A new device for bone anchor fixation in laparoscopic sacrocolpopexy: The Franciscan laparoscopic bone anchor inserter

Background A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed.Methods We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse.Results Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum.Conclusion Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.     

Biological tissue adhesive for mesh-application in pigs: An experimental study

Background Tissue damage during herniotomy may attribute to postoperative complications including chronic pain, bleeding and infection. Thus the aim of this study was to evaluate a due and simple operative procedure with intraperitoneal application of mesh with glue in an experimental model prior to use in humans.Method Laparoscopic insertion of a mesh was performed in three pigs. The meshes were fixed with a collagen glue. The pigs were sacrificed after 8 weeks and macroscopic and microscopic evaluation of the meshes, were performed.Results The intraperitoneal placed meshes did not migrate through the study period, and there was no sign of inflammation in surrounding tissue or adhesions around the meshes.Conclusions If these findings can be applied to human inguinal herniotomy, this may lead to significant fewer complications including development of acute and chronic pain, formation of seroma and infection. Furthermore the operation technique is very simple.     

The susceptibility of prosthetic biomaterials to infection

Background Despite the use of a sterile technique and the administration of prophylactic antibiotics during surgical procedures, mesh infection continues to complicate the use of biomaterials. The purpose of this study was to compare the susceptibility to infection of prosthetic biomaterials in a live-animal model.Methods The following seven prosthetic mesh biomaterials were used in this study. Expanded polytetrafluoroethylene (ePTFE) with silver/chlorhexidine (DM+), ePTFE (DM), porcine intestinal submucosa (S), polypropylene (M), ePTFE/polypropylene (X), hyaluronate/carboxymethylcellulose/polypropylene (SM), and human acellular dermal matrix (A). Lewis rats (n = 108) underwent creation of a single ventral hernia; 105 of them were repaired with a different mesh (2-cm² piece). Twelve pieces of each mesh were inoculated at the time of hernia repair with 10⁸ Staphylococcus aureus (n = 84). Three pieces of each mesh were placed without bacterial inoculation (n = 21). In three animals, no mesh was placed; instead, the peritoneum of the hernia defect was inoculated (n = 3). After 5 days, the animals were killed and the mesh was explanted (peritoneum for the nonmesh control). The mesh was vortex-washed and incubated in tryptic soy broth. Bacterial counts were determined using serial dilutions and spot plates and quantified in colony-forming units (CFU) per square centimeter of mesh present in the vortex wash fluid (wash count) and the soy broth (broth count). Data are presented as the mean log₁₀, with analysis of variance (ANOVA) and Tukey’s test used to determine significance (p < 0.05).Results The DM+ material had no detectable live bacteria in the wash or broth counts in 10 of 12 tested samples (p = 0.05). Of the samples that showed bacterial growth, the peritoneum control group had a lower wash count than A (p = 0.05) and the lowest broth count of all the materials except for DM+ (p = 0.05). In addition, SM had a significantly lower wash count than A (p = 0.05), with no broth count difference. In regard to wash and broth counts, DM, M, X, SM, S, and A were no different (p = NS).Conclusions The DM+ material was the least susceptible to infection. Impregnation with silver/chlorhexidine killed the inoculated bacteria, preventing their proliferation on the mesh surface. Other than DM+, native peritoneal tissue appears to be the least susceptible to infection. Silver/chlorhexidine appears to be an effective bactericidal agent for use with mesh biomaterials.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, CO, USA, 31 March-3 April 2004     

A comparative study of adhesion formation and abdominal wall ingrowth after laparoscopic ventral hernia repair in a porcine model using multiple types of mesh

Background The ideal mesh for laparoscopic ventral hernia repair is not yet identified.Methods We laparoscopically placed polypropylene (PPM), expanded polytetrafluoroethylene (ePTFE), and polyester with antiadhesive collagen layer (PCO) in eight pigs using sutures and tacks for fixation. After 28-day survival, we compared adhesion formation, fibrous ingrowth, and shrinkage among the types of mesh.Results Mean area of adhesions to PCO (8.25%) was less than that to ePTFE (57.14%, p < 0.001) or PPM (79.38%, p < 0.001). Adhesions peel strength was less for PCO (2.3 N) than for PPM (16.1 N, p < 0.001) or ePTFE (8.8 N, p = 0.02). Peel strength of mesh from the abdominal wall was less for ePTFE (1.3 N/cm of mesh width) than for PCO (2.8 N/cm, p = 0.001) or PPM (2.1 N/cm, p = 0.05). ePTFE area (94.4 cm²) was less than that for PCO (118.6 cm², p < 0.001) or PPM (140.7 cm², p < 0.02).Conclusion PCO had fewer and less severe adhesions than ePTFE or PPM while facilitating excellent ingrowth of the adjacent parietal tissue.     

