Parshikov V.V., Samsonov A.V., Romanov R.V., Gradusov V.P., Samsonov A.A., Hodack V.A., Petrov V.V., Zibusov S.N., Baburin A.B., Kichlyarov P.V., Kasantzev A.A.
Nizniy Novgorod State Medical Academy. March 2012
Background: The modern approach to abdominal wall repair in patients with hernias is based on the principals of tension-free technique and usage of synthetic materials. The search for the “perfect” implant is being still conducted. At present there are no data concerning the implantation of titanium mesh in hernia surgery.
Methods: Basic group of patients (n=34) was composed of patients with new meshes made of titanium (titanium silk) with diameter of thread 60-140 mkm. In control group of patients standard meshes from usual materials (polypropylene) were used. Abdominal wall repair was undertaken in patients with inguinal hernias with Lichtenstein technique, in cases of umbilical and paraumbilical hernias – according to sublay preperitoneal. The follow up study of the postoperative period was taken clinically, in laboratory and with help of ultrasound tomography (CEM ThermoDiagnostics).
Results: There were no any specific difficulties of implantation procedure of titanium mesh observed. There were no purulent complication, recurrent hernias and mortality. Duration of hospital stay in both groups have no significant difference. Speed of local blood circulation (a. testicularis) 2-7 days post operatively was significantly higher (M=27) than in contra lateral area (M=18) without complications (p=0,005). The difference of thermografic data between the operation zone and comparison point in main and control groups was 0, 8 and 1,90C in control group respectfully. (p=0, 01).
Conclusion. The application of titanium mesh is not associated with the development of any complications. It doesn’t influence hospitalization and complication rate. It doesn’t make worse testicles blood supply. The aseptic inflammatory reaction is less evident while using titanium silk than in operations with polypropylene mesh.
The modern approach to abdominal wall repair in patients with hernias is based on the principals of tension-free technique and usage of synthetic materials.[1,2] Mesh repair can significantly minimize relapse number and provide high quality of life . Usage of synthetic materials is common both in plan and emergency herniology . Nevertheless there may be some complications: chronic pain syndrome, feeling of the foreign body, fertility disorder and purulent inflammation [5, 6, 7, 8]. The main reason of all problems is the existence of permanent inflammation in the area of implantation connected with graft material. There is a great number of different meshes and techniques of implantation, which is the prove of perfect one absence [9, 10, 11]. Meshes made of metal threads have already been used in surgery, the first material being silver . Nowadays titanium constructions are widely used in traumatology and orthopedics . In literature we can find a few number of works devoted to the usage of nikelid titanium threads. There are some notices concerning this material meshes for the surgical hernias treatment [14, 15]. Titanium mesh is used in oral surgery abroad . The description of combined titanium plates and synthetic polymer mesh method is published . The results of the repair with a help of polypropylene mesh with titanium covering proved to be positive . Everything mentioned above gives us an opportunity to consider the interest to the material and its perspectives. In the experiment it was proved that titanium threads mesh is fully integrated in to the tissues and can be implanted [19, 20]. But we didn’t come across the information concerning the use of titanium meshes for the hernia repairs.
The objective of work
To study first experience of titanium silk meshes appliances in clinical practice.
Materials and methods
Department of clinical surgery named after Korolev B.A., clinical department of City Hospital № 35.
Prospective controlled study was conducted. There were under supervision 86 patients of 49-86 years of age with inguinal, umbilical and paraumbilical hernias: with umbilical and paraumbilical (M,W1-2,R0-1 by Chevrel-Rath), inguinal (M,L,R0-1,Finger 1-3 according to the classification of European Hernia Society 2008). The main experimental group (n=34) was composed of subjects operated with a help of new meshes (titanium mesh “Titanium silk” for the reinforcing plastics of soft tissues- implant made of 60-140 mkm thickness titanium threads). Control group was composed of patients (n=52) with polypropylene meshes implants ( mesh thickness -500 mkm, thread- 120mkm, weight- 62g/m2). In inguinal hernias method I.L.Lichtenshtein was used, in umbilical and paraumbilical sublay preperitoneal method was used. Interventions were conducted under local or total infusion anesthesia (groups had no significant differences).All patients received antibiotic prophylaxis in the area of future intervention and preventive measures for venous thrombo embolism. Operation technique was according to resolution requirements of VII Russian Herniological Conference (2010), International Congress of European Hernia Society (2011), recommended and described in literature [1, 21, 22, 23] Groups were correlated according to gender, age, main and co-pathology, abdominal wall defects size and methods of repair. All the operations in both group were conducted in the same clinical department and at the same period of time. The experiment included patients both with elective operation and emergency. Titanium silk meshes implantations in the cases of inguinal and umbilical hernias are shown in pictures 1 and 2. Postoperative period follow up was taken clinically, in the laboratory, with a help of ultrasonograf (Madison) in 2D regimes, colored Doppler and impulse Doppler scanning and local thermo graphics( CEM Thermo Diagnostics) [24,25]. Data were analyzed statistically with Origin Pro 8 ( Mann-Whitney Test) Windows 7 on the computer Emachines. Patients are followed in the 3 and 7 months term.
