Chapters Transcript Video Materials Matter — Hybrid biomaterial science, experience with GORE® SYNECOR Biomaterial - Cheguevara Afaneh, M.D. um, so we already sort of talked about by away, so I'm not gonna spend too much time on this. Um, interesting that you can see that the vascular charity increases in by away as early as one week after implantation, which is nice, Um, in the cellular in growth is, um, really sort of takes off right around that sort of second week after implantation. Um, I have a pretty large experience using cynic or in England hernias, Um, with very respectable outcomes. You know, like everybody said, it's pretty strong stuff. Works well, um, use it, uh, in a lot of England hernias, Um, that we do. It's not one size fits all. Just like Dr Hannaford said, It's variety, just like patients are different. Um, do a little bit of a video review here, but this is, uh, obese patient and sort of with the bariatric background. Um, you sort of general surgery, things that are, uh, slightly larger patients tend to show up in your office as well. So, um, wind up sort of doing a lot more of the morbidly obese inguinal hernias, then the general and trauma surgeons in the hospital. And sometimes these are our own patients here, Um, using our tap technique. Um, we've done two instruments and three instrument England hernias. In fact, I'll show a little bit of data on a paper that we published on that to sort of see where the sweet spot is and doing that. Um, this patient had a BMI of 44. So 45? Not sure. But here you can see, we find that Cooper's ligament and really sort of expose it. You can see there's a lot of prepare to kneel fat, just based on the size of the patient. There's a cord lymphoma as well. Um, the way we tackle these is sort of medial, then lateral. And then we sort of go for the hernia at the end to sort of take the tension off the dissection. Uh, that way, um, this patient ends up having the lymphoma as well, which we end up reducing for our sort of inferior dissection. We make sure we get down to the so s tendon and make sure that we've got ample room for sort of mesh placement. And here we're really sort of pushing the hernia sac away as an indirect hernia, as can clearly be seen at this point, um, we do this whole dissection using the mono polar scissors as well as the administrative bipolar. And then when we end up featuring the flap closed at the end will end up switching to a large needle driver. Here, we're pushing the hernia sac away from us, making sure that the chord structures come down. And then we want to make sure that the peritoneal flap is really sort of nice and flat. It's fairly large hernia in a fairly large patient here. We've almost got the sack completely reduced. And now we really want to sort of flatten out the, uh, peritoneal flap at this point so that the mesh doesn't roll as we close it. Uh, these cases aren't always pretty, just based on the fat of all, based on the fact of all the fat. But you can see here wide and pretty large hernia sac completely reduced. This is a sheet of 12 by 15 cynic or pre, Um, we, uh we mark the corner, the medial corner more so because 12 by 15 sometimes looks like a square when you put it in. Uh, a little harder to tell, um, the sides of the rectangle. So we just put a marking so we know where we're gonna end up fixating. And then we take a, Uh, three ov locks future, and we fixated to, uh, the pubic cubicle here. A few places, we break it, we drop our new mo, and then we close the flat Pretty easy to manipulate. Um, this is a slightly larger defects, and we'll put a couple extra stitches more so So it doesn't move as we're closing, As there's no real strength to sort of placing these stitches, we just don't want it moving around. Uh, so much as we're closing the flap here, we drop the new MO. You can drop it as low as four or six if you really need to. If there's any adhesions to the peritoneum from the colon, it's nice to take those down sometimes just to avoid, um, too much weight on the sack. This is a paper we talked about. Where we compared two versus three instrument England. A hernia is using the robot. This is a paper where all of the all of the mess used is a cynic or in this case, and what we did is we matched consecutive England hernia patients, Um, undergoing, um, anyone Hernia repair with us in a corporate mash with two instruments where one is a super cotton needle driver versus three instruments where there's no super cut needle driver. And instead they're scissors. Um, and we found that the only difference was the operative time was about six minutes faster in the, uh, three instrument group. And the study is really more about cost effectiveness. It really depends on where you practice, so a minute in our operating room costs about 88 or $89. Um, so for us where we practice, it's actually cheaper to go with three instruments as opposed to two. But let's say you practice, um, in a state where A minute in the operating room may be only $30, then it's a lot cheaper for you to then go on and use uh, two instruments instead. The