This document announces a one day endoscopy workshop and continuing medical education event taking place on September 1, 2013 at Lotus Hospital in Erode. It will be hosted by the IMA Tamil Nadu State Branch AMS Wing, IMA Erode Branch, and ASI Erode City Chapter. The event will include live endoscopy workshops, lectures, panel discussions, and case scenarios focused on diagnostic and therapeutic endoscopy techniques. Delegates and postgraduates can register for Rs. 1000 and Rs. 500 respectively. The workshop and CME will run from 8am to 6pm and cover topics such as variceal banding, stricture dilation, endoscopic guidelines, and management of corrosive strictures

2. Endoscopy Conclave
One Day Live Endoscopic Workshop & CME
01.09.2013
Sunday, 8am-6pm
AC Auditorium-Level V
@ Lotus hospital, Erode
Hosted by
IMA TN SB- AMS Wing
IMA Erode Branch
ASI Erode City Chapter
Delegates: Rs:1000/- Postgraduates: Rs: 500/-

3. Morning Session: ( 8am-1`pm)
•Live Endoscopy workshop: Basic
Diagnostic/ Banding of Varices/Sclerotherapy
Dilatation of Stricture esophagus
•10 min Lectures on ‘Endoscopic Practice Guidelines ‘
Endoscopic management of Corrosive stricture: When and How?:
Management of variceal bleeding: Before and after endotherapy:
Role of endoscopy in Upper GI malignancy
FB esophagus:
•Live Endoscopy Workshop: Advanced
Stent deployment/Glue Injection of Fundal varices
Polypectomy
•‘Futuristic’ Lectures:
 Tomorrow’s World of Endoscopy
Why surgeons should always be doing endoscopy?:
Endoscopy in the era of Laparoscopy:
•Endo quiz:
Post Lunch Session(2-4pm)
•Panel Discussion: Team approach in the management of GI disorders:
GERD, Achalasia, Upper GIBleeding , Bile duct stones,
•Live Colonoscopy/ERCP Workshop
Colonoscopic polypectomy
Bile duct stone removal/Stenting
Pancreatic endotherapy
•Challenging situations for endoscopist
Upper GI bleeding with normal endoscopy: How to proceed?:
Difficulty reaching caecum during Ccolonoscopy : Tricks of the Trade:
Post Tea Session( 4-6pm)
•Humour in Gastroenterology
•Convocation and Award Ceremony at 4.30pm

4. CURRENT MANAGEMENT OF
INCISIONAL HERNIA
Dr.S.Easwaramoorthy
Dr.TC.Gnanasekaran
Dr.KV.Durairaj
ASI Erode City Branch
PROF.JR.SANKARAN SYMPOSIUM
@TN&P ASICON 2013

5. Symposium on Management of
Incisional hernia.
 Dr.S.Easwaramoorthy 20min
 Pathogenesis of Incisional hernia
 Prevention of incisional hernia
 Evaluation and Current management of incisional hernia
 All, we should know about Mesh for hernia!
 Dr.T.G.Gnanasekaran 15min
 Open mesh repair and abdominoplasty
 Dr.K.V.Durai raj 15min
 Laparoscopic mesh repair of incisional hernia
 Case scenarios and discussion 10min

7. Incisional Hernia
Why it happens?
Patient factors
Surgeon factors
Disease factors

8. Patient Factors
 Obesity
 Diabetes
 Renal Failure
 Anaemia and Hypoproteinemia
 Post Operative Chest Infection

9. Disease Factors
 Peritonitis
 Visceral Cancer/ascites
 Colostomy

10. Surgeon’s Factors
 Incision
 Low midline/ Subcostal
 Drain/Stoma
 Wound Protection
 SuturingTechnique

11. Suturing Technique
 Type of Suture material
 Absorbable :Vicryl/PDS/Dexon
 Non absorbable : Nylon/Prolene/Ethibond
 Size of Suture
 Technique of Suturing

12. Peritoneum?
1 cm across and 1 cm apart
Rule of 4

13. Clinical Assessment
Lying Standing

14. Loss of Abdominal Domain

15. Role of Imaging in Incisional Hernia
CT Abdomen

16. How to manage Incisional hernia?
 Open procedure (with Abdominoplasty)
 Anatomical Repair
 Component Separation technique
 Mesh repair
 Sublay, Inlay, Onlay
 Laparoscopic repair
 IPOM

18. How to manage Incisional hernia?
 Open procedure (with Abdominoplasty)
 Anatomical Repair
 Component Separation technique
 Mesh repair
 Laparoscopic repair
 Mesh repair

19. Why Mesh?
 Low recurrence rate
 Inguinal hernia repair
 Bassini’s repair : 10%
 Shouldice repair : 1%
 Lichtenstein’s Mesh repair : <1%
 Ventral hernia
 SutureVs Mesh: : 50%Vs 10%
 Tension free & Pain free
 Quick recovery
 Quick to learn and easy to do!

