Modified fixation free plug technique using a new 3D multilamellar implant for inguinal hernia repair

A regenerative 3D scaffold for inguinal hernia repair. MR imaging and histological cross evidence. Qualitative study

BACKGROUND

Inguinal hernia is a degenerative disease occurring in a high motile surround. Stopping degeneration and promoting tissue regeneration should be the treatment goal. Groin hernias are conventionally managed with static flat meshes, mostly fixated to the delicate inguinal environment. Far from a regenerative effect, the biologic response of conventional hernia meshes is characterized by a foreign body reaction leading to a stiff/shrunken scar plate, which is often the source of unpleasant complications. Recently, a newly engineered 3D device for inguinal hernia repair - ProFlor-has been developed to produce a regenerative biological response. Unlike conventional hernia meshes, this regenerative 3D hernia scaffold seems to demonstrate suitable features for a pathogenetical and physiological coherent treatment of the disease. The aim of this manuscript is to cross evidence these features through magnetic resonance imaging (MRI) and histology.

STUDY DESIGN

The biological response of ProFlor at three defined post-implantation stages has been evaluated through MRI signal intensity and compared to neighbouring muscles and fat. As additional proof, histology of tissue specimens excised at the same post-implantation periods from porcine models during an experimental attempt were also evaluated.

RESULTS

MRI of newly ingrown tissue in ProFlor demonstrated similar signal intensity of muscles while fat tissue showed remarkably higher values. These data matched with the histology of ProFlor biopsies excised from pigs.

CONCLUSIONS

The motile compliance to groin movements of ProFlor appears to induce a probiotic biologic response comparable to a regenerative scaffold, allowing to physiologically resolve the degenerative source of inguinal hernia disease.

Inguinal Hernia: Defect Obliteration with the 3D Dynamic Regenerative Scaffold Proflor™

Prosthetic inguinal hernia repair presents significant challenges. Some of these, such as mesh fixation and quality of the biologic response, are still debated among surgeons. For example, there is no strong consensus regarding a specific condition that characterizes the surgical procedure during herniorrhaphy. This issue concerns management of the hernia defect, which in conventional hernia repair with flat meshes remains patent. However, a critical analysis of typical postoperative complications after inguinal hernia repair reveals that some of these adverse events are related to patency of the hernial opening. Postoperative discomfort, pain with specific movements and even hernia recurrence can be caused by incomplete or defective management of the hernia defect. For this reason, a deeper understanding of this topic would be useful for improving postoperative outcomes. A recently updated concept for inguinal hernia repair takes this technical aspect into consideration. It is based on the use of a newly developed 3D scaffold-ProFlor™ (Insightra Medical, Inc., Clarksville, TN, USA)-that is intended to be deployed into the defect. This novel hernia repair device has interesting and original features, such as dynamic responsivity in compliance with inguinal movement, fixation-free mode and regenerative behavior that counteracts the degenerative effects of the disease. Another additional proprietary feature of this 3D scaffold is the full and permanent obliteration of the defect, which is a crucial aspect to improve outcomes by avoiding the typical adverse effects of this surgical procedure. Obliteration of the hernia defect with the 3D dynamic regenerative scaffold ProFlor™ appears to be superior to coverage by means of static (passive) flat meshes/plugs used in conventional hernia repair. This report highlights the principles of this procedural approach.

Enhanced angiogenesis in the 3D dynamic responsive implant for inguinal hernia repair ProFlor

Biologic response to hernia prostheses represents a continuous source of debate. Conventional hernia meshes, in their typical static, passive configuration have been used for decades to reinforce the herniated abdominal wall. These flat implants, mainly fixated with sutures or tacks, induce poor quality fibrotic ingrowth that shrinks the mesh. In groin hernia repair, flat meshes are applied in the delicate inguinal surrounding where uncontrolled development of a scar plate can impair movement and may incorporate the sensitive nerves crossing this area. Complications deriving from mesh fixation and nerve entrapment are frequent and unpleasant for patients. To remedy these problems, a multilamellar shaped 3D device with a dynamic responsive behavior has recently been developed to repair inguinal hernia. Its inherent dynamic compliance during inguinal movements has shown to induce enhanced biological response with ingrowth of newly formed connective tissue, muscle fibers, and nerves. The function of these highly specialized tissue structures is supported by the contextual development of newly formed arteries and veins. The scope of the study was to assess quantity and quality of vessels, which had ingrown in the 3D hernia device in the short-term, medium-term, and long-term post-implantation, in biopsy specimens gathered from inguinal hernia patients operated with the 3D device. Starting from an early stage, widespread angiogenesis was evident within the 3D structure. Arteries and veins increased in quantity showing progressive development until full maturation of all specific vascular components throughout the mid-term, to long-term, post-implantation. High quality biologic ingrowth in hernia prosthetics needs an adequate vascular support. The broad network of mature arteries and veins evidenced herewith seems to confirm the enhanced biological features of the dynamic responsive 3D device whose features resemble a regenerative scaffold, an ideal feature for the treatment of the degenerative source of inguinal hernia disease.

