DEPENDENCE OF THE ABDOMINAL WALL-MESH INTERFACIAL STRENGTH ON THE FIXATION METHOD FOR VENTRAL HERNIA REPAIR by Hummad Mohammad

Tasneem

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Science

Major: Biomedical Engineering

The University of Memphis May 2014

Copyright 2014 Hummad Tasneem All rights reserved

ii

ACKNOWLEDGEMENTS

Without the support of a number of people, completion of this research project would not have been possible. First and foremost, I would like to thank my friends and family for being the best support group a person could ask for, cheering me on every step of the way. I also want to thank Dr. Elaina Paulus, Dr. Nate Stoikes, Dr. John Sharpe, Mr. Samir Rustom, and the rest of the UT team for leading the animal study and surgical portion of the experiments. I want to extend gratitude to Robert Jordan and Rick Voyles for providing maintenance and technical support with the Instron machine. In addition, I would like to thank my fellow graduate students, in particular Thien-Chuong Phung, Corey Holt, Adentoun Komolafe, Jie Gao, and Dema Assaf, all of whom advised and assisted me through my thesis work. Similarly, I want to extend thanks to Jenina Madrid, Phillip Nuvue, Hadiya Khan, Bilal Tasneem, and Alex Richardson for reviewing my writing and helping me to develop my final report. Finally, I would like to thank my thesis committee members: Drs. Eugene Eckstein, Nate Stoikes, and Esra Roan. Their guidance and support during the course of this thesis study has been indispensable. A special thanks goes out to my head advisor, Dr. Esra Roan, for keeping me motivated during this process.

iii

ABSTRACT

Tasneem, Hummad. M.S. The University of Memphis. May 2014. Dependence of the Abdominal Wall-Mesh Interfacial Strength on the Fixation Method for Ventral Hernia Repair. Major Professor: Esra Roan, Ph.D.

Hernia occurrence is on the rise. The most common approach to repair today is a hernioplasty repair using a surgical mesh for permanent reinforcement after repairing the hernia defect. Different fixation techniques using materials such as tacks, staples, sutures, or adhesives are utilized to provide initial fixation until tissue ingrowth occurs. Currently, regarding ventral hernia mesh repair operations there is inadequate amount of information available regarding the efficiency of a mesh repair using adhesives. Consequently, this study compares the interface strength between mesh and tissue when mesh is fixed with either of the two following techniques: a) adhesives or b) sutures. Lap shear test conducted on excised tissue specimens determined the fixation strength of the interface between tissue and mesh at 24 hours, 1 week, and 2 weeks post recovery. Uniaxial experiments were used to obtain nonlinear material properties of mesh and tissue. The material properties were then utilized toward building a computational model of the mechanical experiments.

iv

Table of Contents
List of Tables ................................................................................................................................. vii List of Figures ............................................................................................................................... viii Chapter 1: Introduction .................................................................................................................... 1 Chapter 2: Background .................................................................................................................... 5 2.1 Surgical Repair....................................................................................................................... 5 2.1. A. Surgical Mesh ............................................................................................................ 6 2.1. B. Adhesive Fixation Technique .................................................................................... 8 2.2. Hernia Repair Complications ................................................................................................ 9 2.3. The Mesh-Tissue Interfacial Strength ................................................................................. 13 2.4 Interfacial Strength Measurements ...................................................................................... 14 2.4. A. Lap Shear Test ......................................................................................................... 16 2.5. Material Properties .............................................................................................................. 17 2.5. A. Linear Material Properties ....................................................................................... 18 2.6 Finite Element Method in Biomechanics ............................................................................. 20 2.6. A. Non-Linear Mechanical Properties .......................................................................... 21 Chapter 3: Methods and Materials ................................................................................................. 24 3.1 Mechanical Testing Instrument and Software ..................................................................... 28 3.2 Biomechanical Evaluation ................................................................................................... 29 3.2. A. Uniaxial Test Method and Procedure ...................................................................... 29 3.2. B. Nonlinear Material Properties .................................................................................. 29 3.2. C. Lap Shear Test ......................................................................................................... 31 3.2. D. Data Analysis........................................................................................................... 31 3.3 Finite Element Analyses of the Uniaxial Extension and Lap Shear Experiment ................. 33 3.3. A. Simulation of Uniaxial Extension Using FEA......................................................... 34 3.3. B. Lap Shear Simulation Using FEA............................................................................ 36 Chapter 4: Results and Discussion ................................................................................................. 39 4.1 Uniaxial Extension Experiments.......................................................................................... 39 4.1. A. Average Normalized Force ...................................................................................... 40 4.1. B. Nonlinear Mechanical Properties for Mesh and Tissue ........................................... 42

4.2 Lap Shear Tests for Obtaining Interfacial Strength ............................................................. 45 4.3 Computational Study using FEA to Simulate Mechanical Experiments ............................. 53 4.3. A. Uniaxial Simulation with FEA ................................................................................ 53 4.3. B. Lap Shear Simulation with FEA .............................................................................. 57 Chapter 5: Conclusions .................................................................................................................. 61 5.1. Conclusions ......................................................................................................................... 61 5.2. Clinical Significance ........................................................................................................... 61 Chapter 6 Future Work .................................................................................................................. 63 6.1 Mechanical Experiments and Sample Preparation............................................................... 63 6.1. A. Future Work............................................................................................................. 63 6.1. B. Limitations that need to be addressed in Future Studies .......................................... 64 6.2 Finite Element Models for Computational Simulations....................................................... 65 6.2. A. Next Step toward Developing Full Robust Model of a VHMR .............................. 65 6.2. B. Limitations in Current Models that should be addressed in Future Work ............... 66 References ...................................................................................................................................... 67 Appendices..................................................................................................................................... 71 A. Experiment Results ............................................................................................................... 71 B. Matlab Code: F-D Data Evaluation ....................................................................................... 75 C. Matlab Code: Box Plots ........................................................................................................ 77 D. ABAQUS INP File: Tissue Uniaxial Model ......................................................................... 78 E. Strain Energy Model vs. Uniaxial Tissue Experiments ......................................................... 80 F. FEA Uniaxial Simulation vs. Uniaxial Tissue Experiments .................................................. 83 G. ABAQUS INP File: Surgical Mesh Uniaxial Model ............................................................ 86 H. Strain Energy Model vs. Uniaxial Surgical Mesh Experiments............................................ 88 I. FEA Uniaxial Simulation vs. Uniaxial Surgical Mesh Experiments ...................................... 90 J. ABAQUS INP File: Lap Shear Model ................................................................................... 92 K. FEA Lap Shear Simulation vs. Lap Shear Experiments ....................................................... 92 L. Artist Permission ................................................................................................................... 92

vi

List of Tables
Table Page Table 1: Literature Review On Interfacial Strength ..................................................................... 12 Table 2: Mechanical Strength Of Mesh And Tissue ..................................................................... 20 Table 3: FEA Model Part Characteristics ..................................................................................... 35 Table 4: Uniaxial Results With Averaged Normalized Forces ..................................................... 41 Table 5: Strain Energy Function Coefficients For Abdominal Wall Tissue................................. 43 Table 6: Strain Energy Function Coefficients For Mesh .............................................................. 44 Table 7: Averaged Normalized Forces For Glued Vs. Sutured Specimens .................................. 49 Table 8: Statistical Analysis Using Mann-Whitney-Wilcoxon U-Test ........................................ 49 Table 9: 2-Way Anova Test .......................................................................................................... 49 Table 10: Lap Shear Test Failure Mode Occurrences .................................................................. 53 Table 11: Mesh Convergence Study For Tissue ........................................................................... 55 Table 12: Mesh Convergence Study For Surgical Mesh .............................................................. 56 Table 13: Goodness Of Fit Of Experimental Data With Uniaxial Simulation ............................. 57 Table 14: Goodness Of Fit Of FEA Simulation To Experimental Data ....................................... 59 Table 15: Mesh Convergence Study For Lap Shear Models ........................................................ 60

vii

List of Figures
Figure Page

Figure 1: Schematic Of A Typical Ventral Hernia With Intestinal Protrusion ............................................. 1 Figure 2: Hernioplasty Repair For An Onlay Ventral Hernia Surgery ......................................................... 6 Figure 3: Bard Soft Knitted Polypropylene Surgical Mesh .......................................................................... 7 Figure 4: Mesh Placement. Top) Onlay, Middle) Inlay, Bottom) Sublay..................................................... 8 Figure 5: A) Peel Test Schematic, B) Indention Test Schematic ................................................................ 15 Figure 6: Lap Shear Test Schematic ........................................................................................................... 16 Figure 7: Mesh To Tissue Ratio For Mechanical Testing. ......................................................................... 17 Figure 8: Uniaxial Tension Test Schematic ............................................................................................... 19 Figure 9: Description Of The Orientation ................................................................................................... 25 Figure 10: Implanted Surgical Mesh With Different Fixation Techniques ................................................ 26 Figure 11: Lap Shear Test Specimens. Left) Glued Fixation, Right) Sutured Fixation .............................. 27 Figure 12: Typical Sample Division ........................................................................................................... 27 Figure 13: A) Instron 3380 B) Bluehill Readings ...................................................................................... 28 Figure 14: Uniaxial Mesh Tests. Left) Direction 1, Right) Direction 2...................................................... 29 Figure 15: Lap Shear Test Sample .............................................................................................................. 31 Figure 16: Zoomed In Image Of Surgical Mesh. Left) Threads; Right) Pores ........................................... 35 Figure 17: Partitioned Part For Uniaxial Simulation .................................................................................. 36 Figure 18: FEA Model Of Lap Shear Experiments .................................................................................... 38 Figure 19: Representative Uniaxial Test Data ............................................................................................ 40 Figure 20: Representative Tissue Experimental Response And The Material Model ................................ 44 Figure 21: Representative Mesh Experimental Response And The Material Model .................................. 45 Figure 22: Representative Lap Shear .......................................................................................................... 46 Figure 23: Summary Of Results From Lap Shear Experiments ................................................................. 48 viii

Figure 24: Typical Mesh-Tissue Response At 2 Weeks Vs. Excised Tissue Response ............................. 50 Figure 25: Failure Modes ............................................................................................................................ 51 Figure 26: Stress Contour Plot A) Surgical Mesh B) Abdominal Tissue ................................................... 54 Figure 27: Mesh Convergence Study For Tissue Model ............................................................................ 55 Figure 28: Representative Tissue Experimental Response And The FEA Model ...................................... 55 Figure 29: Mesh Convergence Study For Surgical Mesh Models .............................................................. 56 Figure 30: Representative Mesh Experimental Response And The FEA Model Results. .......................... 56 Figure 31: FEA Model Reaction Force Contour Plot ................................................................................. 58 Figure 32: Comparison Of Experimental And FEA Results Of Lap Shear Experiments ........................... 59 Figure 33: Mesh Convergence Study For Lap Shear Models ..................................................................... 60

ix

Table of Abbreviations
Abbreviation
HMR VHMR SEF FEA FE

Unabridged
Hernia Mesh Repair Ventral Hernia Mesh Repair Strain Energy Function Finite Element Analysis Finite Element Poissons Ratio Sum of the Residuals Sum of the Total Squares Residual Squared Force vs. Displacement Boundary conditions Three- Dimensions Two- Dimensions Second Order Reduced Polynomial Strain Energy Function First Order Ogden Strain Energy Function Mega-Pascal centimeters Stress Strain Cross-sectional Area Polypropylene Peak Force Per Unit Width Stress vs. Strain Ultimate Tensile Strength Peak Force Per Unit Surface Area Sum of the Ranks Sample Size Specimen bound in Stationary Clamp Specimen bound in Dynamic Clamp Center of Specimen Specimen Institutional Animal Care Unit Committee

RSS TSS R2 F-D BC 3D 3D nd SEF 2 Order R.P. SEF 1st Order Ogden MPa cm

A PP N/cm

-
UTS N/cm2 Rs N S.C. D.C. C.S. Sp. IACUC

Chapter 1: Introduction

Hernia is a defect in the tissue wall that surrounds various organs of the body. It eventually leads to protrusion of organs through the weak spot in the muscle, or connective tissue, called fascia, as illustrated in Figure 1. The two important factors involved in the formation of hernia are i) local weakness of tissue and ii) increased intraabdominal pressure. Some hernias are asymptomatic, whereas some can cause significant symptoms such as pain, nausea vomiting and change in bowel habits in the affected individual. These symptoms can progress to surgical emergencies in the event of incarceration, obstruction, or strangulation. This can instigate further complications as the affected tissue begins to break down (Canziani et al., 2009; Carriquiry, 1996; Shell IV, de la Torre, Andrades, & Vasconez, 2008). Hernias are usually repaired surgically and require that the protruding organ be pushed back into the human body and the defect zone repaired. This is followed by closing of the defect in the soft tissue via suturing. Last, if the surgeon chooses to do so, it is possible to reinforce the sealed hole by fixating a piece of mesh over it. Complications that can occur after surgical repair of the hernia include reoccurrence of the hernia, post-operative pain, and post-operative infection (Shell Iv et al., 2008).

B
Hernia

Figure 1. Schematic of a Typical Ventral Hernia with Intestinal Protrusion. A) Cross-Sectional View, B) Gross Appearance.
1

While there are different types of hernias that occur in the body, this specific study applies to ventral hernias, which appear in the abdominal wall at a location of a previous incision. In 2003, it was estimated that nearly one million abdominal wall hernia repair operations were performed in the United States, with a predicted 1% annual growth rate (Rutkow, 2003). Rutkows work inspired a more recent study by Poulose et al. which determined that in 2006 there were 365,400 ventral hernia operations in the United States, with an annual increase of 3% (Poulose et al., 2012; Rutkow, 2003). This number is thought to have grown with the increase of obesity in the population, a wellacknowledged factor in the development and recurrence of ventral hernias. Together, these factors elevate the necessity of developing better ventral hernia repair techniques. Traditional ventral hernia mesh repair (VHMR) surgery, using sutures as a mean of mesh fixation, has proven very effective in practice in reducing recurrence rates compared to non-mesh repair operations. The recurrence rate of non-mesh repairs is 23% whereas the recurrence rate of mesh-repairs is 46% (Luijendijk Rw Fau - Hop et al., 2000 ). However, post-operative pain associated with sutures still remains a major concern, which has been postulated to be due to stress associated with sutures and tissue penetration (Stoikes et al., 2013). Recently, modern adhesives, such as biological glue, have been utilized as an alternative fixation technique that does not require suturing to hold the mesh in place (Canonico et al., 2005; Kaul et al., 2012). In Canzianis (2009) study, a sutureless incisional hernia repair technique was examined and found to result in a low occurrence of chronic post-operative pain. Only 1 out of 40 patients reported recurring post-operative pain, indicating that the use of staples, or sutures, for securing the mesh, was in fact

invasive and unnecessary (Canziani et al., 2009). This was previously indicated in a 2006 study by Petter-Puchner et al., where perforation of the bowel was noted in techniques involving staples to fixate hernia meshes in surgeries performed on rats. This indicated that fixation techniques involving tissue penetration raised the risk of damage to other organs and also increased the risk of possible infections, or further post-op injury ( PetterPuchner et al., 2006). One of the major determining factors of the strength and durability of the overall repair is the mesh-tissue interface, which must remain intact during recovery such that adequate tissue growth occurs to seal the hernia defect and embed the implanted mesh. Grevious et al. stated that on average a typical adult requires a tensile strength of 16 N/cm to prevent a sealed and repaired abdominal wall from reopening (Cobb, Kercher, & Heniford, 2005; Grevious, Cohen, Shah, & Rodriguez, 2006). On the other hand, it was reported by Cobbs and Kercher that on average polypropylene mesh could withstand a force of 32 N/cm (W. S. Cobb et al., 2005; Grevious et al., 2006). Ultimately, these prior studies suggest that the use of fibrin glue fixation is both viable and generally preferred. However, lack of data on fixation response of the sutureless methods, especially in ventral HMR surgeries, is preventing most surgeons from adopting this technique (Deeken, Faucher, & Matthews, 2012; Katkhouda et al., 2001). The main goal of this masters thesis project is to measure and compare the strength of the mesh-tissue interface a) with sutures and b) with adhesive in a porcine model. This study looks at the effect of biological glue, specifically human fibrin glue, and 2-0 polypropylene sutures on the interface strength between the mesh and abdominal wall. The goal being that with such information available there will be less controversy in

accepting the biological glue as an acceptable replacement in practice compared to current traditional methods. Moreover, this experimental study provided data to validate a preliminary computational model of the mesh-tissue interface.

