restoring abdominal wall function: the holy grail? brian jacob md facs

Restoring Abdominal Wall Restoring Abdominal Wall Function The Holy GrailFunction The Holy Grail

Brian Jacob MD FACSBrian Jacob MD FACS

My patient needs to do a sit-up after a My patient needs to do a sit-up after a successful hernia operationsuccessful hernia operation

Definition of dynamic abd wallDefinition of dynamic abd wall

What is a dynamic abdominal wallWhat is a dynamic abdominal wall

What is an adynamic What is an adynamic (or (or poorly functioningpoorly functioning) abdominal wall) abdominal wall

What we donrsquot wantWhat we donrsquot want

bull Bowel can adhere to polyester surface

bull Inadequate overlap

bull Inadequate fixation



Recipe for SuccessRecipe for Success

PathophysiologyPathophysiology

Wound HealingWound Healing

Midline or Defect Closure

Mesh TissueInterface

ldquoThe main challenge for surgery is to find the best technique in a given situation (patient hernia anatomy) which

provides the best overlaphelliprdquo Uwe Klinge Aachen Germany 2011

Matrix deposition the fibroblastMatrix deposition the fibroblast

Collagen FIBRILS then bond to form FIBERS

If something is wrong you need to search If something is wrong you need to search for the source of the problemfor the source of the problem

Volume please

Type I III Collagen RatioType I III Collagen Ratio

Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patients with recurring hernia after implantation of alloplastic prosthesis

bull Type I tensile strength (mature collagen)

bull Type III thinner diameter aka immature collagen

bull Quality of a wound is based on a high type IIII rationdash Reduced ratio (higher proportion of type III)

bull Reduced stability of connective tissue

Type I IIIType I III

Junge K Klinge U Rosch R etal (2004) Decreased collagen type IIII ratio in patiens with recurring hernia after implantation of alloplastic prosthesis

bull N = 78 50 M 28 F

bull Primary inguinal 25

bull Recurrent inguinal 18

bull Primary incisional 11

bull Recurrent incisional 24

Type I III ratio Type I III ratio and indication for mesh removaland indication for mesh removal


N= 78 explants

N=46 N=18 N=14



bull Reduced in patients with recurrent herniasndash Provides new possibilities for future research

regarding novel wound healing agents

MMP-2 (gelatinase A)MMP-2 (gelatinase A)

bull Proteolytic enzymendash Degrades collagen fibers (ECM proteins)ndash Degrades vessel wall integrity

bull Tumorogenicndash Implemented in colon breast lung adrenal

bull Connective tissue diseasesndash Aortic Aneurysmndash Ehler ndash Danlosndash Marfanrsquos syndrome

bull 1) indirectbull 2) directbull 3) recurrence

bull All groups were significantly higher (plt005) than CONTROL GROUP those without a hernia

Smigielski J Kolomecki K Ziemniak P et al Eur Surg Res 2009

Collagen Fiber CrosslinkingCollagen Fiber CrosslinkingWound Strength IncreasesWound Strength Increases

bull Stabilizes the collagen fibersbull Resists collagen breakdown

by enzymesbull Reaches up to 90 strengthbull Cellular turnover stops

Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS

Material are not all equalMaterial are not all equalbull Ongoing inflammatory processes can last at least a year bull This poor biocompatibility may lead to poor mesh

compliance

Novitsky YW Cristiano JA Harrell AG Newcomb W Norton JH Kercher KW Heniford BT (2008) Immunohistochemical analysis of host reaction to heavyweight- reduced-weight and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdminal implantations Surg Endosc 22 1070-76

Ki-67

bull Protein coagulumProtein coagulumbull Platelet adherencePlatelet adherencebull Chemoattractant Chemoattractant

releasereleasebull PMN influxPMN influxbull Macrophage Macrophage

fibroblastsfibroblastsbull Collagen secretionCollagen secretionbull Connective tissueConnective tissue

ndash 80 original 80 original strengthstrength

Why does the material matter

Tissue Ingrowth

bull Good fibrous Good fibrous growth into and growth into and through fibersthrough fibers

bull Completely Completely incorporates the incorporates the mesh materialmesh material

Why does the material matterTissue Ingrowth

Polyester-based mesh after Polyester-based mesh after IPOMIPOM fixationfixation

Polyester-based mesh at 3 year follow-upPolyester-based mesh at 3 year follow-up

Polyester vs PPM vs ePTFEPolyester vs PPM vs ePTFEtissue ingrowth strengthtissue ingrowth strength

