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1
Q

10 layers

A
  1. Skin
  2. Subcutaneous Fat- Sub Q
  3. Scarpus Fascia
  4. External Oblique Muscle
  5. Internal Oblique Muscle
  6. Transverse abdominal Muscle
  7. Transverse Fascia
  8. Pre Peritoneal Space
  9. Peritoneum
  10. Inta Abdominal Cavity
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2
Q

Onlay where does the mesh lye

A

Between Subcutaneous Fat (Sub Q) and Scarpas Fascia

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3
Q

Underlay same as intra abominably where does the mesh lye?

A

Btw Peritoneum and Intra Abdominal cavity

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4
Q

Retro Rectus where does the mesh lye

A

Btw Transverse Fascia and Pre Peritoneal Space

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5
Q

Superior and Cephald

A

Towards the Head

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6
Q

Inferior and Caudad

A

Towards the Feet

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7
Q

Anterior

A

front

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8
Q

Posterior

A

Back

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9
Q

Proximal

A

Near trunk- point of orgin

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10
Q

DIstal

A

Away from center of body

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11
Q

Ventral Hernia working Group

A

Grade 1- Cookie cutter. 77% of Hernias
Grade 2- Multi Co Morbidity- infection- diabetic. 4th Co morbidity= 67% infection
Grade 3- Potentially contaminated. Colostomy- removal of the colon. Illiostomy- large or small intestine coming out. 8%
Grade 4- Contaminate= outside of the body & infection= inside of your body. 4%

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12
Q

Modified Ventral Working Group

A

Grade 1- Same- cookie cutter. 77% —- products= Synthetic
Grade 2- Co morbid —- Products= Synthetic/Phasix
Grade 3&4- prior infection—- Products Phasix/Zen

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13
Q

Onlay Pros/Cons

A

Pro- Easiest Visualization, easiest technique, cheapest, 5cm each side of overlap
Cons- Closest to the skin= highest rate of infection

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14
Q

What is a biologic

A

100% resorbable. It goes away infection eats it up into the body

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15
Q

Underlay Pros/cons

A

Pro- Less Seroma on mesh

Negative- Cost, hard to do, Puts tension on the mesh

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16
Q

Retro Rectus Pros/Cons

A

Positive- Sutured to Muscle & Vasculization(Blood flow) on both sides
Con- Bowl injury

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17
Q

Anterior Component Separation what is it?

A

Rectus Abdominal Reconstruction

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18
Q

Anterior Release what is it?

A

Top Abdominal cut- Has a Sub Q flap- done onlay or underlay

eliminates tension

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19
Q

TAR what does it stand for & what is it?

A

Transverse Abdominoius
Puts Mesh in the Transverse Abdominous plane
*- No Sub Q Flaps & No Seroma

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20
Q

3 typers on Inguinal Hernias?

A
  1. Indirect
  2. Direct
  3. Femoral
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21
Q

What is an Indirect Inguinal Hernia?

A

They occur bc of a weakened internal Ring, which is the location where the spermatic cord exits the pelvis. These are also congenital and make up 70% of ___ Hernias

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22
Q

What is a Direct Inguinal Hernia?

A

Internal oblique and transverse abdominal muscle dont go all the way to the inguinal ligament. Make up 30% of ___ Hernias. Trasnverse Fasica called “ wear and tear” - caused by straining

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23
Q

What is a Femoral Inguinal Hernia?

A

Occur at the femoral space- below the inguinal ligament. Make up 5% of hernias in women. It is where the illiac vessels pass out of the pelvis and travel down the femor just below the inguinal ligament

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24
Q

The tissue layer where the spermatic cord exits the internal ring?

A

Internal Oblique Muscle

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25
Q

The tissue layer where the testicular vessels and Vas Deferens become the spermatic cord?

A

Transversalis fascia

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26
Q

Difference between tissue/muscle layers ventral vs groin/inguinal?