Results and discussion
During the operations there was no difficulties connected with new material implantation. No mortality was noted. Eventrations and recurrences were not noted either. There was no infiltrations and purulence. 1 hematoma in main group and 1 hematoma in the control group were observed p=0.63 Bed- day was 8.5 and 9.1 respectively p=0.77. Patients with inguinal hernias had a. testicularis blood flow in the norm ratio (6-26sm/s), but it was lower on the hernia side. Data mentioned correlate with other authors’ data .
The same indexes became significantly higher (M=27) than contra laterally ( M=18) on the 2-7th day under the condition of no complications (p=0.005). Blood flow dynamics correlation from mesh material in short term period was not determined. So, Titanium silk mesh application for inguinal hernia repair doesn’t deteriorate testicles blood supply. Thermo graphic picture of the early postoperative period showed the first stage of reparative process after operation (aseptic inflammation). Inflammatory reaction after titanium silk happened to be less prominent than after polypropylene mesh repair (Pic. 3, 4).
By the 6th day after titanium mesh implantation aseptic inflammation mainly reduces, but after polypropylene mesh implantation it has prolonged characteristics (pic.5,6). In uncomplicated postoperative period anizothermia between intervention area and point of comparison in experimental and control group were 0.8 and 1.9 respectfully, p=0.01. So local tissue reaction to the titanium silk implant was less. Those data do not counteract with other data . Technological development, clinical data analysis and experimental works allow invention of better and more perfect implants and their application in practice [26, 27, 28, 29]. The majority of authors support the idea that mesh should have macro pores and enough weight and durability [28, 29]. It provides the least inflammatory response and graft elasticity . It’s known that durability of some implants is too high . On the other hand light mesh application is associated with higher recurrence rate . Mild inflammatory reaction may lead to unsatisfactory durability of the tissues formed around the mesh that can influence the recurrence. Another moment to take into consideration and study in the future is the effect of mesh wrinkling as a reason of unsatisfactory treatment results. In the following study this phenomenon wasn’t observed under ultrasound examination, but the time of follow up studies was not large. According to the data available this phenomenon is common for the majority of modern Minimal inflammatory reaction.
The first clinical experience of titanium silk mesh application proved to be positive. The mesh usage had no purulent and inflammatory complications. Implantation had no rejection reaction. Titanium mesh application is not connected with any specific for this material complications. Titanium mesh use doesn’t increase the hospital stay and complication rate in comparison with the group of patients who got polypropylene mesh repair. Plastics by Lichtenshtein with titanium silk don’t deteriorate testicles blood supply. Aseptic inflammation reaction is less in titanium silk application than in polypropylene mesh implantation. Data obtained proved the possibility of titanium silk implants usage in herniology. This question needs further investigations.
- Zverov I.A., Bazaev A.V. Surgical treatment of patients with ventral hernias: current issues. Modern Technologies in Medicine. 2010. № 4. С. 122-127.
- Yermolov A.S., Blagovestnov D.А., Upirev A.V., Ilichev V.A. General principals of strangulated abdominal wall hernia surgical treatment. Medical Anthology. 2009. № 3 (8). С. 23-28.
- Snyder C.W., Graham L.A., Vick C.C. et al. Patient satisfaction, chronic pain and quality of life after incisional hernia repair: effects of recurrence and repair technique. Hernia. 2011. № 15. Р. 123-129.
- Parshikov V.V., Medvedev A.P., Samsonov A.A. Non stretching plastics in abdominal wall hernia treatment. Surgical Anthology after the name of Grekov I.I. 2010. № 5. С. 74-79.
- Petrov V.V. Life quality of patients after hernioplasty. Medical Anthology. 2009. № 1 (6). С. 100-103.
- Rehman S., Khan S., Pervaiz A., Perry E.P. Recurrence of inguinal herniae following removal of infected prosthetic meshes: a review of the literature. Hernia. 2011. Р. 20. Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed/21858435. urgical
- Moussi A., Daldoul S., Bourguiba B. et al. Gas gangrene of the abdominal wall due to late-onset enteric fistula after polyester mesh repair of an incisional hernia. Hernia. 2010. С. 5.
- Hallen M., Sandblom G., Nordin P. et al. Male infertility after mesh hernia repair: A prospective study. Surgery. 2011. № 149 (2). Р. 179-84.