Chapter 2: Background
Ventral hernia is classified such that the herniated tissue region occurs anywhere on the abdominal wall where a previous incision has created a weakness in the tissue layers. Some factors that contribute and increase the risk of ventral hernia manifestation include abnormal collagen formation, malnutrition, vitamin deficiency, ageing, obesity, pregnancy, previous invasive surgery, mechanical strains (i.e., chronic coughing or constipation), and physical trauma (Norton et al., 2008). While environmental conditions can result in hernia, most reported cases are generally due to uncontrollable congenital factors (Shell IV et al., 2008). In the case where a ventral hernia is left untreated, patients risk the possibility of the protruding organs to be subjected to incarceration and strangulation leading to bowel obstruction and possibly death (Norton et al., 2008). 2.1 Surgical Repair Hernias are usually repaired surgically and require that the protruding organ be reduced into the human body before the defect is repaired. There are a handful of surgical techniques that can be used when treating a hernia on an abdominal wall. The more traditional method of repair is the tension repair technique (also known as herniorrhaphy), which involves suturing together the edges of the tissue defect zone (Norton et al., 2008). Tension repair has mostly been replaced in modern practices with the tension-free repair technique (also known as hernioplasty), which involves fixating a piece of mesh on top of the hernia to cover up and seal the defect while allowing a brace to exist, on top of which tissue integration will occur (Figure 2) (Lau, Patil, & Yuen, 2006). A general consensus of tension-free repair being superior to traditional tension repair is due to the significant reduction in post-operative morbidity and complications
5

(Luijendijk Rw Fau - Hop et al., 2000; Prieto-Diaz-Chavez et al., 2005).

Figure 2. Hernioplasty Repair for an Onlay Ventral Hernia Surgery

2.1. A. Surgical Mesh The success of a surgical mesh in terms of preventing hernia-related complications depends on several factors which include, among others, biocompatibility, pore size, weight, and mechanical strength (Norton et al., 2008; Patel et al., 2012). While surgeons are opt to select their preferred mesh product, it has been noted in literature that polypropylene (PP) mesh (Figure 3), characterized as macro-porous, light-weight (LW), with monofilament threads, is more commonly used in hernia related surgeries then other mesh types (Canonico et al., 2005). A tensile test study performed on eight different types of surgical meshes showed that not all the meshes behaved as effectively in vivo when compared to a PP mesh (Patel, Ostergard, & Sternschuss, 2012).

Figure 3. Bard Soft Knitted Polypropylene Surgical Mesh. Left) Scaled, Right) Close Up

Mesh fixation with the host tissue can occur using any combination of sutures, staples, clips, tacks, and biological glues; while mesh placement can be done at either ends, or within, the site of the herniated tissue (i.e. onlay, sublay, inlay mesh placement) (Clarke et al., 2011) (see Figure 4). There is no specific surgical approach that has been acknowledged as the gold standard for a hernia repair, and as such it is the operating surgeons preference on mesh type, placement, and fixation technique used for repair (Clarke et al., 2011; Israelsson, Smedberg, Montgomery, Nordin, & Spangen, 2006; Kingsnorth, Shahid, Valliattu, Hadden, & Porter, 2008).

Onlay Mesh Placement

Rectus Abdominis

Peritoneum

Inlay Mesh Placement Rectus Sheath

Sublay Mesh Placement

Figure 4. Mesh Placement. Top) Onlay, Middle) Inlay, Bottom) Sublay 2.1. B. Adhesive Fixation Technique The use of biological glue for fixating mesh onto tissue is still relatively new to VHMR operations in comparison to the standard suturing techniques. One common product applied for adhesive fixation is the off label use of Tisseel (Baxter, Deerfield, IL, USA), fibrin-based glue. This adhesive is biodegradable and formed by combining human-derived fibrinogen, calcium chloride, and thrombin to create a matrix of polymerized fibrin fibers. The biological properties of Tisseel allow homeostasis, wound healing, and fibroblast proliferation to occur at the fixation site, all of which are added benefits over the sutured or stapled mesh-fixation techniques (Campanelli et al., 2012). It is important to note that there are currently no FDA approved adhesive products in the
8

market for this surgical application. Katkhouda et al. has demonstrated the comparable efficacy of fibrin glue to staple fixation in a 2001 study using porcine tissue for inguinal hernia repair. Samples prepared after a 12-day recovery showed the two methods to be generally comparable in tensile strength when subjected to a make-shift pull-off test (Katkhouda et al., 2001). Regarding data for ventral hernia repair, Chevrel and Rath reported in a trial including 389 patients that there was a recurrence rate of 18.4% when no mesh was used to reinforce the repair, 5.5% with mesh onlay reinforcement, and 0.97% when fibrin glue was used to fixate the mesh in place (Chevrel & Rath, 1997). The use of fibrin glue was further supported by Canonico, (2005), who presented an argument for the sutureless repair technique (n = 80), showing drastic reduction in surgical time and greater surgeon satisfaction, especially the perceived ease of the operation and reduced reports of post-operative pain (Canonico et al., 2005). 2.2. Hernia Repair Complications Some general complications associated with hernia repair operations include recurrence of the hernia, nerve entrapment (chronic pain), bowel obstruction, seroma build-up, fistula formation, post-operative pain, and wound infection (Norton et al., 2008). Failure modes of the mesh upon being implanted into the host include mesh mechanical failure, mesh contraction, mesh migration, mesh curling/buckling, mesh infection, undesired adhesion of mesh with other organs or local tissue, fistula formation, erosion of mesh, and seroma formation (Chevrel & Rath, 1997; Robinson, Clarke, Schoen, & Walsh, 2005). Variations in fixation techniques for tension free repair will additionally alter the likelihood of particular complications from occurring.

Traditionally, the tension-free technique was performed with fixating mesh onto the abdomen using any combination of sutures, staples, clips, or tacks; the mesh suturing fixation method being the most popular in traditional tension-free repair operations. The one thing all of these fixation methods have in common is that they require tissue penetration for mesh anchoring. Consequently, any location where such an incision is made into the abdominal tissue wall will become susceptible to the reoccurrence of future incisional ventral hernias. A brief summary of the fixation strength obtained from different fixation techniques for VHMR is shown in Table 1. In comparison to the tension repair procedure any combination of these fixation techniques are superior in reducing complications. As stated previously in this document, the main concerns associated with sutured mesh-fixation is the post-operative, acute and chronic, pain speculated to be caused by the excess tissue penetration necessary for mesh-anchoring (Canonico et al., 2013). A detailed investigation comparing post-operative pain associated with fixation techniques was done in a 2009 study by Canzianis. In this study, a sutureless incisional hernia repair technique was examined and found to result in an extremely low occurrence of chronic post-operative pain (only one out of 40 reported recurring post-operative pain), indicating that the use of staples or sutures for securing the mesh was in fact invasive and unnecessary (Canziani et al., 2009). Further support toward suture alternatives was provided by a 2012 meta-analysis of PubMed data for inguinal hernias which demonstrated comparable recovery times and recurrence rates of sutureless mesh (e.g. fibrin glue) fixation to sutured mesh fixation, as well as reduced occurrences of postoperative pain in the sutureless reinforcement (4% sutureless compared to 12% sutured)

10

which is a clear advantage over the traditional sutured technique (Kaul et al., 2012). In the end, these prior studies suggest that the use of fibrin glue fixation has an upper hand in i) reducing acute and chronic post-operative pain ii) recurrence rate iii) surgical time iv) seroma formation v) better patient acceptability, and is both viable and generally preferred. Even so, the amount of data available in literature has proven to be insufficient in convincing many surgeons from adopting this sutureless technique in VHMR operations and therefore additional experiments, such as this study, are being performed to provide greater support.

11

Table 1. Literature Review on Interfacial Strength

Literature Animal Model/ Mesh Fixation Technique Tiseel Nothing Staples Tiseel Tiseel & Tacks Tacks Suture & Tack Healing Time Mechanical Testing Procedure Pull-off Interfacial Strength (as reported) 0.955 kg 1.03 kg 0.46 kg 5.2 x 104 N/m2 5.0 x 104 N/m2 6.4 x 104 N/m2 6.8 x 104 N/m2 Translated values for comparison (N/cm) 1.87 N/cm 2.02 N/cm 0.90 N/cm 31.20 N/cm 30.00 N/cm 38.40 N/cm 40.80 N/cm

(Katkhouda et al., 2001)

Pigs / PPm

12 Days

(Clarke et al., 2011)

Pigs / PPm

4 Weeks

Pull-off

(A. Petter-Puchner, Fortelny, Mittermayr, hlinger, & Redl, 2005) (Eriksen, Bech, Linnemann, & Rosenberg, 2008) (McGinty, Hogle, McCarthy, & Fowler, 2005) (Majercik, Tsikitis, & Iannitti, 2006)

Burst (80 mmHg) Rats / Ti mesh Rats / VYPROII Tiseel Staples 17 Days Pull-off (300 g pull force) Peel Test No failure in any interface No failure in any interface

Pigs/ Motif Pigs / Proceed Pigs/ PPm Pigs / ePTFE Pigs / PCO Pigs/ ePTFE

Tiseel Ti Tacks Tiseel Ti Tacks Suture & Tack

30 Days

28 Days 2 weeks 4 weeks 6 weeks 12 week

Peel Test

Tacks

Lap Shear

3.0 1.5 N/cm 3.87 1.2 N/cm 3.44 0.7 N/cm 2.69 1.3 N/cm 2.1 N/cm 1.3 N/cm 2.8 N/cm 0.83 0.06 lbs 1.06 0.07 lbs 0.88 0.08 lbs 1.13 0.07 lbs

3.00 1.50 N/cm 3.87 1.20 N/cm 3.44 0.70 N/cm 2.69 1.30 N/cm 2.10 N/cm 1.30 N/cm 2.80 N/cm 1.85 0.13 N/cm 2.36 0.16 N/cm 1.96 0.18 N/cm 2.51 0.16 N/cm

(d'Acampora, 24.03 4.53 N/cm Rats/ PPm 48.05 9.05 N Kestering, Soldi, & Nothing 28 Days Lap Shear Rats / Vypro 45.32 16.8 N 22.66 8.40 N/cm Rossi, 2007) 0.32 0.05 N/cm (Schug-Pass, Lippert, Pig/ PPm Nothing Indention 3.17 0.50 N 0 hour & Kckerling, 2010) (Bard soft) Tiseel 73.6 13.4 N 7.36 1.34 N/cm (Gonzalez et al., Pig / PPm 159 N 23.73 N/cm Sutures 3 Months Pull-off 2005) Pig / PEm 194 N 22.30 N/cm Polyester mesh (PEm); Polypropylene mesh (PPm); Expanded polytetrafluoroethylene mesh (ePTFE) ; Polyester mesh with anti-adhesive collagen layer (PCO)

12

2.3. The Mesh-Tissue Interfacial Strength Before the hernia is fully healed, stress due to intra-abdominal pressure will concentrate and build up at the hernia repair site. Respectively, the mesh-tissue repair is responsible in resisting the internal loads until a time arrives that the wound has fully healed. In most cases it is not as much necessary for the repair site to be fully healed to resist the internal loads as much as for complete tissue ingrowth to occur. While waiting for adequate tissue in-growth, the mesh-tissue interface becomes an important determining factor in preventing recurrence (Majercik, Tsikitis, & Iannitti, 2006). In light of this, it was determined in a previous study by Majercik et al., that nearly 70% of the full tissue ingrowth occurred within 2 weeks of wound healing (Majercik et al., 2006). It was therefore suggested that prior to this time the mesh-tissue interface was a significant contributor when predicting the possibility of particular failure modes occurring (i.e., mesh migration, curling/buckling, and reoccurrence) (Eriksen, Bech, Linnemann, & Rosenberg, 2008). Since the fixation strength of the mesh-tissue interface is reliant on the fixation technique used for binding mesh and tissue together. There becomes a relative need to better understand the fixation techniques in order to understand and improve the meshtissue interface and respectively the mesh-tissue repair. More specifically, in any system subjected to loading there is a buildup of stresses. How the system distributed these stresses provides insight on which part of the system is most responsible toward resisting failure. In regards to mesh-tissue fixation there becomes a fundamental difference in stress distribution, which is specific to the fixation technique.

13

In the case of sutured mesh fixation the stresses will concentrate at the site where the sutures are embedded within the tissue. On the other hand, when adhesive fixation is used, the stress will distribute uniformly over the entire mesh-adhesive surface area. As such, suture fixation prior to adequate tissue ingrowth will be reliant on the tensile strength of the sutured material and the surrounding fascia it is embedded within; whereas glued fixation will be dependent on the adhesive strength of the product and the surface area of the mesh-adhesive interface. Because of this, one of the added benefits of using sutures over adhesives is that sutures have a relatively stronger raw tensile strength than biological glue and will be able to withstand a greater load before failing (Klinge et al., 1996; Klinge, Klosterhalfen, Muller, Ottinger, & Schumpelick, 1998). 2.4 Interfacial Strength Measurements Due to the importance of the fixation strength of a mesh-tissue repair it is necessary to perform mechanical tests, which can provide quantitative data of the interfacial strength. This information would make it possible to compare different fixation techniques and better evaluate the added benefits of fixation strength to other related complications. One mechanical approach that is often utilized for determining interfacial strength is called adhesion tests. A few of the most common types of adhesion tests performed, among others, include indention, lap shear, peel-off, pull-off, and burst. For meaningful results, the mechanical test chosen must be designed to subject the meshtissue specimen to the stresses it would encounter in vivo within the abdominal wall. Mechanical failure of the interface due to stress build-up initially may occur by developing a defect within the interface at a reentrant corner of the bonded stiffener (i.e. the mesh). A bonded stiffener is the substrate material in the system that increases the

14

global stiffness of the composite structure (Lacombe, 2005). Consequently, once this initial weakness occurs within the interface the failure site will propagate and increase in size over the distance of the implanted mesh piece. For mechanical tests where a tensile load is applied laterally through the gauge length the failure will occur along the samples width. Therefore, it is common practice within literature for report values, from such mechanical tests, to be normalized in the form of peak force per unit width (N/cm). In vivo, when internal pressure of the abdominal wall is applied to the mesh interface, failure propagation can occur along any direction. For adhesive tests such as peel and lap shear the load is applied on the specimen in one particular direction, which is labeled as the length (Figure 5A). For mechanical tests such as indention or burst were the load is applied over the entire surface area of the specimen the resulting max force cannot be normalized using the width since failure could have occurred along any direction (Figure 5B). For those mechanical tests the data is generally normalized using the surface area of the mesh and reported as UTS (N/cm2).