A

Posterior layer of the rectus fascia ends

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27
Q

What are the 4 products for complex abdominal wall repair?

A

1- XenAB
2- Xen Matrix
3- Phasix ST
4- Phasix Flat sheet

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28
Q

When is Synthetic not a good option?

A

When infection or contamination presents itself or for complex cases

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29
Q

What is XenAB and when is it used?

A

Complex Abdominal wall repair

  • 1st antibacterial coated surgical graft for hernia reapir demonstraed to prevent the olonization of MRSA, E Coli, MRSE and E aerogenes in Pre Clinical models
  • Orange sheet
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30
Q

What is Xen Matrix and when is it used?

A

Complex abdominal wall repair

  • Regenerative collagen matrix, non cross linked, open collagen structure for hernia and abdominal wall repair
  • early tissue remodeling
  • since 2006
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31
Q

What is Phasic ST and when is it used?

A

Complex Abdominal wall reapir

  • Fully resorbable biologically derived scafflod with an absorbable barrier based on Sepra technology
  • Hydrogel barrier- repair strength of a synthetic
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32
Q

What is Phasix Flat sheet and when is it used?

A

Complex Abdominal wall repair

  • fully resorbable biologically 12- 18 month derived scaffold.
  • Not intra abdominal
  • In between Synthetic mesh and Biologic graft= this
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33
Q

What are the 4 synthetic abdominal ventral hernia repair products?? (OVHR)

A
  1. Ventrio
  2. Ventrio ST
  3. Ventralex
  4. Ventralex ST
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34
Q

What is Ventrio and when is it used?

A

Synthetic Abdominal VENTRAL hernia repair

Self expanding polypropylene and ePTFE patch for soft tissue reconstruction with SorbaFlex Memory Technology

Anterior= 2 layers form a pocket to assist w/ positioning and fixation.
Posterior- ePTFE w/ overlap- minimize chances of bowel adhesion
SorbaFelx memory technology ring- absorbs 6-8 week.
- Patch inserted through small incision, then pop open and lay flat

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35
Q

What is Ventrio ST and when is it used

A

Synthetic Abdominal Ventral Hernia Repair

Uncoated monofilament polyporpylene mesh with SobraFlex Memeory Technology and an absorbable barrier based on Sepra Technology.

Anterior= 2 layers form a pocket to assist w/ positioning and fixation.
Posterior- Absorbable = 30 days

Key Study Facts:

  • key to a successful technique- pre tensioning
  • Available in 9 sizes
  • Can be placed intraperitonally (entering the Peritoneum) bc of the hydrogel barrier
  • absorbs 6-8 months
  • has a full pocket - competition only has a lateral skirt
  • 1% reoccurrence rate
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36
Q

What is Ventralex and when is it used?

A

Synthetic Abdominal Ventral Hernia repair- used for umbilical repairs

Designed for ventral, incisional, umbilical and epigastric hernia rapair as well as the trocar site closure and features of sorbaflex memory technology

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37
Q

What is Ventralex ST and when is it used?

A

Synthetic Abdominal Ventral Hernia repair- used for UMBILICAL repairs

A clinically proven umbillical hernia repair solution with sorbaflex memory technology and an absorbable barrier featuring sepra technology

dissolves 30 days posterior
absorbable ring- dissolves 6-8 months
- has straps for easy use

Key Study facts:
- #1 umbilical patch sold in the market today
- 88 patients- 0 reocurrence rate
- Anterior- medium pore polyprop mesh
- SorbaFlex™ Memory Technology – Absorbable Recoil Ring (PDO) in 6-8 months
- 3 sizes
- clear space- twice the size of defect
- Surgeon must pull apart straps bc 2- they dont come seperated 2- gain acess to pocket
- Technigue to fixate U stiches in a minimum of 2 Quadrants for a small patch and 4 Quadrants for a medium or large patch
- Doesn’t need a barrier overelap bc it swells when hydrated minimizing attachment to the edge of the patch
- Designed to fit down a trocar
Indicated for repair of trocar site deficiencies

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38
Q

What are the 5 ventral Laparoscopic hernia repair products?? (LVHR)

A
  1. Composix EX
  2. Composix LP
  3. Echo PS
  4. Ventralight ST
  5. SepraMesh LP
39
Q

What is Composix EX and when is it used??