For

ce in

Nc

m

McGinty et al 2005Jacob BP et al 2007

Polyester vs PPM vs encPPMPolyester vs PPM vs encPPMtissue ingrowth strengthtissue ingrowth strength

For

ce in

Nc

m

Strong tis

sue ingrowth = Durability

ldquoldquodonrsquot reward yourself too soonhelliprdquodonrsquot reward yourself too soonhelliprdquo

LVHRLVHR

bull Since the 1990s wersquove taught that LVHR worked best with IPOM bridge and wide overlap

bull All the while open repairs working best with a closed midline and mesh reinforcement

Rosen et al JACS 2007

Surgeons can use pathophysiology to Surgeons can use pathophysiology to reduce the risk of recurrencesreduce the risk of recurrences

bull Mesh implants require sufficient integration within the host tissue to prevent dislocation and reduce recurrencesndash Bridged mesh does not get incorporatedndash Wide Overlap in some situations may not be enough


Kinge U Prescher A Klosterhalfen B et al (1997) Development and pathophysiology of abdominal wall defects Chirurg 293

Stock market exampleStock market example

bull In one year a successful investment will grow

bull A) 2

bull B) 5

bull C) 10

bull D) 15

bull E) 20 or greater

5cm x 10cm defect[50 cm2]

Hypothetical defectHypothetical defect

Mesh with 5cm overlap (20 x 15)

20 x 15 mesh (5cm overlap)[300 cm2]

Ingrowth = 250 cm 2 (300-50)

Closing the defect increases the surface area for tissue ingrowth

By adding 50 cm2 of ingrowth surface area is increased by 20 (50250)

LVHR Closing the defectLVHR Closing the defect

bull By closing the defect during a LVHRndash Permits natural wound healing process at midline

bull Potentially will require to dissect out edge of fascia muscle and peritoneum

ndash Increases surface area for tissue ingrowth into meshndash More anatomic dynamic physiologicndash Potential to decrease morbidity (seroma)ndash May offer cosmetic and functional benefits (esp in

larger defects)bull Less bulging (known morbidity)

LVHR IPOM bridgedLVHR IPOM bridged

Large defect sp LVHRLarge defect sp LVHR

Closing the defect during LVHR Closing the defect during LVHR not a new conceptnot a new concept

bull randomized trial intraperitoneal onlay mesh (IPOM)

bull with or without cauterization of the hernia sacndash No cauterization (n = 26)

bull 425 seromas (3 recurrences)

ndash With cauterization (n = 25)bull 125 seroma (one recurrence)

bull Sac obliteration may reduce seromas and recurrences

Surg Laparosc Endosc Percutan Tech 2001 Oct11(5)317-21Seroma in laparoscopic ventral hernioplastyTsimoyiannis EC Siakas P Glantzounis G Koulas S Mavridou P Gossios KI

Close the defect during LVHRClose the defect during LVHR

bull 47 patients LVHR with defect closure

bull BMI = 32

bull Defect size = 82cm2 (16 ndash 300)ndash 2 required ECS

bull No wound morbidities or seromas

bull Closing the defect during LVHR is feasible and safe

Orenstein S Dumeer J Monteagudo J Novitsky etc 2010 Outcomes of laparoscopic ventral hernia repair with routine defect closure using ldquoshoelacingrdquo technique Surg Endosc

Chelala (EHS)Chelala (EHS)bull 335 bmi n = 733 pts (608 controlled vs 85 second looks)bull Routine defect closure during most LVHRbull Tissue ingrowth strength is what eventually has to resist lateral sheer forces

bull Mean fu 56 monthsbull Morbidities of the 608

ndash Seroma 22 ndash Pain 31 ndash Recurrence = 41 (25 608 cases)

bull ldquoadvantagesrdquo to closing the defect during LVHR ndash Less seroma low infection less recurrence less bulging less mesh migration into the cavity

more functional abdominal wall

bull Did not mention defect size but suggested minilaparotomy to assist closure for greater than 7cm

Chelala E Debardemaeker Y Elias B etal 2010 Hernia Eighty Five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia adhesion and recurrence analysis

Treat each case individuallyTreat each case individually

bull There is no single solution for every case

bull Success depends on your chosen technique mesh product and patient

Concept Preparing the defect edges for Concept Preparing the defect edges for closure closure

bull Taking into account wound healing physiology simply bringing edges of peritoneum together may not be sufficient

