Combined Absorbable and Nonabsorbable Prostheses in the Treatment of Major Defects of the Abdominal Wall
The existence of polyester and polypropylene prosthetic meshes has provided a new dimension in the treatment of inguinal and incisional hernias. With the safety of these materials established, methods have been devised that would at last conquer pathology
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The existence of polyester and polypropylene prosthetic meshes has provided a new dimension in the treatment of inguinal and incisional hernias. With the safety of these materials established, methods have been devised that would at last conquer pathology that was once thought untreatable. These methods have gained popularity in Europe and throughout the world, thanks to the efforts of the French authors Rives et al. 1 and Stoppa and Warlaumont2 in particular. They and other authors3.4 have described operative techniques using prosthetic materials in preperitoneal sites. Unfortunately, despite the success of materials and procedures, infection and detachment of prostheses can still occur. Recurrence of a hernia after preperitoneal prosthetic mesh repair can and does happen and presents a situation that is not easily solved. The mesh becomes markedly adherent to surrounding tissues; granulomas, often infected, make it difficult if not impossible to handle the detached prosthesis. On occasion, the peritoneum is fused to a thinned out and ulcerated skin: a situation Rives et al.I called "loss of abdominal wall substance," a wide loss of soft tissues such that the margins of the breach cannot be approximated. These factors stimulated us to develop a technique involving the use of two prostheses. 5 The first one, absorbable (polyglycolic acid), substitutes for the peritoneum; the second one, nonabsorbable and made of polyester, functions as a supporting endoabdominal fascia.
tents are reduced into the peritoneal cavity. The peritoneum is incised along a curved line, extending bilaterally from the pubic tubercle, along the Cooper's ligament, anterior to the iliac vessels and psoas muscle, further laterally along the parietocolic gutter, to the anterior superior iliac spine, to reach anteriorly, along the flat muscles and the semicircular line of Douglas to the umbilicus (Fig. 39.1). The urinary bladder is partially mobilized anteriorly. A free edge of peritoneum is thus obtained that has not been scarred by previous operations and is therefore easily identified. A Vicryl® prosthesis is secured with inverted absorbable interrupted sutures to the peritoneal free edge so prepared. The Vicryl prosthesis, placed in direct contact with the viscera, allows closure of the peritoneal cavity, creating a new preperitoneal space between the Vicryl prosthesis and the abdominal wall (Fig. 39.2). A new, nonabsorbable mesh is then positioned in this space and anchored to the two ligaments of Cooper with Prolene® sutures. This nonabsorbable mesh (Dacron® or, more recently, Bard® mesh) is located in a deep retromuscular, preperitoneal site, adjacent to the just inserted Vicryl mesh (Fig. 39.3). The old prosthesis with its adherent parietal peritoneum remains in situ, acting as an additional supporting and padding layer. When possible, the muscular layer is approximated over the prostheses with interrupted full-thickness sutures.
Discussion Surgical Technique The technique is proposed for recurrent, often bilateral, inguinal hernias and
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