An ambispective observational study in the safety and efficacy of posterior colporrhaphy with composite Vicryl-Prolene mesh

There is increasing evidence to show that the use of surgical meshes reduces recurrence rates of hernia repair and anterior vaginal wall prolapse. The aim of this study was to determine the safety and efficacy of posterior colporrhaphy with mesh in patients with posterior vaginal prolapse. An ambispective observational study involving 90 patients was conducted with retrospective chart review and prospective subjective and objective assessments at the end of a 1-year study period. Apart from 2 of 90 (2.2%) minor hematoma incidents, there was no other major perioperative morbidity. Prevalence of common prolapse complaints of vaginal lump sensation, constipation, defecation difficulty and dyspareunia all improved significantly postoperatively (p<0.001). Surgical correction was achieved in 27 of 31 (83.9%) at 6 months and beyond. There was no mesh infection but minor vaginal mesh protrusion was found in 7 of 90 (7.8%) patients at 6–12 weeks and 4 of 31 (12.9%) patients at 6 months and beyond. All these were treated easily with trimming without the need of mesh removal. We conclude that posterior colporrhaphy with mesh is effective in treating posterior vaginal prolapse in short term.Editorial Comment: This study reflects the authors experience in using a Vicryl-Prolene mesh, Vypro II, for treatment of rectocele in 90 patients. No serious operative or postoperative complications occurred. The most common minor complication was vaginal mesh protrusion, with a 9 of the 90 being found with this problem; all but 1 of these were resolved with a simple clinic procedure. In a group of 31 patients followed for at least 6 months, the authors note a 16% recurrence rate of rectocele. In a questionnaire given after the surgeries, comparing pre-op and post-op symptoms, 63–79% of the respondents felt improved, depending on the symptom. The authors feel that vaginal colporrhaphy with Vicryl-Prolene mesh will prove to be more efficacious than the existing popular approaches, including site-specific defect repair. Clearly, randomized controlled studies with longer follow-up comparing this method with other colporrhaphy techniques will be needed to validate this assumptionAn erratum to this article can be found at     

Single-dose oral ciprofloxacin compared with single-dose intravenous cefazolin for prophylaxis in inguinal hernia repair: a controlled randomized clinical study

The aim of this study was to compare the efficacy of single-dose intravenous cefazolin prophylaxis with single-dose oral ciprofloxacin prophylaxis in patients undergoing tension-free inguinal hernia repair with polypropylene mesh. In a prospective and randomized setting, 395 patients received either a single dose of 500 mg of ciprofloxacin orally, 1--2h before the operation, or a single dose of 1g cefazolin intravenously on induction of anaesthesia. The primary outcome was to determine the wound infection rate within one year. The overall infection among the entire study population was 2% (eight of 395) including 2% (four of 199) of those receiving intravenous cefazolin and 2% (four of 196) of those treated with oral ciprofloxacin. There was no statistically significant difference between groups (P=0.59). All the infections were superficial incisional surgical site infections, and none progressed to a deep infection. Escherichia coli was the most commonly isolated bacterium. None of the infected patients developed recurrence of hernia. The rate of recurrence was 1.3% (five of 395) at one year including 2% (four of 199) of those receiving cefazolin and 0.5% (one of 196) of those receiving ciprofloxacin. Oral ciprofloxacin prophylaxis was found to be an attractive option with its wide antibacterial spectrum, low cost and ease of administration in patients undergoing tension-free inguinal hernia repair with polypropylene mesh.     

Treatment of full-thickness skin defect with concomitant grafting of 6-fold extended mesh auto-skin and allogeneic cultured dermal substitute

The aim of this clinical study was to evaluate an allogeneic cultured dermal substitute (CDS) as a biological dressing for highly extended mesh auto-skin grafting. The subjects were five patients with extensive deep burn wounds. Allogeneic CDS was prepared by seeding fibroblasts on a spongy matrix of hyaluronic acid and atelo-collagen. Six-fold extended auto-skin graft was applied to the debrided wound, on which allogeneic CDS was placed. A conventional ointment-gauze dressing was used to protect the CDS. The CDS was applied repeatedly at intervals of 5-7 days. In all cases, the wounds were closed by successful take of mesh auto-skin graft and prompt epithelization from the grafted skin. The skin on the grafted area had a cicatrix appearance, but was soft and thin, maintaining good quality. The application of 6-fold extended auto-skin graft in conjunction with allogeneic CDS is an effective method for treatment of extensive severe burn wounds.     