Size mattersSize mattersbull Defect Sizes

ndash Small lt 5cm (lt25cm2)bull Surgeon preferencebull Suggest suture passer

ndash Moderate 5cm ndash 10cm (25cm2 ndash 100cm2)bull Surgeon preferencebull Suture passer or minilaparotomy

ndash Large gt 10 cm (gt100cm2)bull Close all defects

ndash Minilaparotomy orndash Component release if necessary

ldquoldquoMinilaparotomyrdquo during LVHR to close the defectMinilaparotomyrdquo during LVHR to close the defect

ECS to close the defectECS to close the defect

Closing the defect during LVHR Closing the defect during LVHR words of cautionwords of caution

bull Do not try to close defects under a lot of tensionndash Expect a recurrence if you dondash Good indication for hybrid techniques

bull Hybrid or Combination techniquesndash Use an open incision to assist your

laparoscopic mesh fixation

1) External Oblique Fascia releases (both left and right)

1) Dissection of fascia to healthy tissue2) 20cm Mesh and trocars are placed loose in abdomen BEFORE

midline is closed3) Midline closed and abdomen insufflated4) Mesh is fixed in traditional laparoscopic IPOM position

Combined open component separation with Combined open component separation with laparoscopic mesh fixation (hybrid)laparoscopic mesh fixation (hybrid)

Aka converting to laparoscopy

PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR

RESULTS OF A PROSPECTIVE STUDY

bull abdominal wall strength score (AWSS)ndash validated and reported scoring systemndash physical exam-based measure

bull double leg lowering and trunk raising

ndash significant AWSS change is a change of 2 points or morendash higher scores indicate better abdominal wall function

Ross F Goldberg MD Armando Rosales-Velderrain MD Tatyan M Clarke MD Michael Parker MD Madi Dinkins Mauricia A Buchanan RN John A Stauffer MD Horacio J Asbun MD FACS C Daniel Smith MD FACS Steven P Bowers MD FACS Mayo Clinic ndash Florida (SAGES 2012 Abstract Poster of Distinction)

PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONPATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTIONAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDYAFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY

bull Goal objectively measure improvement in abdominal wall function after ventral incisional hernia (VIH) repair

bull Prospective

bull N = 56 but 29 finished 8-12 month fundash 19 lap and 10 open repairs



bull 15 patients (517) had ge2 point increase of AWSS whenbull 12 (414) were unchangedbull 2 (69) had ge2 point reduction bull No statistical difference between laparoscopic and open approaches in overall AWSS improvement or in number of patients with deterioration at 4 months

bull Conclusion

bull There is a measurable improvement in abdominal wall strength in patients undergoing VIH repairbull (need to use this tool to compare defect closure vs bridge)


Outcomes and defect sizeOutcomes and defect size

bull 310 consecutive patients with incisional herniasndash excluding patients with primary hernias and hernias smaller than

5 cm

bull Overall recurrence rate was 6 after an average follow-up of 60 months ndash A multivariate analysis showed that only obesity and defect size

were independent prognostic factorsndash A defect size greater than 10 cm is strongly predictive of

recurrence after laparoscopic incisional hernia repair

bull Conclusionndash Defects larger than 10 cm may require a modified laparoscopic

technique to increase the mesh tissue interface plus

Moreno-Egea A Carrillo-Alcaraz A Aguayo-Albasini JL Is the outcome of laparoscopic incisional hernia repair affected by defect size A prospective study Am J Surg 201220387-94

bull 44 cases bull22 endoscopic 22 openbullendoscopic

Endoscopic versus open component separation in complexabdominal wall reconstruction

Karem C Harth MD MHS Michael J Rosen MDThe American Journal of Surgery (2010) 199 342ndash347



open lap

Hospital stay 11days 8 days

Wound complications 52 27

Wound related intervention

45 33

Recurrence 32 27

Open vs Endoscopic Components Open vs Endoscopic Components SeparationSeparation


Preliminary Experience and Development of an Algorithm for the Optimal Use of the Laparoscopic ComponentSeparation Technique for Myofascial Advancement During Ventral Incisional Hernia Repair

Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS and Steven P Bowers MD FACS

JOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUESVolume 21 Number 5 2011






Michael Parker MD Jillian M Bray MD Jason M Pfluke MD Horacio J Asbun MD FACS C Daniel Smith MD FACS

and Steven P Bowers MD FACSJOURNAL OF LAPAROENDOSCOPIC amp ADVANCED SURGICAL TECHNIQUES