A
  • Ventral laprascopic Repair

Polpropylene/Posteriro- ePTFE prosthesis for laproscopic verntral hernia repair

40
Q

What is Composix LP and when is it used??

A
  • Ventral laprascopic repair

Low profile, large prore polypropelyne/ posterior ePTFE prothesis for laproscopic verntrla hernia reapir

lighter weight mesh- has an introducer tool- can come w/ echo PS positioning system compared to Composix EX

41
Q

What is Echo PS positioning system and when is it used??

A

Ventral Lap Repair

pre attached low profile balloon to help facilitate deployment, placement and positioning in Lap ventral hernia

  • 3rd hand for surgeon
  • Comes pre attached to Compsix LP or Ventralight ST
  • Balloon is removed from patient

Key Facts:

  • The center of mesh is indicated by Bard logo
  • Reduces frustration involving placing and positioning
  • Roll & Deploy ( rotate 1/2 turn to relaseas- opposite direction)
  • how to remove: grasping removal point to trocar and remove both simultaneously
  • Makes learning curve easier for new surgeons
  • 61% time saving for mesh positioning using
  • how to deflate: cut the inflation tube as close to skin as possible
42
Q

What is Ventralight ST and when is it used??

A

Ventral Lap Repair

Uncoated Lightweight monofilament polyprop mesh on the anterior side with an absorbable hydrogel barrier base on sepra technology on the posterior for lap repair

43
Q

What two products can come with Echos PS Postioning system already pre attached??

A

Ventralight ST mech or Composix LP

44
Q

What is SepraMesh LP and when is it used??

A

Ventral Lap repair

Combines the strength of polyprop mesh with an absorbable hydrogel barrier based on sepra technology for verntrla hernia repair

Hydrogel barrier- absorbs in 30 days
PGA fibers- absorbs in 50-80 days

45
Q

what are the 6 Inguinal hernia repair products??

A 
1- PerFix Plug 
2- Per Fix Plug Light
3- OnFlex
4- Phasix Plus & Patch
5- 3D Max 
6- 3D max light
46
Q

What is PerFix Plug and when is it used??

A

Inguinal Hernia Reapir

Plug ad patch designed for use in a tension free open inguinal hernia repair

Top selling. Fluted outer cone- expands and contracts for a tension free repair
- Customizable
- plant A- Traumatic tip- wont pierce peritoneum
- Onlay Patch- helps prevent hernia in adjacent areas
- 4-5cm incision
- Mean time for operation is 28 minutes- study by Keith Millikan
- Tension Free
- 4 million inplants worldwide= .15% reocurrence rate & .5% cronic pain
-

47
Q

What is On Flex and when is it used??

A

Inguinal Hernia Repair

Self- expanding light weight mesh for open preperitoneal inguinal hernia repair with sorbaflex memory technology
- pocket design helps w/ placement
- Anatomical shape designed to cover the myopectinela artifice
- absorbs in 6-8 months
- medium weight
- uncoated monofil polyprop
- pocket= positioning and placement
- The SorbaFlex™ PDO monofilament absorbs via
hydrolysis in 6-8 months
- Technique can be performed through one small
4-6 cm incision

48
Q

What is SorbaFlex Memory Technology??

A

helps to avoid
buckling and folding of the mesh, which helps the
mesh lay flat and conform to the anatomy in the
preperitoneal space

49
Q

What is Phasix Plug and Patch and when is it used??