inflection point based on the cost instrumentation happens right around five and six minutes. Um, this is just sort of showing another piece of mesh of the cynic, or it's pretty easy to manipulate. Sits nicely in the groin. Pretty strong stuff. Um, showed our outcomes recurrence rates right around 1%. Sort of on par for the course. Um, the nice thing, though, um, that we studied was that, um the incidents of chronic pain is a little lower compared to when we use some, uh, some more synthetic type meshes. Um, but, uh, outcomes from a recurrence rate are about the same. The nice thing, though, is that you use less office resources. If you can avoid some phone calls about them feeling the mass, you're feeling pain. We're gonna move on for the sake of time. Um, this is what cynic or looks like it's really sandwiched by away. And this is the intraperitoneal virgin, the i p. But it's got by away on one side. Um, by the way, on both sides and PTSD, right in the middle, sort of sandwiched. And then the I P form obviously has the the coating on it to prevent the bow from sticking. You know, over the 6 to 7 months to buy away portions are re absorbed in your own tissue college and gets deposited in its place. But you're still up with some synthetic material in the sense that the P T. F E s sort of is your your permanent material. The prepared meal form is exactly the same, with the main difference being is that it's an uncoated mesh. Um, And then again, as Dr Goldblatt brought out, you know, we're gonna look at some cellular pictures here, Um, and then this is looking at bacterial adherence in the actual knit fibers and sort of comparing it to polypropylene, where the bacteria is green and the polymers and red, And you can see really a big difference between, uh, cynic or, um and, um, polypropylene knit material in terms of bacteria is sort of being harbored in these sort of knots of the knit fiber. So we take the P T f e, and we sort of mix it to buy a way. That's really sort of how we get the cynic or mesh at the end of it. Um, talk a little bit about our ventral and decisional hernias. I'd say about 40, um, 40% of the abdominal wall hernias that we repair are done in a pre peritoneal fashion. Um, the remainder are retro muscular. Um, sometimes in on lay in specific situations. Uh, and then I palms are really sort of reserved for middle of the night operations. Usually, um, or patients who are sort of noncompliant with the treatment plan. We asked them to stop smoking or lose weight. They don't and they come in and they're incarcerated. Which case? Typically in those cases, we will just, you know, opt to do closure of the fashion with a lap hybrid, slash open approach or robotically. We'll just close the defect and, uh, and just put in sort of an IPOD mesh, sort of like Dr Cobb said, um, we're not really docking the robot at two o'clock in the morning for emergencies yet at our hospital, if we're using the robot that day and something comes in and it's sort of still relatively, um, early in the evening, like six or seven o'clock, we'll probably able to Dr Robot for those cases. But if we sort of finished cases for the day, they're not really gonna let me Dr Robot at two in the morning. The biggest reason is probably because not all the staff are really sort of well versed. And, uh, like you said, you may have the cardiac circulator and the neurosurgery scrub tech sort of scrubbed in for the cases. We've had good outcomes with the prepare to kneel work. Um, really sort of works. Well, it's my choice for smaller hernias if you have a little umbilical hernia, three cm or so ventral hernias, you know, even for up to about 5cm. Um, typically, I'll not want to violates, um, the retro muscular space for some of the smaller hernias and sort of save it for another day in case the patient needs it. Um, when we get to larger hernias or incision, ALS were more likely to do retro muscular work. Um, and that's sort of our approach. We close these defects under low nu mo using zero Villach futures. Usually, sometimes we have to put in an interrupted stitch or two to sort of bring things back together and take some of the tension off of it. And then I will fast forward a little bit on the suit string. Sure, it was our sort of mesh covering our defect. And then we close our flap using a three OV locks future. Um, we do have an earache protocol. Um, pre operatively. They do get a slew of medications, including, uh, amend. Um celecoxib, Uh, Lyrica, Tylenol. Um, we use tap locks routinely. In fact, we got into the habit of doing tap blocks for everything. We even use it for gall bladders at this point. So anybody who undergoes surgery typically gets a tap lock and then post up patients, uh, get Tylenol standing and they usually go home with some kind of mild narcotic. We take a look at cynic or, um, vascular charity, sort of at one week. Um, this is sort of an ex plant at one week. And looking at it, you can see that there's already sort of neo angiogenesis and some vascular pretty within the mesh itself. So it leads to good tissue integration. We take