20. Why Mesh?
Pathogenesis of Hernia
 Defective Collagen
 Reduced ratio of type I and type III collagen
 Type I: MatureCollagen, strong and normal tissue
 Type III: ImmatureCollagen, weak, in healing wounds
 Type I :Type III ratio normally is 4:1
 Connective tissue pathology is not only a cause of primary
herniation but its presence can prevent cure!
 Increased matrix metalloproteinase activity(MMP)
‘Understand theWound Biology’
A role for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia?
Raphael Rosch, Uwe Klinge, Zhongyi Si, Karsten Junge, Bernd Klosterhalfen, and
Volker Schumpelick, BMC Med Genet. 2002; 3: 2.

21. Lichtenstein’s Mesh Repair
Tension Free repair
•Under LA
•Day care
•Low recurrence rate!

22. Billroth’s Vision
‘‘If we could artificially produce tissues of the density and toughness of
fascia and tendon the secret of the radical cure of hernia would
be discovered’’.
- Beitrage zur Chirurgie (1878)

23. Inventor of Prosthetic Mesh repair:
Dr. Francis Usher (1908-1980)
• Inventor of Polyehylene(Marlex) and Polypropylene mesh
• Several Animal studies about their inertness
• 20 papers
• Innovative ways of placing the meshes: Inlay,Overlay, Sandwich tech etc

24. Stoppa’s Mesh Repair
Pre peritoneal Mesh Over Myopectineal Orifice
GPRVS
‘‘In the adult, repairing
inguinal hernias in the inguinal canal and femoral hernias
in the femoral canal is like closing the curtain instead
of shutting the window’’

25. Mesh repair of Incisional Hernia
 Why Mesh?
 What type of Mesh?
 Where to place the Mesh?
 How to fix the mesh?
 Mesh related complications

26. Types of Mesh
 Synthetic Mesh
 Non absorbable
 Polyprophylene(Prolene)
 Polyethylene(Marlex)
 Polyester(Dacron)
 PTFE (Teflon/Gordex)
 Absorbable
 Vicryl
 Combined
 Vipro
 Synthetic with Absorbable Barrier( Dual mesh)
 Parietex
 Proceed
 Etc
 Biological Mesh
 Surgisis ( Porcine submucosa)
 Alloderm (Cadaveric human dermis)

27. What Mesh
Light weight Vs Heavy weight?
Light weight Mesh Heavy weight Mesh
Definition? Light wt, thin fibres,
macro pores (>1.5mm)
Less amt of FB
Heavy wt, thick fibres,
micro pores (< 1.5mm)
So more amount of FB
Qualities Flexible
Less FB reaction and pain
Stiffer
More FB reaction and pain
(Problem of adhesion, fistula)
Shrinks more
Stronger! - so what
Examples Ultrapro,Vipro Marlex, Dacron, PTEF
The lightweight and large porous mesh concept for hernia repair.
Klosterhalfen B, Junge K, Klinge U. Expert Rev Med Devices. 2005 Jan;2(1):103-17.

28. Laparoscopic Ventral Hernia Repair
Choice of Composite Mesh
Name Parietal side Visceral Side Longevity Remarks By
Parietex Polyester Atelocollagen,
PEG, Glycerol
20 days expensive Covidien
Proceed Polypropylene Oxidised (ORC)
regenerated
cellulose/PDS
30 days Ethicon
Sepramesh PP PGA/Hydrogel 30 days Davol
C QUR PP Omega 3 FA Atrium
ProVISC 160 Polyester Polyurethane Life Cost effective Lotus
Dual Mesh e PTFE (rough) e PTFE(smooth) Life Gore
Kugel/
Composix
PP(HW) e PTFE Life Cann’t trim Bard

29. Parietex Mesh
Features:
 Polyester with Collagen
cover on the visceral side
 No adhesion or infection
 Handles well during Lap
 Holds sutures well
 Can be trimmed
Moreno-Egea A, Liron R Girela E, Aguayo JL. Laparoscopic repair of ventral and incisional hernias
using a new composite mesh (Parietex): initial experience.
2001 Surg Laparoc Endosc PercutanTech Apr;11(2):103-6