Volume 21 Number 5 2011














outcomesoutcomes

Confirm durability with a crunch or sit-up but prove with a scoring system

Conclusions LVHR and Close Conclusions LVHR and Close the Defectthe Defect

ndash More anatomic dynamic physiologicbull Need more proof that this matters

ndash Decreases seroma incidencendash Less bulging

bull cosmetic and functional benefits (esp in larger defects)

ndash Allows natural wound healing process at midlinebull Potentially will require to dissect out edge of fascia muscle and

peritoneum

ndash Increases surface area for tissuevascular ingrowth into mesh

ndash Currently indicated (at least) for defects greater than 10cm or where mesh fixation will be less secure

Restoring Abdominal Wall Function The Holy Grail

My patient needs to do a sit-up after a successful hernia operation

Definition of dynamic abd wall

What is a dynamic abdominal wall

What is an adynamic (or poorly functioning) abdominal wall

What we donrsquot want


Slide 8

Recipe for Success

Pathophysiology

Wound Healing

PowerPoint Presentation

If something is wrong you need to search for the source of the problem

Type I III Collagen Ratio

Type I III

Type I III ratio and indication for mesh removal

Slide 17

MMP-2 (gelatinase A)

Slide 19

Collagen Fiber Crosslinking Wound Strength Increases

Material are not all equal

Slide 22

Slide 23

Polyester-based mesh after IPOM fixation

Polyester-based mesh at 3 year follow-up

Polyester vs PPM vs ePTFE tissue ingrowth strength

ldquodonrsquot reward yourself too soonhelliprdquo

LVHR

Slide 29

Surgeons can use pathophysiology to reduce the risk of recurrences

Stock market example

Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36

LVHR Closing the defect

LVHR IPOM bridged

Large defect sp LVHR

Closing the defect during LVHR not a new concept

Close the defect during LVHR

Chelala (EHS)

Treat each case individually

Concept Preparing the defect edges for closure

Size matters

Slide 46

Slide 47

Slide 48

ldquoMinilaparotomyrdquo during LVHR to close the defect

ECS to close the defect

Closing the defect during LVHR words of caution

Slide 52

Slide 53

Slide 54

Slide 55

Combined open component separation with laparoscopic mesh fixation (hybrid)

PATTERNS OF DETERIORATION AND IMPROVEMENT IN ABDOMINAL WALL FUNCTION AFTER VENTRAL INCISIONAL HERNIA REPAIR RESULTS OF A PROSPECTIVE STUDY


Slide 59

Outcomes and defect size

Open vs Endoscopic Components Separation

Slide 62

Slide 63

Slide 64

outcomes

Conclusions LVHR and Close the Defect

My patient needs to do a sit-up after a My patient needs to do a sit-up after a successful hernia operationsuccessful hernia operation




















Volume please









bull N = 78 50 M 28 F







N= 78 explants

N=46 N=18 N=14















Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS


compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes





















Volume please









bull N = 78 50 M 28 F







N= 78 explants

N=46 N=18 N=14















Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS


compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes










bull N = 78 50 M 28 F







N= 78 explants

N=46 N=18 N=14















Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS


compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes




N= 78 explants

N=46 N=18 N=14















Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS


compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes
















Wo

un

d S

tren

gth

7 14 21 28 35 42 49 56 63 DAYS


compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes



compliance


Ki-67






Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes







Tissue Ingrowth







For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes








For

ce in

Nc

m



For

ce in

Nc

m

Strong tis



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes



LVHRLVHR










bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes









bull A) 2

bull B) 5

bull C) 10

bull D) 15






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes






Ingrowth = 250 cm 2 (300-50)



















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes




















bull BMI = 32









































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes






































bull Prospective





bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes




bull Conclusion





5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes




5 cm












open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes







open lap




45 33

Recurrence 32 27



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes



























outcomesoutcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes







peritoneum










Slide 8

Recipe for Success

Pathophysiology

Wound Healing




Type I III


Slide 17


Slide 19



Slide 22

Slide 23





LVHR

Slide 29



Hypothetical defect

Slide 33

Slide 34

Slide 35

Slide 36


LVHR IPOM bridged




Chelala (EHS)



Size matters

Slide 46

Slide 47

Slide 48




Slide 52

Slide 53

Slide 54

Slide 55




Slide 59



Slide 62

Slide 63

Slide 64

outcomes


restoring abdominal wall function: the holy grail? brian jacob md facs

Documents

recurring hernia

collagen ratiojunge

klinge u

rosch r etal

dynamic abdominal wall

chart data range

abdominal wall function

functioning abdominal