Figure 5. A) Peel Test Schematic, B) Indention Test Schematic

15

2.4. A. Lap Shear Test For this study, the mesh-tissue interface was evaluated using a lap shear test procedure. Similar to peel, the lap shear test is performed by having a tension load applied on the specimen such that stress concentration occurs at the interfacial region. In lap shear tests the loading occurs differently in both ends of the sample, such that a different substrate is loaded on either end (see Figure 6). Specifically, one substrate is displaced at a particular velocity while the second substrate is fixed in place, preventing all movement and rotation. This will cause the stress propagation to occur within the interface; in an ideal case, failure would occur due to shearing of the two substrates.

Figure 6. Lap Shear Test Schematic

In respect to the previous testing methods mentioned in this text, the main advantage of using a lap shear test over an indention test is that it does not require a
16

larger tissue to mesh ratio of surface area for individual test specimens (Figure 7). However, the loading can only be applied in one specific direction versus all directions as would have occurred in an indention test. On the other hand, compared to the peel test the advantage of the lap shear experiment is that the axial loading is applied in the same direction as shear stresses that occur in the interfacial region in vivo; one failure mode directly related to shearing is mesh migration.

Figure 7. Mesh to Tissue Ratio for Mechanical Testing. Green) Surgical Mesh, Red) Tissue Specimen 2.5. Material Properties Biocompatibility of an implant is not limited to the chemical reaction of the host body but also its biomechanical compatibility to the unique environmental loads of the biological system. The presence of embedded mesh within a tissue will ultimately make the repaired tissue stiffer than its healthy counterpart. Consequently, a stiffer tissue response in the abdominal wall is associated with a reduction in the physiological compliance of the tissue (Hernndez et al., 2011). The compliance of the abdominal wall is very important as it enables the
17

abdominal wall to withstand and adjust to increased stresses and minor pressure changes due to simple and/or strenuous activities. Since the abdominal wall is anisotropic, it has become essential to consider the following two factors to achieve a superior repair: 1) the finest material and 2) accurate mesh orientation for each hernia repair. This would ensure that the mesh has characteristics that match closely to the natural characteristics of the abdominal wall (Hernndez-Gascn et al., 2011). The mechanical anisotropic behavior of the surgical mesh is determined by the filament composition, mesh weave, and spatial arrangement of the filaments, while in the abdominal wall, it is the collagen fibers rather than muscle fibers responsible for determining passive tissue tensile strength (Hernndez et al., 2011). It is therefore important, to determine the material properties of the implanted prosthetics and the associated tissues as to determine if the presence of a particular prosthetic will cause any biomechanical change in the system. In this study, material properties were obtained by performing uniaxial mechanical tests on samples of excised abdominal tissue and surgical mesh. 2.5. A. Linear Material Properties Uniaxial tension experiments are a type of tensile test used for obtaining mechanical properties of materials (Lacombe, 2005). These tests cannot account for the anisotropic nature of a material and instead obtain isotropic material properties, which are characterized by a specific orientation. The test is done by loading the ends of a uniform material specimen such that the sample is stretched until failure along a specific axial direction. Figure 8 shows a schematic of a uniaxial tensile test, when done using a testing apparatus raw data will be in the form of force vs. displacement (F-D).

18

Figure 8. Uniaxial Tension Test Schematic Material properties cannot be directly derived from the F-D data and must first be translated to stress vs. strain (-), which is done using Equation 1. In this study the stress () was translated from this data by dividing every force (F) data point by the specimens initial cross-sectional area (A) (i.e. Sample width x thickness). Similarly the strain () was translated from the data by dividing every displacement (l) data point by the initial gauge length (lo) (i.e. specimen height subtracted by specimen height bounded within clamps). Comparably, other studies have also obtained material properties of abdominal tissue, PP surgical mesh, and PP sutures. Table 2 provides a brief list of some of the material properties reported in literature regarding similar studies to this thesis.

(1)

19

Table 2. Mechanical Strength of Mesh and Tissue

Literature (Klinge et al., 1996) (W. S. Cobb et al., 2005) (Schug-Pass et al., 2010) Manufacturers Information (Cobb, Harris, Lokey, McGill, & Klove, 2003) (Hernndez-Gascn et al., 2011) (Klinge et al., 1996) Material Mesh PP Mesh PP Mesh (BARD soft) PP Mesh (BARD soft) PP Mesh PP Mesh (Optilene) PP sutures Test Type Indention Test Indention Test Indention Test Indention Test Indention Test Uniaxial Tests: Direction 1 Direction 2 Uniaxial Uniaxial Test: Horizontal Direction Vertical Direction Theoretical Value: (rupture strength) Theoretical strength: (at max intraabdominal pressure) Average Strength STD 40-100 N/cm 43.2 N/cm 29 N/cm 36 N/cm 32 N/cm 7.57 0.74 N/mm 10.79 1.05 N/mm 30 N/cm 60-80 N/cm 20-30 N/cm 4-16 N/cm 11 27 N/cm

(Klinge et al., 1996)

Human Abdomen

(William S. Cobb et al., 2005)

Human Abdomen

2.6 Finite Element Method in Biomechanics Computational modeling refers to an engineering application at which material, loading, and environmental conditions are simulated virtually giving a visual representation of how mechanical loads would propagate within a composite structure (Reddy, 2004). One common method for computational modeling is finite element analysis (FEA), which is a numerical technique used to compute approximate solutions to boundary-value problems (i.e., a differential equation with specific boundary conditions) (Venkatesh, 2011). In this approach for theoretical computations, the stress distribution is evaluated by creating a virtual simulation of the system with particular characteristics, such as loading, geometry, material properties, boundary constraints, and material interface conditions, translated into the form of mathematical equations (Reddy, 2004). The
20

mathematical equations used are generally determined from known material values or experimental data which is translated into an approximate numerical solution using various principles of solid mechanics. The goal is to find values for unknown stresses at points on or within the system (Holzapfel, 2000; Seshu, 2004). These stresses are known as field variables which are infinite in number due to the continuous nature of the body (Holzapfel, 2000). 2.6. A. Non-Linear Mechanical Properties In FEA it is required to give material properties for each simulated part. In regards to surgical mesh and abdominal wall tissue these properties cannot be described as linearly elastic materials and require a relatively more complex application of continuum mechanics. In brief, continuum mechanics is an area of mathematical physics which describes the fundamental laws governing motion and deformation of a structure as a continuum mass rather than as discrete particles (Reddy, 2004). Within the field of continuum mechanics, nonlinear materials such as hyperelastic materials are often described using the constitutive laws with corresponding constitutive equations (Holzapfel, 2000). Respectively, the constitutive equations are further described in the field of solid mechanics (Holzapfel, 2000). For constitutive theories, it is important to note that the resulting mathematical model created to represent a real-life material behavior is based off of actual experimental data obtained from mechanical testing (e.g. excised tissue and surgical mesh). Constitutive models or material models are very important and necessary when creating a computational model. These models are generally quite simple for elastic behavior but become relatively more complex and less likely to predict realistic behavior

21

when used toward describing nonlinear continuum mechanics (Holzapfel, 2000). One approach to modeling the behavior of nonlinear hyperelastic material is using a strain energy function (SEF) to describe a mechanical response. Some of the more well-known strain energy functions that are readily available to be used in engineering software packages include Hookean, Mooney-Rivlin, Polynomial, Reduced Polynomial, and Ogden descriptions (Holzapfel, 2000). Modern softwares used for computational studies such as finite element analysis (FEA) have built in curve fitting generators that can take experimental stress-strain values and relate potential fits with various strain energy functions (ABAQUS/CAE user's manual : version 6.4, 2003). Two of the more relevant strain energy functions used in this study were the 2nd order reduced polynomial and the 1st order Ogden SEFs. The corresponding equations and characteristics of these functions are described in the Equation 2 and Equation 3 (ABAQUS/CAE user's manual : version 6.4, 2003). In the equations below W is work, U is energy, J is Jacobian and is used to describe the total volume change at any given point, is stretch ratio, and , and N are

material constants, D is the constant used to describe rate of deformation and is dependent on the Poissons ratio, the different I values are strain invariants, and Ci is a temperature-dependent material parameters.

22

(First Order Ogden SEF)

(2)

(Second Order Reduced Polynomial SEF)

(3)

23

Chapter 3: Methods and Materials

The aim of this thesis was to obtain a more in-depth understanding of the load carrying capacity of the mesh-tissue interface resulting from a VHMR operation. The major interest in this research is in whether there is a difference in the resulting interfacial strength if fixation of the prosthesis is performed using fibrin glue instead of sutures. The end goal is to shed light towards the application of adhesive fixation techniques in VHMR surgeries so that surgeons can better weigh the benefits of either technique when making an informed decision regarding their surgical approach. Animal Model Dr. Stoikes and his team at the University of Tennessee Health Science Center (UTHSC) obtained porcine abdominal specimens through an animal study. All procedures were approved by the Institutional Animal Care Unit Committee, IACUC ID # 12-103.0-A. Female mongrel pigs that weighted 25-30 kg were used as the animal models. Polypropylene soft knitted (BARDTM) surgical mesh was implanted onto the abdominal wall using the onlay mesh placement. Specific tissue layer onto which mesh was fixated was generally the rectus sheet and rectus abdominis. Two prosthetic mesh pieces with an area of 6 by 4 cm were implanted in each animal model with 2-3 cm of space between them. Both soft tissue and surgical mesh are anisotropic materials (see Figure 9). In this particular study the mesh was implanted by the surgeon without consideration of mesh/tissue alignment.

24

Direction 2

Direction 2 Direction 1 Direction 1

Figure 9. Description of the Orientation

Of the two implanted mesh pieces, one was fixated using 4 ml of the Tisseel fibrin glue (Baxter Healthcare), spread uniformly on and throughout the mesh surface by the surgeons finger (see Figure 10). The second mesh piece was fixated onto the abdominal wall using 4, 2-0 Prolene PP sutures (Ethicon); which were sewn near the edges of the mesh as shown in Figure 10. After the mesh was implanted the animal specimens were allowed to recover for a given amount of time so that tissue ingrowth into the mesh could occur. The amount of time allowed for recovery was regulated at 24 hours, 1 week, and 2 weeks for 8 animal models per group. For these experiments, animal care and operations were carried out at the UTHSC and only excised samples provided by Dr. Stoikes and his team was brought over to the University of Memphis for testing. Samples of mesh-tissue specimens are shown in Figure 11.

25

Sutured Fixation

Glued Fixation

Mesh Placement Prior to Fixation

Figure 10. Implanted Surgical Mesh with Different Fixation Techniques The excised abdominal wall for each animal specimen was used to create two specimens for mechanical testing, as shown in Figure 11. The individual samples included the 6 by 4 cm2 mesh piece fixated onto tissue that on average had a surface area of 8 by 5 cm, the extra 2 cm of tissue height extending from one end of the sample; thickness of samples were on average 0.75 cm. An area of approximately 1 by 4 cm of mesh-tissue was cut away from the sample for a separate study regarding histological, mesh contraction, and tissue ingrowth evaluation at the Department of Pathology of the UTHSC (see Figure 12A) (Stoikes et al., 2013). The removal of part of the mesh-tissue sample damaged the end of the mesh and tissue, which was cut away, creating defects where stress propagation under loading could occur. This defect zone was accounted for in the mechanical tests by binding and directly loading that specific region (see Figure

26

12B). Biomechanical testing of the interfacial strength was done using a lap shear testing procedure and uniaxial testing procedure for determining material properties of tissue and mesh.

Figure 11. Lap Shear Test Specimens. Left) Glued Fixation, Right) Sutured Fixation

Zone A: grips only mesh Zone B: grips only tissue

Figure 12. Typical Sample Division

27

3.1 Mechanical Testing Instrument and Software Mechanical testing was done using an Instron 3380 (Canton, MA) testing device (see Figure 13A). The device functioned by displacing the position of a single clamp. This moving clamp was capable of exerting either a tension or compressive load on the sample, depending on the direction of the clamps movement. The load developed by stretching the tissue is measured using a load cell and the displacement of the clamp measured with a built in extensometer. The proposed test procedure used a 5 kN load cell and a software protocol programmed to provide a displacement velocity of 0.42 mm/s. The specific velocity was used to apply a relatively slow loading so that a near quasistatic material response could be recorded. Raw force and displacement data was recorded by a digital output reader running the Bluehill 2 software (see Figure 13B), and extracted as an excel comma separated spread sheath, .csv file type. The multiple peaks/spikes in the F-D data for sutured fixation, in Figure 13B, marks the point of the lap shear test when a single suture pulls out of the mesh-tissue specimen.

Figure 13. A) Instron 3380 Mechanical Testing Apparatus with Pneumatic Clamps B) Bluehill 2 Force vs. Extension Readings

28

3.2 Biomechanical Evaluation 3.2. A. Uniaxial Test Method and Procedure The mechanical response of the mesh and abdominal tissue under loading was measured through uniaxial extension experiments. The tissue was cut so that each tested sample had dimensions approximately 4 cm in width, 5 cm in height, and on average 0.75 cm in thickness. The thickness of individual samples varied between 0.5 and 1 cm depending on the topological location of the specimen and was never uniform. The tested mesh pieces were 3 cm in width, 6 cm in height, and 0.044 cm in thickness. Figure 14 shows a sample uniaxial test on surgical mesh in both directions; in these tests the fiber orientation strongly influenced the load bearing capacity of the specimen.

Figure 14. Uniaxial Mesh Tests. Left) Direction 1, Right) Direction 2

3.2. B. Nonlinear Material Properties The non-linear hyperelastic material model was determined in ABAQUS by curve fitting various SEFs with the experimental data to obtain a best fit. In this step, the curve fitting was done to the experimental data up to a strain of 1, = 1, such that the corresponding SEF modeled the initial mechanical response of the material. Additionally, SEFs in ABAQUS require the input of a Poissons ratio for the material. These values

29

were not determined in the scope of this study and were instead approximated from known information. For surgical mesh a Poissons ratio of 0.45 was applied, = 0.45, this value corresponds to the poisons ratio of a solid block of polypropylene. In regards to soft tissue, previous literature has modeled this material with a nearly incompressible Poissons ratio (0.4 < < 0.5). For the sake of this study, different Poissons ratios between 0.46 and 0.498 were tested and a best fit was selected. The best fit was decided by evaluating the goodness of fit as determined by the R2 value between the experimental and theoretical data sets. This was done by first plotting the material response of the SEF in Excel (Microsoft, Redmond, WA) and curve fitting it with a tread-line so that an equation which matched the data set could be obtained. This equation was then used to determine the stress from the material model for all strains in the uniaxial experimental data sets, such that the size of the array would be identical for both data sets. The array of values for experimental stress and theoretical stress were compared for a goodness of fit using a coefficient of determinates method, 0 < R2 1 where a value of 1 portrays identical data sets. The outputted R2 value was determined by first solving the sum of the squares (TSS) using Equation 4A, followed by the residual sum of the squares (RSS) using Equation 4B, and finally using TSS and RSS values to solve for R2 as denoted in Equation 4C.