Burst strength of laparoscopic and open hernia repair

Background: There are few reports of overall strength of laparoscopic and open incisional hernia repair. Methods: After anesthesia, a 2-inch circular defect was made in the abdominal wall of 28 female swine. Gore-Tex DualMesh Biomaterial (W. L. Gore & Associates, Flagstaff, AZ) was used for all repairs. Sixteen animals underwent open repair and 12 underwent laparoscopic repair. Burst strength was detected within 2 weeks and at 6 weeks by euthanizing the animals and insufflating the abdominal cavity with water while measuring the intraabdominal pressure until it could no longer be pressurized. Results: Three events occurred after insufflation: rupture around patch (R), dissection from insufflation or pressure monitoring sites (D), or rectal prolapse (P). Failure after open early repair occurred at 289 (range 219–388) mmHg with 7-R, 1-P and late 289 (196–343) mmHg with 1-R, 6-P. Failure after laparoscopic early repair occurred at 259 (191–388) mmHg with 4-R, 1-P, 1-D and late 291 (140–330) mmHg with 2-R, 1-P, 3-D. Late groups were less likely to rupture. Conclusion: Both hernia repairs are durable at early and late periods. Tissue ingrowth adds to repair strength. We could not show that one repair was stronger than the other. Nonetheless, laparoscopic repair tended to degrade by dissection, which was our highest pressure event.     

Urethral erosion of tension-free vaginal tape presenting as recurrent stress urinary incontinence

The suburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence. Erosion of the mesh into the urethra is rare, usually presenting with hematuria, pain, voiding dysfunction or urge incontinence. A patient with stress incontinence was treated with a TVT suburethral sling. One month later, symptoms of recurrent stress incontinence developed. Cystourethroscopy revealed urethral mesh erosion. Surgical removal involved cystourethroscopic-assisted transurethral resection of the mesh, followed by vaginal dissection and periurethral withdrawal. Urethral mesh erosion should be considered in a patient who presents with atypical symptoms after being treated with a suburethral sling. It is important to obtain a detailed history and have a high clinical index of suspicion for erosion. Careful and comprehensive urethroscopy, in addition to cystoscopy, should be a mandatory part of the TVT procedure. Further study is needed to determine the optimal technique for mesh removal.Abbreviations TVT Tension-free vaginal tape     

Radiolucent cage for cervical vertebral reconstruction: A prospective study of 17 cases with 2-year minimum follow-up

In cervical spondylotic myelopathy, extended anterior spinal cord decompression necessitates subsequent stable vertebral reconstruction. Reconstruction with an iliac crest graft and screw-plate fixation gives satisfactory clinical and radiological results, but they are often compromised by morbidity involving the bone harvest. The purpose of this study was to evaluate the contribution to cervical reconstruction of a biocompatible, radiolucent cage combined with screw-plate fixation, making use of bone harvested in situ. This prospective study was performed between July 2000 and March 2001 in eight women and nine men (mean age, 55 years) operated for cervical spondylotic myelopathy. Situated between levels C3 and C6, the cage was inserted after one corporectomy in ten patients, two corporectomies in five patients, and three corporectomies in two patients. The cage consisted of a polyester mesh impregnated with poly-L-lactic acid (PLLA) conferring temporary rigidity to the cage during bony fusion. Clinical and radiological follow-up (plain films, computed tomographic reconstruction in three cases) was performed at 2 months, 6 months, 12 months, 24 months and 36 months, postoperatively, with a mean follow-up of 30 months. Functional results were evaluated according to the Japanese Orthopaedic Associations scoring system. An independent surgeon assessed the radiological evidence of anterior cervical fusion using the grades proposed by Bridwell [6]. Every patient experienced neurological recovery. At last follow-up, radiological findings were consistent with grade I (complete fusion) in five cases, grade II (probable fusion) in ten cases, grade III (radiolucent halo in favor of non fusion) in one case, and grade IV (graft lysis) in one case with persistent neck pain. In three cases there was screw breakage (two grade II, one grade IV). None of these cases required surgical revision at latest follow-up. In extensive spinal cord decompression through an anterior approach, cervical reconstruction using the present type of cage can achieve clinical results comparable to conventional techniques. The rigidity of the cage meets biomechanical imperatives. Its radiolucency permits one to monitor the course of consolidation, contrary to metal cages. The cases of probable non-fusion and screw breakage were not accompanied by signs of instability on the flexion extension films. This cage meets the biologic and biomechanical imperatives of cervical reconstruction. It obviates complications involving bone harvest.