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Natural orifice imaging of the abdominal wall
At the Focal Point
Natural orifice imaging of the abdominal wall
A 58-year-old woman underwent elective repair of an umbilical hernia in October 2002. A dual-facing mesh (Parietex Composite; Covidien, Mansfield, Mass) made of polyester covered with an absorbable hydrophilic film on the visceral side was implanted by using the laparoscopic approach and was secured to the abdominal wall with a double crown of titanium helical fasteners (Protack; Covidien). In April 2008, the patient was again referred to our outpatient clinic because of a positive Hemoccult screening test. Physical examination demonstrated a normal abdominal wall, almost invisible scars from the previous laparoscopic surgery, a soft abdomen, and no palpable lesions in the rectum. After standard bowel preparation with polyethylene glycol, a colonoscopy was performed with the patient under light sedation. During withdrawal, the previously implanted parietal mesh was seen (A). Manual palpation of the abdominal wall and transillumination with the colonoscope confirmed that there were no obvious adhesions with the mesh. The
colonoscopy findings were otherwise unremarkable. Abdominal US with a 7.5-MHz linear probe was performed (B) and showed the double-layer structure of the mesh without adhesions between the mesh itself (left arrow) and the bowel (right arrow).
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Luigi Bonavina, MD, FACS, Emanuele Asti, MD, Davide Bona, MD, Department of Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, University of Milan, Milan, Italy doi:10.1016/j.gie.2009.05.001
Commentary Prosthetic mesh has been used successfully to reduce the occurrence of incisional hernias. Such mesh is a stimulus for the development of adhesions, however, especially if the mesh is placed within the peritoneal cavity. Polypropylene mesh is most commonly used because it is easy to handle and relatively inexpensive, but it causes a pronounced inflammatory reaction and is a strong stimulus for the formation of adhesions. Therefore, a variety of other modalities have been studied including, most recently, bioabsorbable membranes and coated meshes. The Parietex composite mesh used for this patient is a polyester mesh coated with an absorbable and hydrophilic film on its visceral side. The film is composed of a solution of oxidized bovine (water-soluble) atelocollagen type I, polyethylene glycol, and glycerol. Experimentally, within 3 weeks, the film is completely resorbed and a new peritoneal covering is formed over the mesh. The hydrophilic film has been shown to provide significant protection against bowel adhesions, although there is some concern that this composite may become more easily infected than some other meshes and that it may elicit a stronger inflammatory response. In the present case, we certainly see the close apposition to the bowel, although no adhesions were detectable. This mesh seems to have developed an intimate relationship to the adjacent bowel, but has not followed Kahlil Gibran’s advice for such a relationship, that there should be spaces in your togetherness. Lawrence J. Brandt, MD Associate Editor for Focal Points www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 783
Natural orifice imaging of the abdominal wall
A 58-year-old woman underwent elective repair of an umbilical hernia in October 2002. A dual-facing mesh (Parietex Composite; Covidien, Mansfield, Mass) made of polyester covered with an absorbable hydrophilic film on the visceral side was implanted by using the laparoscopic approach and was secured to the abdominal wall with a double crown of titanium helical fasteners (Protack; Covidien). In April 2008, the patient was again referred to our outpatient clinic because of a positive Hemoccult screening test. Physical examination demonstrated a normal abdominal wall, almost invisible scars from the previous laparoscopic surgery, a soft abdomen, and no palpable lesions in the rectum. After standard bowel preparation with polyethylene glycol, a colonoscopy was performed with the patient under light sedation. During withdrawal, the previously implanted parietal mesh was seen (A). Manual palpation of the abdominal wall and transillumination with the colonoscope confirmed that there were no obvious adhesions with the mesh. The
colonoscopy findings were otherwise unremarkable. Abdominal US with a 7.5-MHz linear probe was performed (B) and showed the double-layer structure of the mesh without adhesions between the mesh itself (left arrow) and the bowel (right arrow).
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Luigi Bonavina, MD, FACS, Emanuele Asti, MD, Davide Bona, MD, Department of Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, University of Milan, Milan, Italy doi:10.1016/j.gie.2009.05.001
Commentary Prosthetic mesh has been used successfully to reduce the occurrence of incisional hernias. Such mesh is a stimulus for the development of adhesions, however, especially if the mesh is placed within the peritoneal cavity. Polypropylene mesh is most commonly used because it is easy to handle and relatively inexpensive, but it causes a pronounced inflammatory reaction and is a strong stimulus for the formation of adhesions. Therefore, a variety of other modalities have been studied including, most recently, bioabsorbable membranes and coated meshes. The Parietex composite mesh used for this patient is a polyester mesh coated with an absorbable and hydrophilic film on its visceral side. The film is composed of a solution of oxidized bovine (water-soluble) atelocollagen type I, polyethylene glycol, and glycerol. Experimentally, within 3 weeks, the film is completely resorbed and a new peritoneal covering is formed over the mesh. The hydrophilic film has been shown to provide significant protection against bowel adhesions, although there is some concern that this composite may become more easily infected than some other meshes and that it may elicit a stronger inflammatory response. In the present case, we certainly see the close apposition to the bowel, although no adhesions were detectable. This mesh seems to have developed an intimate relationship to the adjacent bowel, but has not followed Kahlil Gibran’s advice for such a relationship, that there should be spaces in your togetherness. Lawrence J. Brandt, MD Associate Editor for Focal Points www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 783