(4)

30

3.2. C. Lap Shear Test The interfacial strength between mesh and tissue were measured using a lap shear test procedure. Individual specimens were prepared for testing by shaving off excess tissue from the edges and the tissue thickness. The sample thicknesses were reduced at times so that the specimen would be able to fit within the clamps. Approximately, 1x4 cm2 surface area of mesh was released from the tissue so that it could be held by the upper clamp. The excess tissue, which remained untouched by the prosthetic mesh, was held by the lower clamp. Eventually after enough imposed strain, the ultimate strength of the mesh-tissue interface was observed. For each sample the initial gauge height between the two clamps before testing was recorded as well as the initial width of the mesh, the height of the overall sample, and the location at which failure occurred (i.e. interface, mesh, and tissue). Figure 15 shows a sample of a mesh-tissue lap shear test.

Figure 15. Lap Shear Test Sample 3.2. D. Data Analysis Interfacial strength and the relevant material strength were reported in the form of peak force per unit width (N/cm). These values as well as other computations were done
31

in Matlab (MathWorks Inc., Natick, MA) and Microsoft Excel. In particular, a Matlab code was written that graphed the force to displacement data and outputted all the maximum forces for individual samples. These values were than stored and sorted in Excel, where they were normalized with their respective initial mesh width. Statistical analysis to determine significant difference between fixation techniques at evaluation time was done through a 2 sample t-test for normally distributed variables and MannWhitney-Wilcoxon statistical U-test, also known as a Wilcoxons Rank Sum test, for ordinal variables. Student t-tests were done within excel spreadsheet while Mann-U tests were done using an online statistical package called VarrarStats (VarrarStats, New York). Samples were evaluated at a confidence level of 95%; such that there was a significant difference reported from the t-test if P < 0.05. On the other hand for the Mann-U test significant difference was evaluated using the UA value as the determinate factor (Equation 5). Which was done by comparing the UA value with the lower and upper limit of the U-test; if the value falls outside the range provided, lower-upper limit, the two data sets are significantly different. An additional statistical test was done using a 2-way analysis of variance (Anova), performed in SigmaPlot (Systat Inc., Illinois), which was able to compare the influence of 2 different independent variables on one dependent variable. In this case the two independent variables were the evaluated time points (24 hours, 1 week, and 2 weeks) and the fixation method (glued or sutured), where the dependent variable was the fixation strength reported. Other analysis included identifying outliers in Matlab and removing them from calculations regarding average normalized loads.

32

(5)

3.3 Finite Element Analyses of the Uniaxial Extension and Lap Shear Experiment The long-term goal of the computational study is to generate a simplified, robust model of hernias with mesh repair, which would help researchers better understand the biomechanics of a repaired abdomen. Wound healing after mesh fixation includes a biological response of hemostasis, inflammation, proliferation, granulation, remodeling, and maturation. At two weeks of recovery it has been noted in literature that nearly 70% of tissue ingrowth has already occurred (Majercik et al., 2006). The tissue ingrowth corresponds to the proliferation step where collagen formation and new tissue fibers are created. Therefore, a computational model mimicking interfacial properties at two weeks would provide insight on a repaired abdominal wall where the mesh has been almost completely embedded within the tissue. The first step in creating this model is attempting to create a method to model the mechanical responses of both surgical mesh and the excised abdominal tissue. After which a coupling method was sought for that could accurately mimic the interfacial strength of a repaired abdomen at two- week recovery post operation. Individual tissue and mesh material models were made on the assumption of the continuum theory of finite strain. It was also assumed that the materials were best represented by nonlinear hyper-elastic strain energy functions. The anisotropic response was defined by identifying a preferred material direction (same orientation as recorded during experiments). Lastly, the tissue response was modeled to mimic a passive abdominal wall.
33

3.3. A. Simulation of Uniaxial Extension Using FEA A commercially available FEA software ABAQUS (Providence, Rhode Island) was used for this work. Parts for the mesh and tissue specimens were drawn to the corresponding dimensions recorded for each of the uniaxial experiments. The shapes for both parts were simplified when modeling; for tissue it was assumed that the shape of the specimens were uniform and the material homogenous such that the part could be drawn simply as 3D solid rectangular pieces. In real life surgical mesh is formed of woven threads and contains many pores, see Figure 16, such that the surface area is exceptionally smaller than that of a uniform rectangular block with the same dimensions of length, width, and thickness. Solid parts in FEA, such as those used to model tissue, cannot be in contact with wired elements which would be required to model surgical mesh formed of woven threads (ABAQUS/CAE user's manual : version 6.4, 2003). Therefore, a compromise was made and the surgical mesh was simplified as a homogenous 3D shell rectangular piece. Parts varied in dimension from sample to sample but remained constant in element and design characteristics as listed in Table 3. A sample of the ABAQUS standard input file for these simulations is available in Appendix D and Appendix G.

34

Table 3. FEA Model Part Characteristics Part Type Element Shape Abdominal Tissue 3D Solid Homogenous Hex Dominated C3D8H Elements: quadratic elements, 8 node linear bricks, hybrid formulation, with constant pressure Reduced Polynomial 2nd Order Nearly Incompressible: 0.46 v 0.498 5 x 4 x 0.75 cm Bard Soft PP Mesh 3D Shell/Continuum Homogenous Quad Dominated S4R Elements: Quadratic Elements, 4 node doubly curved think or thick shell structure, reduced integration, hourglass control, finite membrane strains Ogden 1st Order Polypropylene: v = 0.45 6 x 3 x 0.044 cm

Element Type

Material SEF Poissons Ratio Dimensions:

Figure 16. Zoomed In Image of Surgical Mesh. Left) Pores; Right) Threads

The modeled parts were partitioned into three regions; the first region representing the area bound in the upper clamp, the second being the gauge area, and the third being the area bound by the bottom clamp (see Figure 17). The first region was given a displacement boundary condition. The magnitude of this displacement was equivalent to the value obtained in the experimental data at which this specific simulation supposedly failed. The third partitioned region was given a boundary condition to be pinned in all directions such that there was no movement.
35

Figure 17. Partitioned Part for Uniaxial Simulation. Arrows) Upward Displacement, Xs) Fixed Region The computational test was run and the sum of the reaction forces in the ydirection for each node within the fixed region was collected. The reaction forces were divided by the initial cross-sectional area which allowed for the FEA results to output in the form of stress and strain. To compare the computational predictions from FEA with the experimental results, both data sets were graphed simultaneously and a goodness of fit determined by calculating the R2 value. Mesh convergence studies were conducted to determine the number of elements necessary for optimal results with respect to computational time and cost. 3.3. B. Lap Shear Simulation Using FEA This FEA simulation used customized dimensions for each specimen to match recorded dimensions during testing. Each part remained consistent with the part and element characteristics determined by the uniaxial FEA simulations (see Table 3). These parts were then assigned the material SEF coefficients for the orientation where the
36

original test load had been applied. The mesh and tissue were adhered together using an interaction constraint, surface-surface contact. This constraint was further customized to adjust over closures and to tie adjusted surfaces, i.e., surface area of both mesh and tissue part depicted by yellow squares in Figure 18. Contact properties comprised of normal behavior, which included a pressure over closure, Hard Contact. The full FEA model with associated constraints can be seen in Figure 18. The loading in ABAQUS was done by applying a displacement boundary condition onto the mesh shell edge and having it moved upward equivalent to the displacement of the first peak for that specimen from the lap shear experiments. The ABAQUS standard input file for this simulation is available in Appendix J. One other boundary condition was applied; fixing in place the bottom partitioned region of the tissue. The sum of the reaction force at the fixed tissue region was recorded at various extensions and compared to the load vs. extension data of the lap shear experiments. The two data sets were graphed simultaneously and compared to each other by analyzing the goodness of fit. Last, a mesh convergence study was undertaken to determine the number of elements necessary for optimal results with respect to computational time and cost.

37

Figure 18. FEA Model of Lap Shear Experiments. Blue) Mesh, White) Tissue, Arrows) Upward Displacement, Xs) Fixed Region, Squares) Tied Surfaces

38

Chapter 4: Results and Discussion

The aim of this thesis is to determine whether the use of fibrin glue as an alternative fixation method for mesh placement on the abdominal wall results in adequate interfacial strength between mesh and tissue. This was accomplished by measuring and comparing the fixation strength of mesh-tissue interface with fibrin glue or classical sutures. Three major activities were undertaken: (1) uniaxial extension experiments with only the abdominal tissue and only mesh (BARD, New Jersey) to identify the material properties, (2) lap shear test to determine interface strength between abdominal wall and mesh without hernia defect, and (3) FE modeling of the lap shear experiment to initiate a computational modeling effort to model hernia. 4.1 Uniaxial Extension Experiments Uniaxial experiments were conducted to measure the mechanical response of the mesh and tissue. Both Bard soft mesh and abdominal tissue are known to display anisotropy. Due to this characteristic, two different orientations were tested and used as a means of comparison for this study. Representative raw data from the uniaxial experiments from tissue and mesh are shown in Figure 19.

39

60

Uniaxial Test Samples

50 40 Load (N) 30 20 Tissue Uniaxial Test Mesh Uniaxial Test

10
0 0 10 20 30 Extension (mm) 40 50

Figure 19. Representative Uniaxial Test Data. Tissue Specimen (Direction 1), Mesh Specimen (Direction 2) 4.1. A. Average Normalized Force Uniaxial experiments were performed and F-D response of surgical mesh and excised abdominal tissue collected. This data was used to obtain the peak force per unit width used to describe the material strengths (Table 4). The average normalized force for direction 2, the weaker of the two orientations for tissue, was 16 N/cm +/- 3.0 STD (Table 4). A similar value was reported by Grevious et al. as a minimum strength required in mesh repair for a successful operation of an average adult (Grevious et al., 2006). Direction 1 of tissue is characterized as following the fibers along the transverse abdominis and transverse to the muscle fibers in the external oblique. This orientation was previously reported to have a stiffer response than tissue tested in direction 2 (Hernndez et al., 2011; Song, Alijani, Frank, Hanna, & Cuschieri, 2006). While the uniaxial results for tissue indicate an average value relatively stronger in Direction 1 then
40

Direction 2, it was revealed in a 2 sample statistical T-test that there was actually no significant difference between the two orientations. On the other hand, a similar statistical test confirmed that there is a significant difference in the mechanical response of surgical mesh with respect to the orientation tested. As stated previously, a relatively stiffer F-D response of the prosthetic mesh in comparison to the surrounding tissue will result in a stiffer regional response in the abdomen. However, the fittingly stronger mechanical response is necessary in providing reinforcement to resist internal loads at the hernia repair site. Specifically, the axial and radial stresses relevant to a hernia will cause stretching perpendicular to the direction that the hernia defect is propagating. Consequently, in a hernia repair operations, optimal results will be best achieved if anisotropy of the prosthetic implant is orientated such that the weaker direction is aligned to the direction the hernia is propagation. For this study however, where there is no hernia defect, optimal results will be best achieved if anisotropy of the prosthetic implant closely resembles the fixated tissue (i.e. direction 2 of mesh is aligned to direction 2 of tissue). Table 4. Uniaxial Results with Averaged Normalized Forces Material Average +/- STD Direction 1 22.0 +/- 7.4 n=6 48.0 +/- 1.3 n=5 Average +/- STD Direction 2 16.0 +/- 3.0 n=6 17.0 +/- 1.6 n=5 P-Value P = 0.21 No Significant Difference P < 0.01 Significant Difference

Abdominal Wall

Bard Soft Mesh

41

4.1. B. Nonlinear Mechanical Properties for Mesh and Tissue When curve fitting a strain energy function with experimental data the ABAQUS software will provide coefficient values for the specific SEFs such that the equation will be able to simulate the non-linear material response. Each strain energy functions used a total of 3 coefficients. For the 1st order Ogden SEF the coefficients were , , and D1 and for 2nd order reduced polynomial the coefficients were C10, C20, and D1. These coefficients represented specific material properties. For example , C10, and C20 were coefficient related to shear modulus and were expressed in the units of MPa. Alpha is a dimensionless and unitless constant which plays a role in the theory of finite elasticity. Last the D1 constant called Dashpot is the time derivative of strain, resisting changes in length; the units are in MPa-1. All coefficients for the material models have been summarized in Table 5 and Table 6. The goodness of fit between the material model and experimental data is shown in Figure 20 for tissue and in Figure 21 for surgical mesh. All curve fitting results for both mesh and tissues are included in Appendix E and H. The Poissons ratio of the abdominal wall soft tissue was not solved for in our experimental tests. However, other studies indicate that soft tissue can be modeled using a nearly incompressible Poissons ratio (0.45 < 0.499). Poissons ratios were tested and a best fit was selected for each individual model, such that the uniaxial simulation in ABAQUS gave similar results to the experimental data. Best fit at this stage was determined through visual inspections, but quantitative values were determined for the final fit using the coefficient of determinate method. It is worthwhile to note, that Poissons ratio for best fit varied between 0.46 and 0.499 between models of individual specimens. It is very unlikely that the compressibility of soft tissue is ever at a value of

42

0.499, which suggest that further investigation should be done on the significance of the Poissons ratio for abdominal soft tissue with respect to our current experimental set-up. In using this method a few assumptions were made to simplify the problem. In reality the abdominal tissue samples included many different types of tissue including superficial fascia, rectus sheath, and rectus abdominis muscle tissue as well as possibly fascia from the linea alba and tendinous intersections. However, for the simplification of determining a function, which could represent the material properties of the tissue sample it, was assumed that the tissue was a homogenous structure. Similarly, surgical mesh which is a woven structure with many pores was modeled in this study as a continuous homogenous shell part. Additionally, the surgical mesh model used a 1st order Ogden SEF, with a Poissons ratio of 0.45, to model mechanical response. This Poissons ratio is the material property value for a block of polypropylene and would be significantly lower for a woven material. Consequently, because of these simplifications there is a chance the material model will be unable to fully account for the mechanical response of different fiber orientations in the structure. Table 5. Strain Energy Function Coefficients for Abdominal Wall Tissue SEF: Reduced Polynomial n=2 Tissue Direction 1 Tissue Direction 2 2 C10 C20 D1 R C10 C20 D1 Coefficients MPa MPa Mpa-1 MPa MPa Mpa-1 Units 1.14 0.985 1.02E-02 1.28E-02 0.99 Specimen 1 4.40E-03 2.62E-02 3.34 0.993 1.00E-02 1.24E-02 1.57 Specimen 2 2.00E-04 4.50E-03 2.58 0.999 1.50E-03 3.90E-03 3.66 Specimen 3 7.82E-03 1.06E-02 8.60E-04 2.00E-02 2.33 0.994 3.04E-02 4.32E-02 1.60 Specimen 4 1.12 0.934 1.76E-03 3.24E-02 1.14 Specimen 5 1.80E-02 1.10E-02 1.54 0.913 1.30E-02 1.50E-02 1.40 Specimen 6 1.0E-09* 4.25E-03 5.21E-03 1.27E-02 1.15 1.12E-02 1.99E-02 1.34 Average 0.01 0.01 0.01 0.01 STD * Unusual output value from ABAQUS software
43