First-in-man permanent laparoscopic fixation free obliteration of inguinal hernia defect with the 3D dynamic responsive implant ProFlor-E®. Case report

INTRODUCTION

In the case of inguinal hernia recurrence after primary anterior repair, international guidelines strongly suggest a posterior laparoscopic approach. The 3D dynamic-responsive prosthesis for inguinal hernia repair ProFlor-E® has recently been introduced to the market. The present report describes the results of the first-in-man laparoscopic inguinal hernia repair carried out with ProFlor-E®.

PRESENTATION OF CASE

A 71-year-old male Caucasian presented with recurrent inguinal hernia after primary anterior repair. A fixation free TAPP procedure with ProFlor-E® was planned. Implant delivery and placement to obliterate the defect was quick and safe. Postoperatively, starting from 2nd postop day, pain was practically absent allowing quick return to normal activities. During follow up, US and MRI scans confirmed the permanence of ProFlor-E® in the hernial gap. During 16-month follow-up no complications were reported.

DISCUSSION

Flat meshes used to reinforce the herniated inguinal area is a well-established concept. Notwithstanding, such static and passive implants leave the defect patent and cause specific complications related to mesh fixation and uncontrolled poor quality fibrotic ingrowth. ProFlor-E® respects the inguinal physiology resolving these issues. Its centrifugal expansion and dynamic responsivity allows for fixation-free defect obliteration, thus avoiding complications, above all tissue tear, bleeding, mesh invagination, discomfort and chronic pain. In accord with the degenerative pathogenesis of hernia disease, by acting as a regenerative scaffold, ProFlor-E® restores the inguinal barrier promoting the regeneration of the typical inguinal components.

CONCLUSION

This initial experience seems to prove that ProFlor-E® can also be used with the laparoscopic approach achieving excellent results.

Comparison of Lichtenstein Repair and Mesh Plug Repair Methods in The Treatment of Indirect Inguinal Hernia

Objective: The lifetime risk to develop an inguinal hernia is 27%-43% for men and 3%-6% for women. Methods of hernia repair currently involve prosthetic mesh applications. The aim of this study is to compare the Lichtenstein repair and Mesh-plug repair methods in the surgical treatment of indirect inguinal hernias and to identify which of these two techniques is superior regarding its conferred advantages.

Materials and Methods: In this study, a total of 102 patients who were diagnosed with indirect inguinal hernia between the years 2014 and 2015 without a previous operation were analyzed. Patients undergoing Lichtenstein repair and Mesh-plug repair were compared, especially during operation time, hospital stay, postoperative pain and other aspects.

Results: The mean age of patients was 28.7 years (19-73). The mean duration of operations and hospitalizations was significantly shorter in patients who had undergone mesh-plug repair. Inguinal pain in the operation area on postoperative day one, two weeks and six months was significantly less in patients who had undergone mesh-plug repair. Patients were followed-up for two years.

Conclusion: We concluded that mesh-plug repair was superior to Lichtenstein repair regarding postoperative pain, quality of life of the patient, shorter duration of operation, and duration of hospital stay although the two methods were similar regarding both recurrence and complication rates. Considering this information, we suggest that mesh-plug repair can be used safely for the treatment of indirect inguinal hernias.

A new fixation-free 3D multilamellar preperitoneal implant for open inguinal hernia repair

SUMMARY

Between September 2014 and December 2015, 32 patients with inguinal hernia were treated using a new 3D mesh in our department. This mesh is characterized by a multilamellar flower-shaped central core with a flat, large-pore polypropylene ovoid disk that has to be implanted preperitoneally. Compared with the traditional Lichtenstein procedure, we observed a shorter mean duration of surgery and a significantly lower mean visual analogue scale (VAS) postoperative pain score recorded immediately after the procedure in the 3D mesh group. The mean VAS score recoded after 4 and 8 postoperative days showed better results in the 3D mesh group than the control group. Moreover, there was reduced postoperative morbidity in the 3D mesh group than the control group, even if no patients experienced severe complications.

Emerging Trends in Abdominal Wall Reinforcement: Bringing Bio-Functionality to Meshes

Abdominal wall hernia is a recurrent issue world-wide and requires the implantation of over 1 million meshes per year. Because permanent meshes such as polypropylene and polyester are not free of complications after implantation, many mesh modifications and new functionalities have been investigated over the last decade. Indeed, mesh optimization is the focus of intense development and the biomaterials utilized are now envisioned as being bioactive substrates that trigger various physiological processes in order to prevent complications and to promote tissue integration. In this context, it is of paramount interest to review the most relevant bio-functionalities being brought to new meshes and to open new avenues for the innovative development of the next generation of meshes with enhanced properties for functional abdominal wall hernia repair.