A

Inguinal hernia repair

Lighter weight version- used when a reduced amount of material is indicated & Fully resorbable biosynthetic implant for soft tissue reconstruction

50
Q

What is 3D Max and when is it used??

A

Inguinal Hernia repair- ONLY Lap

Unique 3 dimensional polyprop mesh for lap inguinal hernia repair

  • doesnt require fixation
  • notch for illiac vessels
  • crest to go over inguinal ligament
  • clinically proven w/ out fixation
  • Mesh Burst Stength- 75 vs medtronic ProGrip 19 - EThican UltiPro- 16

Study Facts:

  • Crest of 3D corresponds w inguinal ligament
  • notch corresponds w illiac vessel
  • m in 3d max stands for medial
  • purpose of reinforced edge= adds memory for patch to pop open
51
Q

What is 3D Max Light and when is it used??

A

Inguinal Hernia repair- ONLY Lap

Lighter weight version of 3D Max, featuring a large pore knit design. Has Unique 3 dimensional polyprop mesh for lap inguinal hernia repair

  • doesnt require fixation
  • notch for illiac vessels
  • crest to go over inguinal ligament
  • 49% less than medtronic Pro Grip
  • Mesh Burst strength= 30 vs medtronic ProGrip 19 & Ethican UltiPro- 16
52
Q

What are the 3 Fixation products??

A

1- Optifix
2- SorbaFIx
3- Capsure

53
Q

What is OptiFix and when is it used??

A

When Fixation is needed- Absorbable PDLLA fasteners available in both a 15 & 30 count configuration delivered via a disposable 5 mm stored energy delivery system.

  • spring loaded
  • longest on the market
54
Q

What is SorbaFix and when is it used??

A

When fixation is needed- Absorbable PDLLA fasteners available in both a 15 and 30 count configuration deliverd via a disposable 5 mm delivery system.

Main difference- fastener- threaded hallow core= tissue ingrowth

55
Q

What is CapSure and when is it used??

A

Only Perminant fixation tool

  • Permanent 136L stainless steel helical coil fastener with a smooth cap available in both a 15 and 30 count configuration via a disposable 5mm delivery system
  • Capsure Fastener- MRI Conditional
  • Capsures cap made of PEEK
56
Q

What is the MK Hernia Technique and what product is it used on??

A

*- Allows for additional posterior coverage of the defect vs classic technique

hernia repair technique is a minimally
invasive, tension-free technique that can be completed
through a small 4-6 cm incision and minimal requirement of fixation. It is a preperitoneal repair performed through an open, anterior approach that can be completed using local or regional anesthesia.

Used for OnFlex

57
Q

What Onlay Patch requires no fixation and doesnt need to be sutured to fascia??

A

PerFIx Plug

58
Q

29 more minutes to place Pro Grib than??? Clinical Data

A

3D Max

59
Q

3D Max vs Ethicon Prolene

A
  • Reduced length in hospital

- decrease in incident of post peroperative urinary retention

60
Q

3D Max vs ProGrip Medtronic

A

Premier Database (Insurance collected by hosptials) 5,000 cases

  • cases w pro grip cost on avg $1,975 more than 3DMax
  • cases w pro grip on avg take 29 mins longer than 3D Max
  • ProGrip more pain in 48 Hours
  • ProGrip made of polyester and hard to place
61
Q

What tissue is the surgeon generally placing 3D Max on?

A

Pre Peritoneal

62
Q

Basic Hernia repair steps??

A
  1. Incision to gain access
  2. Identify and push/reduce hernia
  3. Reair 1- mesh 2- tissue to tissue
    4- close wound and skin
63
Q

How does the body react to mesh??

A

1- Inflammatory response is the intial phase of normal healing process that occurs when tissue is injured
- cells sent to help heal
- mesh reinforcing the area
2- bodys fibrotic response:
- fomration of collegen at a wound site builds a matrix= scar is formed
- new tissue takes over the monofilamnet ( mesh material) & evntually envelopes the mesh

64
Q

How does mesh work in the body??