R2 0.972 0.989 0.954 0.998 0.995 0.997

A
0.25 0.2 Stress, (MPa) Specimen 3 Tissue Direction 1
Uniaxial Data SEF R.P. n=2

B
0.25 Specimen 6 Tissue Direction 2
Uniaxial Data

0.2
0.15 0.1 0.05 0 0 0.5 Strain (mm/mm) 1 0 0.5 Strain, (mm/mm) 1
SEF R.P. n=2

Stress (MPa)

0.15 0.1 0.05 0

Figure 20. Representative Tissue Experimental Response and the Material Model Fit. A) Direction 1 B) Direction 2

Table 6. Strain Energy Function Coefficients for Polypropylene Soft Knit Mesh SEF: Ogden n=1 Soft Mesh Direction 1 Soft Mesh Direction 2 2 D1 R D1 MPa MPa-1 MPa MPa-1 2.80 7.20 0.134 0.976 0.817 4.74 0.253 7.00 6.70 0.031 0.972 0.780 5.20 0.339 4.80 7.20 0.050 0.867 0.840 5.00 0.266 5.20 7.00 0.043 0.891 0.730 4.40 0.325 1.100 4.40 0.234 4.95 7.03 0.065 0.792 4.835 0.296 1.72 0.24 0.047 0.05 0.35 0.04

Coefficients Units Specimen 1 Specimen 2 Specimen 3 Specimen 4 Specimen 5 Average STD

R2 0.992 0.986 0.953 0.984 0.968

44

A
12 10 Stress, (MPa) 8 6 4 2 0 0 0.1 0.2 0.3 Strain, (mm/mm) 0.4 Uniaxial Data SEF Ogden n=1 Specimen 2 Mesh Direction 1 Stress, (MPa)

B
4 3.5 3 2.5 2 1.5 1 0.5 0 0 0.5 Strain, (mm/mm) 1
Uniaxial Data SEF Ogden n=1

Specimen 2 Mesh Direction 2

Figure 21. Representative Mesh Experimental Response and the Material Model Fit. A) Direction 1 B) Direction 2 4.2 Lap Shear Tests for Obtaining Interfacial Strength Biomechanical analyses conducted by lap shear tests measured the mechanical strength of the mesh-tissue interface of the specimens. Maximum force required to cause failure in the specimens, Figure 22, was normalized by the width of the mesh-tissue specimen. Results of these experiments are displayed as a boxplot in Figure 23 numerically summarized in Table 7. Comparisons of normalized force of fixation technique at each individual time point was evaluated using a statistical MannWhitney-Wilcoxon test with 95%, Table 8. An additional statistical test was performed evaluating all fixation techniques and evaluation time points against each other using a 2way Anova test with 95% confidence, Table 9.

45

Lap Shear Test

90 80 70 60 Load (N) 50 40 30 20 10 0 0 10 20 30 40 50 Extension (mm) 60 70 80 24 Hours 1 Week 2 Weeks

Figure 22. Representative Lap Shear

This box plot in Figure 23 shows the spread of fixation strength resulting from the lap shear experiments. At each later time point there is a clear increase in the average fixation strength corresponding to the amount of tissue ingrowth which has occurred. However, the sutured boxplots are clearly stronger then the glued counterparts. The solid orange line marks the 16 N/cm load suggested by Grevious et al., to be the minimal strength required for a successful abdominal repair (Grevious et al., 2006). Both fixation methods pass this benchmark at 2 weeks while at 1 week only sutured specimens do. Supporting this benchmark value, our uniaxial results also indicated that on average the mesh and tissue could withstand a minimum strength around 16 N/cm before failing. Therefore, it can be predicted that once a specimens normalized forces exceed the

46

benchmark value there is a higher likelihood that failure in the mesh-tissue specimen will occur in either the mesh or tissue rather than in the interface. Only at 24 hours did tested specimens fail most frequently in the mesh-tissue interface. The sutured interface had a mean strength relatively higher than the glued interface [9.4 +/- 2.4 STD and 5.3 +/- 3.6 STD]. The mean of the normalized

strength remained stronger in the sutured interface for each higher time point measured. More notably, the load vs. extension graphs revealed a stiffer response in the sutured specimens than to the glued specimens. This outcome was most prominent in the twoweek specimens, where the mesh was fully incorporated into the abdominal wall. Table 7 shows the average normalized force values from the lap shear tests. A complete table of results from all specimens can be found in Appendix A. The lap shear experiments failed the test for normal distribution performed in Sigmaplot. Therefor the Mann-U test which compares ordinal sample distributions of two populations was utilized for evaluating these tests. The analysis revealed a significant difference between glued and sutured fixation at all-time points were sutured specimens were relatively stronger. This difference in average strength was between 44-47 % higher during early recovery, t 1 week; suggesting, that the comparably weaker fixation strength reported in literature for fibrin glue fixation is nearly half of that associated with sutured fixation. An additional statistical test was done using a 2-way analysis of variance (Anova), with 95% confidence, which compared fixation strength with both evaluated time points and fixation techniques. The summary of this statistical tests are as follows. There was a statistical difference between both fixation techniques and all evaluation

47

times. In addition there was a statistical difference between glued and sutured fixation, at both, 1 and 2 weeks but none at 24 hours. Next, there was a statistical difference between glued fixations at all time points except for 1 week comparison to 24 hours, where no difference was reported. Last, there was a statistical difference between sutured fixations between all-time points. A complete tabulated result from this Anova test is shown in Table 9. Matlab code for determining peak force is shown in Appendix B and Matlab code for obtaining the boxplot in Figure 23 is shown in Appendix C.

Figure 23. Summary of Results from Lap Shear Experiments

48

Table 7. Averaged Normalized Forces for Glued vs. Sutured Specimens Healing Time 24 Hours 1 Week 2 Weeks Glue Average +/- STD 5.7 3.6 12.2 4.0 22 7.4 ; (n = 8) ; (n = 7) ; (n = 9) Suture Average +/- STD 9.4 2.4 23.1 12.2 30.9 7.4 ; (n = 8) ; (n = 8) ; (n = 8)

Table 8. Statistical Analysis using Mann-Whitney-Wilcoxon U-test

Glue Suture Zvalue P-Value UA UB 95 % Confidence Level 36 < U < 92 13 < U < 43 18 < U < 54 S.D. S.D. S.D.

24 n=8 n=8 -2.73 0.003 < P < 0.006 109 19 Hours 1 n=7 n=8 2.03 0.021 < P < 0.042 10 46 Week 2 n=9 n=8 -1.97 0.024 < P < 0.049 57 15 Weeks S.D. = Significant Difference; N.S.D. = No Significant Difference

Table 9. 2-Way Anova Test Two Way Analysis of Variance All Pairwise Multiple Comparison Procedures (POC with Holm-Sidak method) Comparisons Diff of Critical Signifi Comparison t P for factor: Means Level cant 2 week vs. 24 hours 18.965 7.847 <0.001 0.017 Yes Time points 1 week vs. 24 hours 10.292 4.126 <0.001 0.025 Yes 2 week vs. 1 week 8.673 3.525 0.001 0.05 Yes Fixation T. Suture vs. Glue 7.86 3.917 <0.001 0.05 Yes 24 hours Suture vs. Glue 3.578 1.032 0.308 0.05 No 1 week Suture vs. Glue 11.129 3.102 0.003 0.05 Yes 2 week Suture vs. Glue 8.875 2.635 0.012 0.05 Yes 2 week vs. 24 hours 16.316 4.844 <0.001 0.017 Yes Glued 2 week vs. 1 week 9.8 2.805 0.008 0.025 Yes Fixation 1 week vs. 24 hours 6.516 1.816 0.076 0.05 No 2 week vs. 24 hours 21.614 6.235 <0.001 0.017 Yes Suture 1 week vs. 24 hours 14.068 4.058 <0.001 0.025 Yes Fixation 2 week vs. 1 week 7.546 2.177 0.035 0.05 Yes

49

One additional evaluation was performed comparing the lap shear and uniaxial results. The mean strength for failure in the sutured specimens was 31.0 +/- 7.4 while the glued specimens failed on average at 22.0 +/- 7.4 STD,

STD. These averages

indicate that the tissue with glued mesh had the same mechanical response as excised abdominal tissue, whereas the sutured specimens had relatively stiffer F-D mechanical response (See Figure 24). Such differences in relative material strength of mesh-tissue specimens and abdominal wall tissue indicate a regionally stiffer tissue response when using sutured fixation (with Prolene sutures).

14 2 Week Sutured 12 Normalized Load(N/cm) 10 8 6 4 2 0 0 0.2 0.4 0.6 0.8 1 Extension (cm) 2 Week Glued Direction 1 Tissue Uniaxial Direction 2 Tissue Uniaxial

Figure 24. Typical Mesh-Tissue Response at 2 weeks vs. Excised Tissue Response

In the lap shear experiments the reported normalized max force indicates the sample has begun to fail. Failures however does not necessary have to occur in the interface and can just as easily occur in the materials, i.e., the bound tissue or mesh, as
50

seen in Figure 25. These locations vary during different stages of wound healing and play a role in identifying how well the mesh was incorporated into the tissue structure. In the case when a majority of failure is no longer occurring in the interface the normalized loads can no longer be reported as the mesh-tissue interfacial strength. The locations at which the tested specimens failed are summarized in Table 10. .

Figure 25. Failure modes. Left: Mesh failure, Center: Interface failure, Right: Tissue failure

At 24 hours, the interface failed for glued samples 87.5% of the time, as was previously predicted for this level of tissue ingrowth. For the sutured samples the interface failed 60% of the time, while the other 40% was failure in the tissue region. Two reasons exist that could cause failure at the tissue region. The first reason for failure would be that enough tissue ingrowth had occurred that the stress was no longer concentrated in the interface, and the second reason would be that there was some level

51

of tissue damage caused by the suturing which resulted in stress build up at the damaged tissue region and ultimately led to failure in the tissue. On the other hand, at 24 hours the glued specimens still had an observable glossy layer of glue surrounding the mesh pieces and had not fully dissolved, this protective layer would limit the amount of tissue ingrowth possible between the mesh and tissue. The sutured specimens had no such layer and tissue ingrowth with mesh was able to occur immediately. At 1 week, both types of specimens had enough time to form an adequately strong interface. However, the level of tissue ingrowth varied from specimen to specimen and depended on the animal model and that individual animals rate of healing. It would be predicted at this stage for results to be in a binomial distribution where the average failures occurred within the tissue. This was indeed observed in the glued specimens; nearly 55% of the time the tissue failed, 30% of these failures were at the interface and 15% of the time they were in the mesh. Results were far more variable in the sutured samples; where 38% of the time the mesh failed, 24% the tissue did, and 38% the interface failed. Standard deviation of the normalized force at failure was also high for sutured specimens at 1 week, with the samples ranged from mesh almost fully embedded to samples with barely any tissue ingrowth. One major concern of sutured fixation, which could cause a delay in tissue ingrowth, was mesh curling; all samples with failed interfaces at 1 week time points had nearly no tissue ingrowth and the sutured specimens had observable mesh curling. Regardless, our failure mode analyses suggest that as early as 1 week there was an adequate amount of tissue ingrowth such that the interfacial strength was stronger than the bound material substrates.

52

At 2 weeks mesh pieces were well embedded into the tissue and presented great difficulty in separating mesh from tissue when preparing samples for lap shear tests. Nearly full tissue ingrowth would be characterized at this stage and stress propagation would be expected to occur along the mesh in the lap shear test. In the glued specimens, there was a 100% failure at the mesh. For the sutured samples there was a 75% failure in the mesh and 25% failure in the tissue. Table 10. Lap Shear Test Failure Mode Occurrences Mesh # Failed Percentage 24 Hours Glue Suture 1 Week Glue Suture 2 Weeks Glue Suture 0 0 1 3 9 6 0% 0% 14% 38% 100% 75% Interface # Failed Percentage 7 5 2 2 0 2 87.5% 62.5% 29% 24% 0% 25% Tissue # Failed Percentage 1 3 4 3 0 0 12.5% 37.5% 57% 38% 0% 0%

4.3 Computational Study using FEA to Simulate Mechanical Experiments 4.3. A. Uniaxial Simulation with FEA Finite element analysis was used to create a uniaxial simulation of the mesh and tissue specimens (Figure 26). The force-displacement data obtained from the uniaxial tests were compared to the sum of the reaction forces at the pinned tissue region of an FEA model created in ABAQUS (Figure 28). The uniaxial model showed a reasonable fit to the experimental results, which validated the individual models for mesh and tissue. The goodness of fit was determined using the coefficient of determinate value R2, Table 13. All results are included in Appendix F and Appendix I. FE mesh size was optimized

53

such that computational time was reduced without drastically influencing the output results. This was done by performing a mesh convergence study on surgical mesh and abdominal tissue uniaxial simulations, Figure 27/Table 11 and Figure 29/Table 12. It was decided from these convergence studies that 1500 elements for tissue models and 160 elements for the surgical mesh was sufficient for the simulations.

Figure 26. Stress contour plot A) Surgical Mesh B) Abdominal Tissue

54

A
3.3 Sum of Nominal Stress (N/cm2) 3.3 3.2 3.2 3.1 3.1

B
Mesh Convergence for Tissue Model

Table 11. Mesh Convergence Study for Tissue

ELEMENTS 24486 10000 1914 1500 864 640 540 416 165 140 80 Sum() 3.11E+00 3.11E+00 3.13E+00 3.14E+00 3.15E+00 3.16E+00 3.17E+00 3.18E+00 3.19E+00 3.21E+00 3.25E+00 Run Time < 10 min < 5 min < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec

0 10000 20000 Figure 27. Mesh Convergence # of Elements Study for Tissue Model

0.25 0.2

Specimen 3 Tissue Direction 1 Stress, (MPa)

0.25 0.2

Specimen 6 Tissue Direction 2

Uniaxial Data

Stress (MPa)

0.15 0.1 0.05 0 0

Uniaxial Data

0.15 0.1 0.05 0

FEA Simulation

0.5 Strain (mm/mm)

0.5 Strain, (mm/mm)

Figure 28. Representative Tissue Experimental Response and the FEA Model Results. A) Direction 1 B) Direction 2

55

Table 12. Mesh Convergence Study for Surgical Mesh Sum of Nominal Stress (N/cm2)

Mesh Convergence for Surgical Mesh

13.0985 13.0980 13.0975 13.0970 13.0965 13.0960 13.0955 13.0950 13.0945 13.0940 0 1000 2000 # of Elements 3000

ELEMENTS Sum(stress) 3240 1800 561 450 378 288 210 162 120 84 45 18 6 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01 1.31E+01

Time < 5 min < 1 min < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec < 30 sec

Figure 29. Mesh Convergence Study for Surgical Mesh Models

12 10 Stress, (MPa) 8 6 4 2 0 0

Specimen 2 Mesh Direction 1 Stress, (MPa)

4 3.5 3 2.5 2 1.5 1

Specimen 2 Mesh Direction 2

Uniaxial Data FEA Simulation 0.1 0.2 0.3 Strain, (mm/mm) 0.4

Uniaxial Data FEA Simulation

0.5
0 0

0.5 Strain, (mm/mm)

Figure 30. Representative Mesh Experimental Response and the FEA Model Results.