30. Proceed Mesh (Ethicon)
 Parietal Side
 PP(LW) encapsulaed in PDS
 Blue stripped side
 Visceral Side
 ORC ( Oxidised regenerated
cellulose)
 Macroporous
 Conforms to anatomy
 Can be trimmed
Downside:
 Ensure meticulous hemostasis
or else adhesions likely
 Shrinks by 30%
 Delamination and seroma

31. Proceed Mesh (Ethicon)
Time line
1 week
2 weeks
Day 1
3 months

32. Pro VISC 160
 Polyester
 White Parietal side
 Polyurethane
 Blue smooth visceral side
 With Sutures
 Pre cut in various sizes

33. Parietal side: PP
Visceral side: e PTFE
Bard (Composix) Gore Dual Mesh
Parietal side: Rough PTFE
Visceral side: smooth PTFE

34. Mesh repair of Incisional Hernia
 Why Mesh?
 What type of Mesh?
 Where to place the Mesh?
 How to fix the mesh?
 Mesh related complications

35. Where to place the Mesh?
On Lay In Lay
Under Lay IPOM

36. Pascal’s Hydrostatic Principle
OnlayVs Inlay
Effect of Intra abdominal Pressure
Choose a mesh at least 5cm larger
than the defect all round.

37. Mesh repair of Incisional Hernia
 Why Mesh?
 What type of Mesh?
 Where to place the Mesh?
 How to fix the mesh?
 Mesh related complications

38. Mesh Fixation Methods…
AbsorbaTack (Covidien)
Permasorb (Davol / Bard )
Fibrin sealant
SpiralTackers
Staples
Fibrin Glue
Suture

39. Trans Facial Suture Fixation

40. Ideal Fixation Method
No Type of Fixation Features
1 Trans Fascial suture
fixation
Chronic pain
2 Suturing 2cm apart
3 SpiralTitatinum
Tackers
2cm apart
Double crown technique
Nerve entrapment, adhesion, rarely tacker hernia
4 Absorbable tackers For initial 1 year
5 Fibrin Glue Suitable for inguinal hernia
?Ventral Hernia: Alternative or Adjunct: needs trial.
Closure of Hernia defect to avoid mesh protrusion or displacement
To with stand the intra abdominal tangential force and also shearing
Force due to abdominal muscle contraction

41. Mesh repair of Incisional Hernia
 Why Mesh?
 What type of Mesh?
 Where to place the Mesh?
 How to fix the mesh?
 Mesh related complications

42. Mesh Related Complications…
 Infection
 Surgeon’s nightmare
 Intestinal adhesions
 Composite mesh for laparoscopic ventral hernia repair
 Bowel obstructions
 Erosion of the prosthesis into the adjacent hollow viscus
 Contraction of prosthesis
 At least 5cm larger than the size of the defect

43. Prevention of Mesh infection
Consider
 Patient factors
 Smoking
 DM
 Obesity
 Re operation
 Big incision
 Type of Mesh
 Macroporous vs microporous
 Impregnated mesh
 Technique
 LapVs Open
 On layVs In lay
 Prophylactic antibiotics
 Avoid unplanned enterotomy
 Infected field
 Absorbable mesh
 Biological mesh
Ventral hernia repair
•Risk of infection is 3-10% in Open mesh repair
•Risk of infection is < 1% in Lap Mesh repair

44. Conclusion
 Mesh repair of abdominal wall hernia is the
Standard of Care.
 Composite mesh has to be used for ventral hernia
 Avoid Mesh related complications , if possible

45. Next
 Dr.T.G.Gnanasekaran 15min
 Open mesh repair and abdominoplasty
 Dr.K.V.Durai raj 15min
 Laparoscopic mesh repair of incisional hernia
 Case scenarios and discussion 10min

46. •21year old lady,
•Para 1
•Large Incisional hernia following c-section
•Yet to complete her family
•SurgeryVs Conservative treatment
•Pregnancy after a mesh repair
•Mesh repair during C-section
Case 1

47. •40 year old obese lady
•Abdominal hysterectomy 5 years ago
•Incisional Hernia in Lower midline scar
•Has Symptomatic Gall stones
•Open /Laparoscopic/Combined
Case 2

48. •35 year old lady
•Laparoscopic hysterectomy 6 months ago
•Umbilical Port site Hernia
•Why?
•SutureVs Mesh?
Case 3

49. Endoscopy Conclave
One Day Live Endoscopic Workshop & CME
01.09.2013
Sunday, 8am-6pm
AC Auditorium-Level V
@ Lotus hospital, Erode
Hosted by
IMA TN SB- AMS Wing
IMA Erode Branch
ASI Erode City Chapter
Delegates: Rs:1000/- Postgraduates: Rs: 500/-