- Fedorov P.F. Implants in hernia surgery: a hundred years evolution. New Surgical Achieve. 2002. № 4 (1). Available from: URL: http://www.surginet. info/nsa/1/4/ns021414.html.
- Bringman S., Conze J., Cuccurullo D. et al. Hernia repair: the search for ideal meshes. Hernia. 2010. № 14 (1). Р. 81–87.
- Brown C.N., Finch J.G. Which mesh for hernia repair? Ann R Coll Surg Engl. 2010. № 92 (4). Р. 272–278.
- Schuh A., Uter W., Kachler W. Comparative surface examinations on corund blasted titanium implants and explants in total hip arthroplasty. Arch Orthop Trauma Surg. 2005. № 125 (10). Р. 676-82.
- Zcherlov G.K., Gunter V.E., Koshel A.P. ret.al.Surgical treatment of reflux-esophagitis. Surgery. 2004. № 7. С. 9-14.
- Zotov V.A. Surgical treatment of abdominal wall hernias. New Surgical Achieve. 2002. № 4 (1). Available from: URL: http://www.surginet.info/ nsa/1/4/ns02145.html.
- Radkevitch A.A., Kuzmenko I.I., Gunter V.E., Ovcharenko V.V. A method for treatment of ventral hernia. Patent Of Russian Federation № 2223050. 2004.02.10.
- Sun J., Shen Y., Li J., Zhang Z.Y. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant. Plast Reconstr Surg. 2011. № 127 (1). Р. 150-60.
- Berthet J.P., Canaud L., D’Annoville T. Titanium plates and Dualmesh: a modern combination for reconstructing very large chest wall defects. Ann Thorac Surg. 2011. № 91 (6). Р. 1709-16.
- Schardey H.M., Schopf S., Rudert W. et al. Titanised polypropylene meshes: first clinical experience with the implantation in TAPP technique and the results of a survey in 22 German surgical departments. Zentralbl Chir. 2004. № 129 (5). Р. 363-8.
- Chernov A.V. Investigation of implant properties of titanium mesh structers. Conference materials devoted to 200-years of Pirogov N.I. Kurgan. 2010. 106-108. Available from: URL: http://www.temp-ekb.ru/artkurganm.html.
- Cheernov A.V., Radchenko S.A., Iryanov U.M., Chernov V.F. Problem of biocompatible grafts integration into alive tissue. Conference materials devoted to 200-years of Pirogov N.I. Kurgan. 2010. С. 108-112. Available from: URL: http://www.temp-ekb.ru/artkurganm.html.
- IgievV.N., Lyadov K.V., Voskresenskiy P.K. Surgery of hernias atlas.– М, 2003. С. 228.
- Crovella F., Bartone G., Fei L. Incisional hernia. Incisional hernia. Springer. 2007. С. 261.
- Simons M.P., Aufenacker T., Bay-Nielsen M. et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009. № 13 (4). Р. 343–403.
- Baburin A.B. Method of infrared thermometry for evaluation of postoperative period in patients with abdominal wall plastics due to hernias. Current Technological issues in Medicine. 2011; 1: 99-101.
- Solovyev A.A., Sahazchik M.N., Popkova S.V., Gayduk V.P. Homodynamic indexes of testicles in patients with inguinal hernias. Andrology and genitalic surgery. 2009; 1: 33-38.
- Sukovatich B.S., Bezchin A.I., Netyaga A.A. et al. Experimental support and clinaical application of domestic implant “Esfil” for the abdominal wall reconstructive surgery. Surgical Anthology after the name of Grekov I.I 2004; 7: 47-50.
- Sedov V.M., Gostevskyi A.A., Tarbaev S.D. et al Mesh grafts made of povinilidenftoride in the treatment of abdominal wall hernias Surgical Anthology after the name of Grekov I.I 2004.8; 2: 16-21.
- Conze J., Kingsnorth A.N., Flament J. B. et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 2005; 92: 1488-1493.
- Zchukovskiy V.A. Polymer implants for herniaplasty. Eskulap 2011: 104.
- Jonas J. The problem of mesh shrinkage in laparoscopic incisional hernia repair. Zentralbl Chir 2009; 134(3): 209-13.
- Sergent F., Desilles N., Lacoume Y. et al. Biomechanical analysis of polypropylene prosthetic implants for hernia repair: an experimental study. Am J Surg 2010; 200(3): 406-12.
- Mamy L., Letouzey V., Lavigne J.P. Correlation between shrinkage and infection of implanted synthetic meshes using an animal model of mesh infection. Int Urogynecol J 2011; 22(1): 47-52.
- Liu X.K., Zhang Q., Li Q. et al. Laryngeal framework reconstruction using titanium mesh in glottic cancer after frontolateral vertical partial laryngectomy. Laryngoscope 2010; 120(11): 2197-202