56

Table 13. Goodness of Fit of Experimental Data with Uniaxial Simulation Specimen 1 2 3 4 5 6 Tissue Direction 1 R2 0.992 0.976 0.990 0.942 0.977 0.987 Tissue Direction 2 R2 0.983 0.979 0.910 0.995 0.983 0.998 Mesh Direction 1 R2 0.584 0.978 0.974 0.984 Mesh Direction 2 R2 0.826 0.843 0.932 0.862 0.942

4.3. B. Lap Shear Simulation with FEA Finite element analysis (FEA) was used to create a lap shear simulation of the 2 week glued test specimens, Figure 31. The load to extension data obtained from the lap shear tests were compared to the FEA simulation. In Figure 32A, there is a noticeable offset between the simulation and the actual test data. The initial toe in region of the lap shear results where rate of load to extension is exceptionally low can be associated with both material (i.e. some uncontrolled property of healing tissue) and experimental conditions (i.e. slack in the sample, fluid leakage from specimen, etc.). Whatever the condition may be that causes this response, it did not occur in the uniaxial experiments (mesh and tissue) and so was not captured in the SEFs mechanical response. For the most part, it was clear the FEA simulation had a stiffer response in comparison to the actual response. Representative results are shown in Figure 32. All results are included in Appendix K. Goodness of fit, R2 value, was determined using the coefficient of determinate method as described in the Equation 4. There was a significant variation between the R2 values reported for all models. Most frequently the simulation

57

and experimental results were within 6% difference of one another; however R2 varied significantly between models ranging from worst case of 64.3% difference to best case at 1.6% difference. The full list of R2 values for lap shear simulations are given in Table 14. The number of elements used in these models was approximately 1500 for the tissue part and 460 for the surgical mesh part; these values were determined by a mesh convergence study performed for each lap shear models created. Since there was a separate model with customized parts created for every single specimen all the individual mesh convergence studies are not shown in this thesis. However, Figure 33 and Table 15 provide a sample of one of the mesh convergence studies, specimen 2_4.

Figure 31. FEA Model Reaction Force Contour Plot

58

A
Load, N

40 35 30

Specimen 2_8

70

B
Specimen 9_4

60
50 Load, N
Lap Shear FEA

25 20 15 10 5 0 0 10 20 Displacement, mm

40 30 20 10 0
Lap Shear Data

5 Displacement, mm

10

Figure 32. Comparison of Experimental and FEA Results of Lap Shear Experiments. Lap Shear Model A) Sub-Optimal Fit and B) A Good Fit by Visual Inspection. Table 14. Goodness of Fit of FEA Simulation to Experimental Data Specimen # Specimen 1_1 Specimen 1_3 Specimen 1_8 Specimen 2_3 Specimen 2_4 Specimen 2_7 Specimen 2_8 Specimen 9_4 Specimen 9_5 R2 0.357 0.836 0.938 0.946 0.469 0.944 0.546 0.984 0.831 % Difference (64.3%) 16.4% 6.2% 5.4% 53.1% 5.6% 45.4% (1.6%) 16.9%

59

Sum of Reaction Force (N)

Mesh Convergence for Lap Shear Model Specimen 2_4

118 117 116 115 114 113 112 0 2000 4000 # of Elements 6000

Figure 33. Mesh Convergence Study for Lap Shear Models Table 15. Mesh Convergence Study for Lap Shear Models
Elements Elements Total # of Sum(RF) Run time in tissue in mesh elements 4070 700 4770 113.023 < 7 min 3400 460 3860 113.074 < 5 min 1500 460 1960 113.816 < 2 min 858 195 1053 114.896 < 1 min 627 154 781 115.033 < 30 sec 540 130 670 115.132 < 30 sec 288 108 396 117.29 < 30 sec 225 80 305 117.335 < 30 sec 168 63 231 117.707 < 30 sec

60

Chapter 5: Conclusions
5.1. Conclusions The average normalized load with sutures is stronger than glued at all-time points. At or greater than 1 week time point, the fixation strength became independent of the technique and failure occurred in the materials rather than the interface. After 2 weeks of recovery, the glued specimens show nearly identical load measurement readings to the material strength of healthy tissue. At 2 week recovery, the sutured samples exhibited interface strength globally stiffer than what is characterized with healthy tissue while glued specimens showed a nearly identical F-D response. The strain energy model used to mimic the material response under loading was comparably similar to experimental data such that FEA uniaxial simulations frequently reported - values less than 9% difference of the experimental data. Modeling approach used for mimicking lap shear experiments was not always comparable to the experimental data and would require further investigation to develop a consistent model. 5.2. Clinical Significance Lower interfacial strength at earlier time points, 24 hours, has a significant relevance for susceptibility of reoccurrence due to mesh migration. However both techniques (sutures or adhesive) lead to a mesh-tissue interfacial strength lower than the benchmark value of 16 N/cm, at this early stage. At two weeks, every sample tested had a mesh-tissue interface exceedingly stronger than the mesh or tissue materials. Samples fixated using sutures had a far stiffer global F-D response and higher strength value than
61

associated with healthy tissue, such that the strength values more closely resembled relative material strength of polypropylene sutures.

62

Chapter 6 Future Work

6.1 Mechanical Experiments and Sample Preparation 6.1. A. Future Work It would be clinically significant to repeat experiments using earlier time points (t 1 week), where fixation technique is still relevant toward the interfacial strength. Additionally, it would be clinically significant to perform experiments where the advantages of using adhesive fixation are compared to the disadvantages of the relatively weaker fixation strength at these earlier time points. For future studies, it may be beneficial to perform tests comparing the efficiency of biodegradable suture fixation with fibrin glue fixation post 1 week recovery, in order to determine if the higher strength values obtained with sutured specimens was due to the use of non-degradable sutures. Other potential studies that could be informative and helpful for medical practitioners include: A) Testing different coating techniques for glue applications in order to determine if there is any relation with coating technique and fixation strength; B) Testing different biological glues other than Tisseel fibrin glue to see if another product is more efficient for mesh repair operations; C) Testing alternative surgical meshes besides BARD soft knit polypropylene mesh to see if another product reacts better with adhesive glue for fixation on soft tissue. Isotropic mesh should be utilized in any future studies where mesh is implanted onto healthy tissue. The significance of anisotropic mesh is in resisting the higher stress concentration along the tissue direction that is perpendicular to the direction
63

the hernia is propagating. In the case where a study is not done on a herniated tissue region the benefit of having the anisotropic mesh becomes irrelevant. 6.1. B. Limitations that need to be addressed in Future Studies Surgical procedures used for suture fixation have four evenly-spread surgical knots tying the corners of the mesh piece to the abdominal tissue. In common surgical practice for VHMR operations, sutures are generally knitted into the mesh and abdominal wall such that the sutures follow through the entire perimeter of the mesh. This technique would uniformly holds the mesh flat onto the abdominal wall and could potentially influence better fixation. Future work should have control samples, which evaluate mesh-tissue interface with no fixation. This would determine the level of tissue ingrowth that would have occurred naturally under the absence of any anchoring or adhesive materials used for fixation. Greater precautions can be taken in future studies to prevent infection, blood clotting, or other such biological responses that artificially reduce the natural strength of the implant. For the lap shear clamping tests, a scalpel was used to free the mesh from tissue, possibly creating many artificial microscopic tears and nicks in the tissue interface before testing. Additionally, the level of tissue ingrowth after 1 week made it difficult to clear all the tissue from the mesh before clamping. It is unlikely that the mesh cleared for clamping was completely unbound from all tissue fibers.

64

Inconsistency on amount of tissue shaved off samples to allow fitting in clamps also added potential error to the tests. Too much tissue shaved off specimens would create an area of weakness where failure could occur while too little tissue would cause samples to slip out of the clamps during clamp tightening. Future studies should consider a more consistent method of preparing specimens for testing.

The most common source of loading on the mesh-tissue repair site of the abdominal wall is due to intra-abdominal pressure. Therefore, future studies may consider using burst tests for biomechanical evaluation to accompany shear experiments.

Lastly, one limitation during sample preparation was the difficulty in visually determining the mesh piece location of 2 week specimens. Use of color coated mesh or other identification method would counter this limitation. Chances of accidently cutting and damaging mesh as well as accidently clamping portions of tissue or mesh into the wrong clamp is significantly higher in the 2 week samples.

6.2 Finite Element Models for Computational Simulations 6.2. A. Next Step toward Developing Full Robust Model of a VHMR A future step is using the material models and interfacial fit to developing a more robust model of a VHMR abdomen. A full model of an abdomen with a hernia defect zone and mesh sealant would help provide a macro scale visualization of how stress distribution or potential failure would occur. The clinical significance of this will be that such a model would be able to provide a general idea on how variation in internal pressure and other loading mechanisms due to trunk

65

movement will influence the stress concentration at the repair site. It can also provide practitioners with a general idea of whether the patient is at high risk of suffering from a hernia reoccurrence due to mesh failure. 6.2. B. Limitations in Current Models that should be addressed in Future Work Further investigation should be done to determine the true Poissons ratio of the surgical mesh and abdominal tissue. Surgical mesh was modeled as a 3D continuous homogenous shell part instead of as a knitted fiber with large pores. Similarly, abdominal tissue was modeled as an isotropic homogenous material rather than a heterogeneous one. Future models should better account for the heterogeneity of tissue and monofilament fiber structure of mesh. The interfacial fit was performed by tying the surface of the mesh and tissue together instead of embedding the mesh in tissue as it occurs in vivo. Interfacial fit will have a different mechanical response than that of an embedded implant. Goodness of fit between FEA simulation and lap shear experiments were inconsistent. FEA models should be further improved so that computational simulations better resemble the experimental data. Future models could also be improved by taking into account the material properties associated with muscle-active tension

66

References
ABAQUS/CAE user's manual : version 6.4. (2003). Pawtucket, RI : ABAQUS. Campanelli, G., Pascual, M. H., Hoeferlin, A., Rosenberg, J., Champault, G., Kingsnorth, A., & Miserez, M. (2012). Randomized, Controlled, Blinded Trial of Tisseel/Tissucol for Mesh Fixation in Patients Undergoing Lichtenstein Technique for Primary Inguinal Hernia Repair Results of the TIMELI Trial. Annals of Surgery, 255(4), 650-657. doi: 10.1097/SLA.0b013e31824b32bf Canonico, S., Santoriello, A., Campitiello, F., Fattopace, A., Corte, A. D., Sordelli, I., & Benevento, R. (2005). Mesh fixation with human fibrin glue (Tissucol) in open tension-free inguinal hernia repair: a preliminary report. Hernia, 9(4), 330-333. Canziani, M., Frattini, F., Cavalli, M., Agrusti, S., Somalvico, F., & Campanelli, G. (2009). Sutureless mesh fibrin glue incisional hernia repair. Hernia, 13(6), 625-629. doi: 10.1007/s10029-009-0555-5 Carriquiry, C. E. (1996). Anatomy and physiology of the abdominal wall. Operative Techniques in Plastic and Reconstructive Surgery, 3(1), 2-6. doi: http://dx.doi.org/10.1016/S10710949(96)80043-6 Chevrel, J. P., & Rath, A. M. (1997). The use of fibrin glues in the surgical treatment of incisional hernias. Hernia, 1(1), 9-14. Clarke, T., Katkhouda, N., Mason, R. J., Cheng, B. C., Algra, J., Olasky, J., . . . Balouch, M. (2011). Fibrin glue for intraperitoneal laparoscopic mesh fixation: a comparative study in a swine model. Surgical Endoscopy and Other Interventional Techniques, 25(3), 737-748. doi: 10.1007/s00464-010-1244-2 Cobb, W. S., Burns, J. M., Kercher, K. W., Matthews, B. D., James Norton, H., & Todd Heniford, B. (2005). Normal Intraabdominal Pressure in Healthy Adults. Journal of Surgical Research, 129(2), 231-235. doi: http://dx.doi.org/10.1016/j.jss.2005.06.015 Cobb, W. S., Harris, J. B., Lokey, J. S., McGill, E. S., & Klove, K. L. (2003). Incisional herniorrhaphy with intraperitoneal composite mesh: A report of 95 cases. American Surgeon, 69(9), 784-787. Cobb, W. S., Kercher, K. W., & Heniford, B. T. (2005). The argument for lightweight polypropylene mesh in hernia repair. Surg Innov, 12(1), 63-69. d'Acampora, A. J., Kestering, D. d. M., Soldi, M. d. S., & Rossi, L. F. (2007). Experimental study comparing the tensile strength of different surgical meshes following aponeuroticmuscle deformity synthesis on Wistar rats. Acta Cirurgica Brasileira, 22(1), 47-52. Deeken, C. R., Faucher, K. M., & Matthews, B. D. (2012). A review of the composition, characteristics, and effectiveness of barrier mesh prostheses utilized for laparoscopic 67

ventral hernia repair. Surgical Endoscopy and Other Interventional Techniques, 26(2), 566-575. doi: 10.1007/s00464-011-1899-3 Elenes, E. (2010). Development and Validation of a 2D/3D Finite Element Model of a Composite Hemipelvis. (Masters Thesis), University of Memphis, Memphis, TN, USA. Eriksen, J. R., Bech, J. I., Linnemann, D., & Rosenberg, J. (2008). Laparoscopic intraperitoneal mesh fixation with fibrin sealant (Tisseel) vs. titanium tacks: a randomised controlled experimental study in pigs. Hernia, 12(5), 483-491. Gonzalez, R., Fugate, K., McClusky, D., Ritter, E. M., Lederman, A., Dillehay, D., . . . Ramshaw, B. J. (2005). Relationship between tissue ingrowth and mesh contraction. World Journal of Surgery, 29(8), 1038-1043. doi: 10.1007/s00268-005-7786-0 Grevious, M. A., Cohen, M., Shah, S. R., & Rodriguez, P. (2006). Structural and Functional Anatomy of the Abdominal Wall. Clinics in Plastic Surgery, 33(2), 169-179. doi: http://dx.doi.org/10.1016/j.cps.2005.12.005 Hernndez, B., Pea, E., Pascual, G., Rodrguez, M., Calvo, B., Doblar, M., & Belln, J. M. (2011). Mechanical and histological characterization of the abdominal muscle. A previous step to modelling hernia surgery. Journal of the Mechanical Behavior of Biomedical Materials, 4(3), 392-404. doi: http://dx.doi.org/10.1016/j.jmbbm.2010.11.012 Hernndez-Gascn, B., Pea, E., Melero, H., Pascual, G., Doblar, M., Ginebra, M. P., . . . Calvo, B. (2011). Mechanical behaviour of synthetic surgical meshes: Finite element simulation of the herniated abdominal wall. Acta Biomaterialia, 7(11), 3905-3913. doi: http://dx.doi.org/10.1016/j.actbio.2011.06.033 Holzapfel, G. (2000). Nonlinear Solid Mechanics: A Continuum Approach for Engineering. West Sussex, England: John Wiley & Sons Inc. Israelsson, L. A., Smedberg, S., Montgomery, A., Nordin, P., & Spangen, L. (2006). Incisional hernia repair in Sweden 2002. Hernia, 10(3), 258-261. Katkhouda, N., Mavor, E., Friedlander, M. H., Mason, R. J., Kiyabu, M., Grant, S. W., . . . Essani, R. (2001). Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Annals of Surgery, 233(1), 18-25. doi: 10.1097/00000658200101000-00004 Kaul, A., Hutfless, S., Le, H., Hamed, S. A., Tymitz, K., Hien, N., & Marohn, M. R. (2012). Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: a systematic review and meta-analysis. Surgical Endoscopy and Other Interventional Techniques, 26(5), 1269-1278. doi: 10.1007/s00464-011-2025-2 Kingsnorth, A. N., Shahid, M. K., Valliattu, A. J., Hadden, R. A., & Porter, C. S. (2008). Open onlay mesh repair for major abdominal wall hernias with selective use of components separation and fibrin sealant. World Journal of Surgery, 32(1), 26-30. doi: 10.1007/s00268-007-9287-9