A

Mesh allows new tissue to grow in place/ strengthen area

tissue ingrowth = strength of repair

65
Q

4 stages of hernias??

A
  1. Incisional- resulting from an incision
  2. Umbilical - belly button
  3. Inguinal- inner groin- Most common
  4. Ventral- bulge of tissue through abdominal wall
66
Q

Advantages and disadvantages of using mesh?? When might mesh be contraindicated?

A

Contraindicated: mesh not suitable for children- where future in growth is compromised by use of mesh. Not suitable for places where infection exists.

Disadvantage: Simply no foreign body - expensive- infection is at a high risk- a DR teaches/knows anatomy well
Advanatages: Less pain, less tension on suture(row of stiches), lower reocurrence rate

67
Q

Advantages and disadvantages of Tissue to Tissue??

A

Adv: Simply no foreign body - inexpensive- infection is at a high risk- a DR teaches/knows anatomy well
DisAdv: Extensive dissection of body, high occurrence, patient pain- row of stiches (Suture), not suitable for large defects

68
Q

Advantages and disadvantages of Onlay??

A

Placed between Sub Q and scarpas fascia

Adv: easiest visualization, cheapest, easiest technique
DisAdv: closest to skin- highest infection rate, cant see other defects

69
Q

Advantages and disadvantages of Retro Muscular??

A

Between Trasnverse Fascia and Pre Peritoneal Space

Adv: suture to muscle, Vasculirization on both sideds(Blow Flow), further from skin
DisAdv: Bowl Injury, increased seroma, time required, damages healthy tissue

70
Q

Advantages and disadvantages of Preperitoneal??

A

Between Pre Peritoneal Space and Peritoneum

ADv: Pascals law- less risk of mesh becoming involved in infection- further from skin
DisAdv: Increased seroma, time required, damages healthy tissue, Bowl Injury

71
Q

Advantages and Disadvantages of Intra- Abdominal Same as Underlay??

A

Strongest Mesh placement!
ADv: Pascals Law, less risk of infection, further from skin, seroma less likely, no lateral dissection needed
DisADv: Bowl Injury, Must compromise Peritoneum

72
Q

Advantages and Disadvantages of LVHR?? And what does LVHR stand for??

A

Lap Ventral Hernia

Adv: Deep placement(Pascals Law), Minimal invasive, reduced infection risk, quick recovery
DisAdv: technically challenging, expensive, increased time for Adhesiolysis, Risk of intra abdominal injury

73
Q

What is Pascals Law??

A

Tire pressure patch spred evenly out.

74
Q

Why is it important to have an adhestion barrier for mesh placed in the intra abdominal cavity??

A
  • Minimizes risk for surgeon, as well as keeps mesh from contacting with the bowel
75
Q

What are Davol’s Adhesion barrier options??

A
  1. Perminate Barrier- ePTFE. All of Davol’s composite (Animal and plat material) products have Submicronic ePTFE
    2- Absorbable - Ex Bard Ventralight ST mesh. Great for against bowel. Absorbs in 30 days.
76
Q

What are the advanatages of PGA Fibers? What do they do?

A

Bioresorbable PGA fibers reinforce
the integrity of the hydrogel barrier by
binding it to the polypropylene mesh.

77
Q

What is the Inguinal canal??

A

It is superior and parallel to the inguinal ligament. The canal serves as a pathway by which structures can pass from the abdominal wall to the external genitalia

78
Q

What structure makes up Hasselbach’s Triangle??

A
  • lateral border of the rectus muscle
  • inferior epigastric artery
  • inguinal ligament
79
Q

What structures join at the internal ring?

