of malignant and benign pancreatobiliary strictures

In the endoscopic management of unresectable malignant biliary obstructions by placement of a metallic stent (MS), longer patency and a lower incidence of stent occlusion are desirable goals. With its mesh structure, the uncovered MS (UMS) is occluded mainly by tumor or tissue ingrowth, making it impossible to remove. The covered MS (CMS) was developed to overcome these disadvantages, and was shown to maintain patency longer than the UMS in our randomized study. The most important characteristic of the CMS is that it is removable, allowing it to be used in patients with resectable malignancies and benign strictures. In addition, the drug-eluting CMS provides an additional approach to the treatment of biliary malignancies. The CMS may also change the treatment paradigm for biliary strictures and strictures due to chronic pancreatitis. The CMS is analogous to a large-bore, expandable plastic stent and is effective both as an endoprosthesis and a dilating or anti-cancer device. However, to better understand the utility of these devices, we need to first consider mechanical properties such as radial force (RF, expansion force) and axial force (AF, straightening force). AF is particularly important when developing CMSs because of related complications.     

Synovial sarcoma of the spine in the lumbar vertebral body: A rare case report

Rationale:Synovial sarcoma (SS) is a soft tissue neoplasm that rarely occurs in the vertebral body and should be considered in the differential diagnosis in patients with SS and vertebral lesions. SS often presents as a painless mass in the spine, which may undergo slow enlargement, resulting in sustained symptoms of neurologic deficit and pain. Due to the difficulty in differentiating between SS from other soft tissue tumors and metastatic tumors, careful histological confirmation is required for definite diagnosis. Furthermore, due to its malignancy, the appropriate treatment procedure for SS should be carefully considered.Patient concerns:A 56-year-old female patient had low back pain. Radiological examination revealed bony erosion of the L-2 vertebral body, and no soft tissue mass around the lumbar spine.Diagnosis:Histopathological and immunohistochemical examination revealed SS.Interventions:The initial treatment of posterior laminectomy decompression and percutaneous vertebro plasty (PVP) was performed, however, this initial treatment course was inappropriate, but she eventually underwent L-2 complete resection and internal fixation. After the second surgery, she was treated by external beam radiation therapy.Outcomes:operation radiotherapy was finally performed. No local recurrence in L-2 vertebral body or distant metastasis was found at 1-year follow up postoperation; the neurologic symptom gradually relieved, and no other symptom was noted. And no local recurrence in L-2 vertebral body and distant metastasis was found in 1 year follow up postoperation.Lessons:Solitary spinal SS is extremely rare. Early surgery for total resection and adjuvant radiotherapy/chemotherapy should be emphasized.