68

Klinge, U., Conze, J., Limberg, W., Brucker, C., Ottinger, A. P., & Schumpelick, V. (1996). [Pathophysiology of the abdominal wall]. Chirurg, 67(3), 229-233. Klinge, U., Klosterhalfen, B., Muller, M., Ottinger, A. P., & Schumpelick, V. (1998). Shrinking of polypropylene mesh in vivo: An experimental study in dogs. European Journal of Surgery, 164(12), 965-969. Lacombe, R. (2005). Adhesion Measurement Methods: Theory and Practice (1st ed.): CRC Press. Lau, H., Patil, N. G., & Yuen, W. K. (2006). Day-ease endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males - A randomized trial. Surgical Endoscopy and Other Interventional Techniques, 20(1), 76-81. doi: 10.1007/s00464-005-0203-9 Luijendijk Rw Fau - Hop, W. C., Hop Wc Fau - van den Tol, M. P., van den Tol Mp Fau - de Lange, D. C., de Lange Dc Fau - Braaksma, M. M., Braaksma Mm Fau - Ijzermans, J. N., Ijzermans Jn Fau - Boelhouwer, R. U., . . . Jeekel, J. (2000). A comparison of suture repair with mesh repair for incisional hernia. (0028-4793). Majercik, S., Tsikitis, V., & Iannitti, D. A. (2006). Strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model. Surgical Endoscopy And Other Interventional Techniques, 20(11), 1671-1674. McGinty, J. J., Hogle, N. J., McCarthy, H., & Fowler, D. L. (2005). A comparative study of adhesion formation and abdominal wall ingrowth after laparoscopic ventral hernia repair in a porcine model using multiple types of mesh. Surgical Endoscopy And Other Interventional Techniques, 19(6), 786-790. Norton, J., Barie, P., Bollinger, R. R., Chang, A., Lowry, S., Mulvihill, S., . . . Jones, D. (2008). Hernias and Abdominal Wall Defects Surgery (pp. 1133-1178): Springer New York: Patel, H., Ostergard, D. R., & Sternschuss, G. (2012). Polypropylene mesh and the host response. International Urogynecology Journal, 23(6), 669-679. doi: 10.1007/s00192-012-1718-y Petter-Puchner, A., Fortelny, R., Mittermayr, R., hlinger, W., & Redl, H. (2005). Fibrin sealing versus stapling of hernia meshes in an onlay model in the rat. Hernia, 9(4), 322-329. Petter-Puchner, A. H., Fortelny, R. H., Mittermayr, R., Walder, N., Ohlinger, W., & Redl, H. (2006). Adverse effects of porcine small intestine submucosa implants in experimental ventral hernia repair. Surgical Endoscopy and Other Interventional Techniques, 20(6), 942-946. doi: 10.1007/s00464-005-0568-9 Poulose, B. K., Shelton, J., Phillips, S., Moore, D., Nealon, W., Penson, D., . . . Holzman, M. D. (2012). Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia, 16(2), 179-183. doi: 10.1007/s10029-011-0879-9 Prieto-Diaz-Chavez, E., Medina-Chavez, J. L., Gonzalez-Ojeda, A., Coll-Cardenas, R., UribarrenBerrueta, O., Trujillo-Hernandez, B., & Vasquez, C. (2005). Tension-free hernioplasty

69

versus conventional hernioplasty for inguinal hernia repair. Surgery Today, 35(12), 10471053. doi: 10.1007/s00595-005-3087-3 Reddy, J. (2004). An Introduction to Nonlinear Finite Element Analysis. USA Oxford University Press. Robinson, T. N., Clarke, J. H., Schoen, J., & Walsh, M. D. (2005). Major mesh-related complications following hernia repair. Surgical Endoscopy And Other Interventional Techniques, 19(12), 1556-1560. Rutkow, I. M. (2003). Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surgical Clinics of North America, 83(5), 1045-1051. doi: http://dx.doi.org/10.1016/S0039-6109(03)00132-4 Schug-Pass, C., Lippert, H., & Kckerling, F. (2010). Mesh fixation with fibrin glue (Tissucol/Tisseel) in hernia repair dependent on the mesh structureis there an optimum fibrinmesh combination?Investigations on a biomechanical model. Langenbeck's Archives of Surgery, 395(5), 569-574. Seshu, P. (2004). TEXTBOOK OF FINITE ELEMENT ANALYSIS. India: Prentice-Hall of India Pvt.Ltd. Shell Iv, D. H., de la Torre, J., Andrades, P., & Vasconez, L. O. (2008). Open Repair of Ventral Incisional Hernias. Surgical Clinics of North America, 88(1), 61-83. doi: http://dx.doi.org/10.1016/j.suc.2007.10.008 Song, C., Alijani, A., Frank, T., Hanna, G., & Cuschieri, A. (2006). Elasticity of the living abdominal wall in laparoscopic surgery. J Biomech, 39(3), 587-591. doi: 10.1016/j.jbiomech.2004.12.019 Stoikes, N., Sharpe, J., Tasneem, H., Roan, E., Paulus, E., Powell, B., . . . Voeller, G. (2013). Biomechanical evaluation of fixation properties of fibrin glue for ventral incisional hernia repair. Hernia, 1-6. Venkatesh, C. (2011). Getting Started with Abaqus - Workbook 0: User Interface and Modeling Overview.

70

Appendix A Experiment Results

The following is tables include the results and specimen dimensions recorded for all the mechanical tests performed.

2 Weeks Lap Shear Experiments

Date Sampl e Fixation Techniq ue Heigh t Wid th Gauge Length Max Force Normalized Max Force Slop e Failure Mode Remove d

cm 2.8 3 3.5 3.5

cm 1.5 3 2 2 1.5 1.5

cm 1.5 2.5 2.3 2.4 2.5 2.3 1.8 3 2.8 2.5 3.7 1.5 1.5 3.6 4.3 3 2.5 2.6 3

N 27.83 50.31 27.06 43.27 26.62 39.41 48.21 50.88 57.91 55.56 53.37 41.30 40.17 57.66 75.04 102.0 92.45 75.17 61.76 18.55 16.77 13.53 21.63 17.75 26.27 19.28 25.44 38.60 37.04 17.79 27.53 23.63 38.44 50.03 34.01 30.82 37.58 16.25 3.86 1.87 9.36 4.35 5.45 5.29 6.21 8.86 10.7 9 3.00 8.00 4.64 20.3 0.99 5.82 7.61 10.6 9.16 2.78 Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Tissue Mesh Mesh Mesh Tissue Tissue Tissue Mesh Mesh Mesh Damag ed Outlier

5/1/12 5/1/12 5/2/12 5/2/12 5/2/12 5/2/12 5/9/12 5/9/12 5/9/12 5/1/12 5/1/12 5/2/12 5/2/12 5/2/12 5/2/12 5/8/12 5/9/12 5/9/12 5/8/12

73-1 74-1 75-1a 75-1b 76-1a 76-1b 80-1 79-1a 79-1b 73-2 74-2 75-2a 75-2b 76-2a 76-2b 78-2 80-2 79-2 77-2

Glue Glue Glue Glue Glue Glue Glue Glue Glue Suture Suture Suture Suture Suture Suture Suture Suture Suture Suture

2.5 3.3 3.3 3 2.5 2.5

2.5 2 1.5 1.5 3 1.5 1.7 1.5 1.5

5 4 3 5

3 3 2 3.8

71

1 Week Lap Shear Experiments

Date Sam ple Fixation Techniq ue Hei ght Wi dth Gauge Length Max Force Normalized Max Force Slope Failure Mode Remo ved

cm 6/6/12 6/12/12 6/12/12 6/13/12 6/27/12 6/27/12 6/27/12 6/13/12 6/12/12 6/13/12 6/27/12 6/27/12 6/27/12 6/6/12 6/12/12 6/13/12 6/5/12 53-1 55-1 56-1 58-1 59-1 60-1 61-1 57-1 56-2 57-2 59-2 60-2 61-2 53-2 55-2 58-2 51-2 Glue Glue Glue Glue Glue Glue Glue Glue Suture Suture Suture Suture Suture Suture Suture Suture Suture 3 4.5 3.7 4.5 5 4.5 5 5.5 4.5 5 4.5 4 5

cm 3 4 3.9 4 4.5 5 4 4.2 3 3 4 3.2 3.5 2 2.5 4 2.6

cm 3.3 4 5 4.2 4.5 3.5 4.5 4.1 5 4.1 4.5 4 4 2.2 4.8 3.3 2.5

N 31.10 50.82 51.05 58.18 35.86 76.53 45.12 90.10 53.39 58.08 47.39 61.52 34.71 78.18 108.6 103.1 55.24 10.37 12.70 13.09 14.54 7.97 15.31 11.28 21.45 17.80 19.36 11.85 19.23 9.92 39.09 43.45 25.77 21.25 2.18 4.49 3.03 1.48 3.01 6.75 3.28 8.32 2.41 6.05 4.35 5.23 3.13 4.91 7.47 8.56 2.76 Tissue Interface Mesh Tissue Tissue Interface Tissue Tissue Interface Mesh Tissue Interface Tissue Mesh Interface Mesh Interface Infect ed Outlie r

72

24 Hours Lap Shear Experiments

Date Sampl e Fixatio n Techni que Hei ght Wi dth Gauge Length Max Force Normalized Max Force Slo pe Failure Mode Remo ved

cm
5/8/12 5/8/12 5/11/12 5/11/12 5/15/12 5/15/12 5/17/12 5/17/12 5/8/12 5/8/12 5/11/12 5/11/12 5/15/12 5/17/12 5/17/12 5/17/12 82-1 81-1 83-1 84-1 97-1 98-1 99-1 100-1 81-2 82-2 83-2 84-2 98-2 100-2 99-2 97-2 Glue Glue Glue Glue Glue Glue Glue Glue Suture Suture Suture Suture Suture Suture Suture Suture 5.2 5 5 5.2 5.1 4.5 5 4.8 5 5.2 5.1 5.1 5.1 5 4.5

cm
3.5 3.4 3.6 3.6 3.8 4 3.7 3.8 3 3.4 3.4 3.6 3.8 3.7 3.6 3.5

cm
4.3 4 4.1 4 3.5 4 4.5 4.2 3 3 4 3.6 4 3.2 3.5 4.5

N
12.02 9.49 18.45 7.74 32.51 30.23 12.30 47.01 29.20 18.97 39.87 27.92 37.80 43.72 33.86 81.64 3.43 2.79 5.13 2.15 8.56 7.56 3.32 12.37 9.73 5.58 11.73 7.75 9.95 11.82 9.41 23.32 0.67 1.11 1.48 0.58 2.65 1.31 1.67 3.49 2.00 1.21 1.69 1.21 1.21 1.60 1.32 3.28 Interface Interface Interface Interface Interface Interface Tissue Interface Interface Interface Interface Tissue Tissue Interface Tissue Interface Outlier

Uniaxial Experiments for Abdominal Tissue Material Strength

Sample Type Orie nt. S p. # Heig ht (cm) Wid th (cm) Thickn ess (cm) Gauge Length (cm) Max Force (N) Normalized Max Force Slo pe Failu re Site

0.5 < t <1 0.5 < t Tissue D1 2 5 4 <1 0.5 < t Tissue D1 3 5 4 <1 0.5 < t Tissue D1 4 5 4 <1 0.5 < t Tissue D1 5 5 4 <1 0.5 < t Tissue D1 6 5 4 <1 Average Normalized Force +/- Standard Deviation Tissue D1 1 5 4

3.5 2.5 2.5 3 2.5 2.5

122.2 48.2 110.3 100.2 89.7 56.0

30.55 12.04 27.57 25.04 22.43 14.00

5.2 0 3.8 1 3.3 6 4.7 7 3.1 2 4.0 5

S.C. S.C. S.C. C.S. D.C. D.C.

21.94 +/- 7.44 (N/cm)

73

Uniaxial Experiments for Abdominal Tissue Material Strength

Sample Type Orie nt. S p. # Heig ht (cm) Wid th (cm) Thickn ess (cm) Gauge Length (cm) Max Force (N) Normalized Max Force Slo pe Failu re Site

2.4 0.5 < t 3 55.09 13.77 <1 1 5.2 0.5 < t Tissue D2 2 3 72.33 18.08 5 4 <1 7 3.0 0.5 < t Tissue D2 3 5 4 3.5 57.48 14.37 <1 2 3.4 0.5 < t Tissue D2 4 5 4 2 78.28 19.57 <1 0 4.3 0.5 < t Tissue D2 5 5 4 3.5 55.62 13.90 <1 4 4.1 0.5 < t Tissue D2 6 5 4 2.5 75.41 18.85 <1 5 Average Normalized Force +/- Standard 16.43 +/- 2.69 (N/cm) Deviation Orient. = Orientation; SP. = specimen; S.C. = Specimen region at Stationary Clamp; D.C. = Specimen Region at Dynamic Clamp; C.S. = Center of specimen Tissue D2 1 5 4

S.C. C.S. D.C. S.C. S.C. S.C.

Uniaxial Experiments for BARD Soft Knitted Polypropylene Surgical Mesh Material Strength
Sample Type Ori ent. Sp . # Height (cm) Width (cm) Thick ness (cm) Gauge Length (cm) Max Force (N) Normalized Max Force Slope Failu re Site

PP Mesh D1 1 6 3 0.044 2 142.9 47.6 16.4 PP Mesh D1 2 6 3 0.044 1.9 145.7 48.6 21.7 PP Mesh D1 3 5.9 3 0.044 1.8 138.6 46.2 19.9 PP Mesh D1 4 6 3 0.044 2 136.3 45.4 14.6 PP Mesh D1 5 6 3 0.044 2 153.9 51.3 16.8 Average Normalized Force +/- STDev 47.83 +/- 2. 29 (N/cm) D PP Mesh 1 6 3 0.044 2 53.0 17.7 3.8 2 D PP Mesh 2 6 3 0.044 2 57.0 19.0 2.8 2 D PP Mesh 3 6 3 0.044 2 45.7 15.2 2.8 2 D PP Mesh 4 6 3 0.044 2 46.4 15.5 2.5 2 D PP Mesh 5 6 3 0.044 2 53.4 17.8 3.1 2 Average Normalized Force +/- STDev 17.03 +/- 1.62 (N/cm) Orient. = Orientation; SP. = specimen; S.C. = Specimen region at Stationary Clamp; D.C. = Specimen Region at Dynamic Clamp; C.S. = Center of specimen 74

S.C. S.C. S.C. D.C. C.S. S.C. S.C. C.S. S.C. D.C.