A

anterior superior iliac spine and the pubic symphysis

80
Q

Optifix key facts

A
  • 39 cm cannula length- superior reach vs AbsorbaTack
  • Optifix maintains 100% of its strength for the 1st 8 weeks well beyond critical healing period
  • essentially resorbed at 52 weeks
  • Optifix cant be put on consignment
  • angled tip for smooth penetration
  • Hollow Core- to promote tissue ingrowth
  • Large smooth head 1- clinical study suggests may help minimize tissue attachment 2- large head easily visible laproscopically 3- superior surface area under the head- lightens blow as the fastener connects w/ mesh to help fastener from over driving deep into tissue
81
Q

What landmark should the surgeon plan to fire Optifix just superior of and toward the medial aspect of in a LIHR??

A

Coopers ligament

82
Q

While fixating in the pocket the surgeon should??

A

1-pre tension the fascia
2- Angled up so they are deploying away from the bowel and towards the rectus sheath
3- Assuring they are 1-2 cm from ring

83
Q

Doctors should never fixate in these areas in inguinal hernia??

A

1- Triangle of doo (Illia Vessels)

2- Triangle of pain ( Femral branch- femral nerve and lateral nerve)

84
Q

6 Selling Points against Ethican - SecureStrap

A

1-* 14% fastener site trama vs OptiFix 1.6% fastener trama
2- Pre Clinical studies indicate- MORE bleeding at point of fixation vs OptiFix
3- 5X Less surface area mesh coverage compared to OptiFix
4- Poor Visualization Lap bc surface are of strap
5- No tissue in growth through fasteners bc no hallow core like OptiFix
6- Only 12/25 straps vs 15/30 optifix
* Claims absorbs after 12 months

85
Q

5 selling points against Covidian- AbsorbaTack (Blind Survey of Doctors at an International Conference)

A

1- Ratcheted deployment system- clunky
2- *Pre Clinical studies indicate it is fully resorbed at 6 months * claims to absorb after 12 months
3- *Depth of purchase 4.1 mm vs 5.9 mm OptiFix
4- Solid Core- doesn’t get tissue ingrowth through fastener
5- Older Technology- been around since 2007
- *Has absrbable tackers of 15,20 &30

86
Q

When targeting SecureStrap what should you focus on?

A

1- Fastener site Trama
2- Device Price= neutral
3- Account Standardization (Absorb able & Perminate)
4- Current at risk SorbaFix Accounts
5- Fastener count difference 15&30 vs 12 & 25

87
Q

Initial targets for OptiFix

A

1- Existing Mesh Accts
2- SecureStrap Accts w/ over 12 months
3- Current at risk SorbaFIx accts

88
Q

Optifix vs SecureStrip pricing?

A

Neutral

89
Q

Optifix vs AbsorbaTac Pricing?

A

Priced Competitive

90
Q

Capsure Vs Protack (Covidian)??

A
  • 4 revolutions vs 2 1/2
  • Covidien overal market leader for fixation
  • stainless stell fastener vs titanium
  • Capsure fastener has a 2.15X greater mesh surface area coverage than ProTack Fastener
  • Cpasure 14% single shear strength vs Protack
  • Capsure out performed the ProTack fixation system in a Preclinical study at 2 weeks and 6 weeks
  • More favorable fastener seating results
91
Q

What are the clinical concerns with ProTack (Covidian)?

A
  • Device reliability issues
  • Design leaves exposed sharp point
  • Difficulties securing large pore mesh
92
Q

OptiFix Open vs OptiFix Differences??

A
  • available in 20 count only
  • Inverted Handle and trigger
  • Cannula length 27 cm vs 39 cm
  • curved vs straight
  • Distial Tip- smooth and broad vs textured
    Guide wire is 304s vs 316
    Upside down vs Gun up
93
Q

Where is the Line of Douglas (LOD)??

A

Landmark halfway between pubic bone and umbilicus
Above the LOD ventral hernias,
Below groin and femoral hernias.

94
Q

What is Phasix made of??

A

P4HB- resorbable polymer derived from Biologic Fermentation. Naturally broken down/degrades from Hydrolisis. The structure of the mesh is open mono filament

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