a look at the actual inflammatory response of the body against the mess. You can see that, Um, that, by a way, which is really on the outside, which is what the body is going to react with, first really has a very, very low inflammatory profile, even less so than some of the biologics, which is really nice. And this is really sort of reiterating the tissue replacement 1-1 with your own tissue collagen. So we get good tissue generation with it when we sort of do a test of sort of ball bearings. We see that at two weeks, Um, compared to six months, it's really twice as strong. So it's the kind of material that just gets better with time, At least at that six month mark. Mhm and sort of comparing it on the barber strength versus poor size. Um, it's, um, sort of behaves like a mid weight mesh, but has some properties of a lightweight mesh as well. So you don't really compromise the strength. Um, so we really sort of get something that really works well for a lot of different uses. And, uh, I use it a lot for ventricles and incision. Als, um, I use it in immuno suppressed patients. Former smokers, um, transplant patients, patients who are undergoing chemotherapy, um, Majority of the hernia. As we deal with our incision a little probably about 3-1 incision, all two ventricles, and again I palms are I did a lot of them early on in my career, but have really sort of moved away because there's just some better options. Do a lot more tap work. Um, you know, Tarr's, you have to sort of be selective. I start to consider its horror right around 89, 10 centimeters, sort of at that size. Um, sometimes you plan on not doing a tar and sort of you feel like you just got a little bit too much tension despite dropping the new mowed down as low as possible. Um, in some of those cases, I may do just a unilateral release. Uh, if I think there's too much tension on the interior fashion closures, Um, I have no problem doing a hybrid tar or hybrid retro muscular repair just to make sure I can get the anterior fascia closed. Patients do well, recurrence rates Pretty low. Um, follow ups just short of two years, but have about a 6% recurrence rate for this, Um, just sort of showing a little bit more of the pre peritoneal work here. I'm just sort of make a little bit more space for the mesh in this case, and we're sort of tackling the rest of this defect at this point. Yeah. Yeah, and then we're just sort of measuring the space here. And, uh, like I said, um, going retro muscular for smaller hernias. Um, just seems like you are using a jackhammer when you really just need a little small hammer to sort of nail something down here. Um, work with trainees regularly. Um, this is where we let them do a lot of their practice sewing on the robot. Um, typically, we don't fixate. Um, the mesh. I'm a firm believer in, uh, you know, uh, try to sort of keep the mesh, um, to be a little bit smaller than the flap size, and it's kind of like a letter in envelope sort of mentality. And then we close the flap, you can kill some of the dead space, and I'll sort of quote fisher for this is that you're responsible for the dead space you create. And I think that's the same minimally invasively as well. So, um, you can really sort of cheat and take more of the flap to make it. Uh, more of the dead space is really sort of reduced at this point. Um, we talked about in form, and Dr Goldblatt has finished talking to us. about inform. So I'm going to sort of move past this. Um, I don't do a lot of open, um, surgery, but the open surgery I do is sometimes hernias by far. It's the most common open surgery that I would do. Um, we have a robust liver transplant program. Um, those patients sometimes go back to the operating room one or two days, three days after surgery for bleeding or the graft is swollen. Um, they used to use biologic to bridge closed, and they sort of got me involved about sort of cost reduction. So we started using n form to bridge the transplants closed that come back for a take back. We try to primarily close them, but sometimes the graft is so swollen that it's it's really impossible. And, uh, we're not gonna do a component separation because that graft is going to shrink in size. So if we wait it out, we can come back and just fix this as a hernia. So Well, Bridget, with a piece of inform tram flaps is another one. Um, that we may end up using, uh, in Foreman to sort of re shape and contour the abdominal wall This is a patient with stiff man syndrome, and that's her stimulator on the left side of her abdomen. She has a bulge on the right side, but no true hernia. We end up sort of reshaping her using inform and some publication of the muscle in that area. All right, so and for a cynic, or is really great for minimal inflammation? Um, it really gets stronger over time, and it's cheaper than some of the biological alternatives by far. And it's pretty easy to use. I'm going to continue on to the next section unless anybody has any questions at this time. All right, please, about No, it is not. So this is off label use, Yeah. Published December 15, 2021 Created by