Appendix B Matlab Code: F-D Data Evaluation

The following is the Matlab code used for evaluating the raw data files retrieved from the Bluhill2 software for the mechanical tests. This graph evaluated the force and displacement data points to determine the maximum force at failure, the slope of the F-D graph to the first peak, and the area under the graph up to the first peak.

% This file opens the .csv files (Raw data files from Bluehill2 software) and obtains F-D results clear all clc close all dirName = ('03082013'); filesInDir = dir(dirName); numFiles = length(filesInDir); %Bard mesh max load: maxLoad = 25*9.81 / 2.2; cc=0; for ii=1:14; if length(filesInDir(ii).name) > 2 & filesInDir(ii).name(1:2)=='Sp' cc=cc+1; fileName = [dirName '/' filesInDir(ii).name]; [num txt raw] = xlsread(fileName); data = num(:,:); data(:,1) = num(:,2); data(:,2) = num(:,3); sizeN(cc,:) = size(data); figure(1) plot(data(:,1),data(:,2),'b') [maxMag(cc) maxInd(cc)] = max(data(:,2)); [maxX(cc) maxY(cc)] = ginput(1); [minX(cc) minY(cc)] = ginput(1); indMax(cc) = min(find(((maxX(cc)-0.01) < data(:,1)) & (data(:,1) < (maxX(cc)+0.01 )))); indMin(cc) = min(find( minX(cc)-0.01 < data(:,1) & data(:,1) < minX(cc)+0.01 )); dataNew = data(indMin(cc):indMax(cc),:); 75

% The slope: P(cc,:) = polyfit(dataNew(:,1),dataNew(:,2),1); Y = polyval(P(cc,:),dataNew(:,1)); figure(3) plot(dataNew(:,1),dataNew(:,2),'r') hold on title(num2str(P(cc,1))) plot(dataNew(:,1),Y,'k') hold off figure(10) plot(data(:,1),data(:,2),'b') axis([ 0 100 0 60]) grid on figure(2) subplot(7,2,cc) plot(data(:,1),data(:,2),'b') axis([ 0 100 0 60]) grid on % Finding the first maxima that is within 40mm. [yMax(cc) yInd] = max(data(:,2) .* (data(:,1) < 40)) % Area under the curve: z(cc) = trapz(data(1:yInd,1),data(1:yInd,2)) hold on plot(dataNew(:,1),Y,'r') title([fileName(10:17) ' Slope =' num2str(P(cc,1)) ' N/mm']) hold off figure(5) plot(data(:,1),data(:,2)) hold on plot(data(yInd,1),data(yInd,2),'ro') pause(1) else continue end end

76

Appendix C Matlab Code: Box Plots

The following is the Matlab code used for evaluating the normalized mas force results from the lap shear experiments. This code performed an anova test which was used as an initial statistical approach to determine difference between data sets. This test was also used to identify and remove outliers from the data set before final averages were determined.
close all % 24 Hour Glue Vs Suture glue24 = ... [ 3.43 2.79 5.13 2.15 8.56 7.56 3.32 12.37 4.16 9.79 1.33 6.02 6.89 1.77 4.72 4.55]; %Normalized Max Force 24 hours Glue suture24 = ... [ 9.73 5.58 11.73 7.75 9.95 11.82 9.41 7.96 NaN NaN NaN NaN NaN NaN NaN NaN];%Normalized Max Force 24 hours Suture %% close all glue1w = ... [ 10.37 12.70 13.09 14.54 7.97 15.31 11.28 NaN NaN NaN NaN NaN NaN NaN NaN NaN];%Normalized Max Force 1 weeks Glue suture1w = ... [ 17.80 19.36 11.85 19.23 9.92 39.09 43.45 25.77 NaN NaN NaN NaN NaN NaN NaN NaN];%Normalized Max Force 1 weeks Suture %% close all glue2w = ... [ 18.55 16.77 13.53 21.63 17.75 26.27 19.28 25.44 28.60 38.60 NaN NaN NaN NaN NaN NaN];%Normalized Max Force 2 weeks Glue suture2w = ... [ 37.04 17.79 27.53 23.63 38.44 50.03 34.01 30.82 37.58 NaN NaN NaN NaN NaN NaN NaN];%Normalized Max Force 2 weeks Suture %% figure [h pi ci] = anova1([glue24(1,:); suture24(1,:); glue1w(1,:); suture1w(1,:); glue2w(1,:); suture2w(1,:)]'); % Anova, T-test title('Normalized Force') axis([0 7 -5 65])% 0-7 x-axis (catagories), -5-65 Y-axis (normalized force magnitude)

77

Appendix D ABAQUS INP File: Tissue Uniaxial Model

The following is an ABAQUS Standard input file for the computational uniaxial simulation of the excised abdominal tissue. The complete list of nodes and elements has been removed in order to shorten the document.

*End Part ** ** ** ASSEMBLY ** *Assembly, name=Assembly ** *Instance, name=TissueUniaxial-1, part=TissueUniaxial *Node [REMOVED] *Element, type=C3D8H [REMOVED] *Nset, nset=Set-1, generate 1, 2184, 1 *Elset, elset=Set-1, generate 1, 1500, 1 ** Section: Section-1 *Solid Section, elset=Set-1, material=Material-1 , *End Instance ** *Nset, nset=Set-1, instance=TissueUniaxial-1 [REMOVED] *Elset, elset=Set-1, instance=TissueUniaxial-1, generate 901, 1200, 1 *Nset, nset=Set-2, instance=TissueUniaxial-1 [REMOVED] *Elset, elset=Set-2, instance=TissueUniaxial-1, generate 1201, 1500, 1 78

*End Assembly ** ** MATERIALS ** *Material, name=Material-1 *Hyperelastic, n=2, reduced polynomial 0.0102, 0.0128, 0.99, 0. ** ---------------------------------------------------------------** ** STEP: Step-1 ** *Step, name=Step-1, nlgeom=YES *Static, direct 0.1, 1., ** ** BOUNDARY CONDITIONS ** ** Name: BC-1 Type: Displacement/Rotation *Boundary Set-1, 2, 2, 3. ** Name: BC-2 Type: Symmetry/Antisymmetry/Encastre *Boundary Set-2, ENCASTRE ** ** OUTPUT REQUESTS ** *Restart, write, frequency=0 ** ** FIELD OUTPUT: F-Output-1 ** *Output, field, variable=PRESELECT ** ** HISTORY OUTPUT: H-Output-1 ** *Output, history, variable=PRESELECT *End Step

79

Appendix E Strain Energy Model vs. Uniaxial Tissue Experiments

The following content include all the graphs for each individual strain energy material model created for each individual abdominal tissue specimen.

80

81

82

Appendix F FEA Uniaxial Simulation vs. Uniaxial Tissue Experiments

The following content include all the graphs for each individual FEA abdominal tissue uniaxial simulation and relates it to the experimental data.

83

84

85

Appendix G ABAQUS INP File: Surgical Mesh Uniaxial Model

The following is an ABAQUS Standard input file for the computational uniaxial simulation of the surgical mesh. The complete list of nodes and elements has been removed in order to shorten the document.

*Heading ** Job name: Surgical Mesh Model name: Model-1 ** Generated by: Abaqus/CAE 6.12-1 *Preprint, echo=NO, model=NO, history=NO, contact=NO ** ** PARTS ** *Part, name=Mesh *End Part ** ** ** ASSEMBLY ** *Assembly, name=Assembly ** *Instance, name=Mesh-1, part=Mesh *Node [REMOVED] *Element, type=S4R [REMOVED] *Nset, nset=Set-2, generate 1, 496, 1 *Elset, elset=Set-2, generate 1, 450, 1 ** Section: Mesh *Shell Section, elset=Set-2, material=Mesh 0.044, 5 *End Instance ** *Nset, nset=Set-1, instance=Mesh-1 [REMOVED] *Elset, elset=Set-1, instance=Mesh-1, generate 86

151, 300, 1 *Nset, nset=Set-2, instance=Mesh-1 [REMOVED] *Elset, elset=Set-2, instance=Mesh-1, generate 1, 150, 1 *End Assembly ** ** MATERIALS ** *Material, name=Mesh *Hyperelastic, ogden 2.7, 7.4, 0.19 ** ---------------------------------------------------------------** ** STEP: Step-1 ** *Step, name=Step-1, nlgeom=YES *Static, direct 0.1, 1., ** ** BOUNDARY CONDITIONS ** ** Name: BC-1 Type: Displacement/Rotation *Boundary Set-1, 2, 2, 2. ** Name: BC-2 Type: Symmetry/Antisymmetry/Encastre *Boundary Set-2, ENCASTRE ** ** OUTPUT REQUESTS ** *Restart, write, frequency=0 ** ** FIELD OUTPUT: F-Output-1 ** *Output, field, variable=PRESELECT ** ** HISTORY OUTPUT: H-Output-1 ** *Output, history, variable=PRESELECT *End Step

87

Appendix H Strain Energy Model vs. Uniaxial Surgical Mesh Experiments

The following content include all the graphs for each individual strain energy material model created for each individual surgical mesh specimen.

88

89

Appendix I FEA Uniaxial Simulation vs. Uniaxial Surgical Mesh Experiments

The following content include all the graphs for each individual FEA surgical mesh uniaxial simulation and relates it to the experimental data.

90

4 3.5 3 Stress, (MPa) 2.5 2 1.5 1 0.5 0 0

Specimen 5 Mesh Direction 2 (R2 = 0.942)

Uniaxial Data

0.5 Strain, (mm/mm)

91

Appendix J ABAQUS INP File: Lap Shear Model

The following is a sample ABAQUS Standard input file for the computational lap shear simulation (specimen 2_7). The complete list of nodes and elements has been removed in order to shorten the document.

*Heading ** Job name: sp27 Model name: Model-1 ** Generated by: Abaqus/CAE 6.12-1 *Preprint, echo=NO, model=NO, history=NO, contact=NO ** PARTS *Part, name=Mesh *End Part *Part, name=Tissue *End Part ** ASSEMBLY *Assembly, name=Assembly *Instance, name=Mesh-1, part=Mesh *Node [REMOVED] *Element, type=S4R [REMOVED] *Nset, nset=Mesh, generate 1, 468, 1 *Elset, elset=Mesh, generate 1, 425, 1 ** Section: Mesh *Shell Section, elset=Mesh, material=Mesh 0.044, 5 *End Instance *Instance, name=Tissue-1, part=Tissue *Node [REMOVED] *Element, type=C3D8H

92

[REMOVED] *Nset, nset=Tissue, generate 1, 1890, 1 *Elset, elset=Tissue, generate 1, 1352, 1 ** Section: Tissue *Solid Section, elset=Tissue, material=Tissue, *End Instance *Nset, nset="Tissue Tied Region", instance=Tissue-1 [REMOVED] *Elset, elset="Tissue Tied Region", instance=Tissue-1, generate 1093, 1352, 1 *Nset, nset="Mesh Edge", instance=Mesh-1 5, 6, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98 99, 100 *Elset, elset="Mesh Edge", instance=Mesh-1, generate 409, 425, 1 *Nset, nset=Set-7, instance=Mesh-1 1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96 97, 98, 99, 100 *Elset, elset=Set-7, instance=Mesh-1, generate 409, 425, 1 *Nset, nset=Set-9, instance=Tissue-1 9, 11, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182 *Elset, elset=Set-9, instance=Tissue-1, generate 132, 1092, 80 *Elset, elset="_MeshTied Face_SPOS", internal, instance=Mesh-1, generate 1, 408, 1 *Surface, type=ELEMENT, name="MeshTied Face" "_MeshTied Face_SPOS", SPOS *Elset, elset="_TissueTied Face_S4", internal, instance=Tissue-1, generate 56, 1092, 4 *Surface, type=ELEMENT, name="TissueTied Face" "_TissueTied Face_S4", S4 *End Assembly ** MATERIALS *Material, name=Mesh *Hyperelastic, ogden, test data input, poisson=0.45 *Uniaxial Test Data [REMOVED] *Material, name=Tissue *Hyperelastic, n=2, reduced polynomial 0.521, 1.275, 0.15, 0. 93

** INTERACTION PROPERTIES *Surface Interaction, name=IntProp-1 1., *Surface Behavior, pressure-overclosure=HARD ** BOUNDARY CONDITIONS ** Name: Tied Region Type: Symmetry/Antisymmetry/Encastre *Boundary "Tissue Tied Region", ENCASTRE ** ** INTERACTIONS ** Interaction: Int-2 *Contact Pair, interaction=IntProp-1, small sliding, type=SURFACE TO SURFACE, adjust=0.0, tied "MeshTied Face", "TissueTied Face" ** ---------------------------------------------------------------** STEP: Step-1 *Step, name=Step-1, nlgeom=YES *Static 0.05, 1., 1e-05, 0.1 ** BOUNDARY CONDITIONS ** Name: Displacement Type: Displacement/Rotation *Boundary "Mesh Edge", 1, 1 "Mesh Edge", 2, 2, 2.3 "Mesh Edge", 3, 3 ** OUTPUT REQUESTS *Restart, write, frequency=0 ** FIELD OUTPUT: F-Output-1 *Output, field, variable=PRESELECT ** HISTORY OUTPUT: H-Output-1 *Output, history, variable=PRESELECT *End Step

94

Appendix K FEA Lap Shear Simulation vs. Lap Shear Experiments

The following content include all the graphs for each individual FEA lap shear simulation and relates it to the experimental data.

95

50 40 Load, N 30 20 10 0 0

Specimen 9_4 (R2 = 0.984)

Lap Shear Data FEA Simulation 5 Displacement, mm 10

96

Appendix L Artist Permission

Artist permission to use specific figures in this thesis
12/20/2013 Dear Ms. Coalinn Golden I am writing to request some images from your collection entitled: Schematic, cross-sectional view, of a typical ventral hernia with intestinal protrusion. Schematic, cosmetic defect, of a typical ventral hernia with intestinal protrusion. Hernioplasty repair for an onlay ventral hernia surgery Mesh placement (onlay, inlay, sublay) Abdominal wall description of orientation This image will appear in a book by Hummad Tasneem currently entitled Dependence of the Abdominal Wall-Mesh Interfacial Strength on the Fixation Method for Ventral Hernia Repair to be published by the University of Memphis Press in the Spring of 2014. This is a scholarly undertaking that will reach a limited and specialized academic audience. I am requesting permission to use the image as both an interior illustration and other forms of illustration connected with this volume, including but not limited to advertising, publicity, and direct mail, or other similar uses, but excluding use as a cover illustration. I ask that you grant nonexclusive world rights for the reproduction, as part of this thesis only, in all languages and for all editions (including ebook). Please sign and return this letter to me along with the image in question. Please contact me if you have any questions regarding this request. Sincerely yours, Hummad Tasneem

Approved:

_________________________________ (signature)

Date: ____________

97

12/20/2013 Dear Ms. Kathryn Hicks I am writing to request some images from your collection entitled: Surgical mesh close up view of mesh pores

This image will appear in a book by Hummad Tasneem currently entitled Dependence of the Abdominal Wall-Mesh Interfacial Strength on the Fixation Method for Ventral Hernia Repair to be published by the University of Memphis Press in the Spring of 2014. This is a scholarly undertaking that will reach a limited and specialized academic audience. I am requesting permission to use the image as both an interior illustration and other forms of illustration connected with this volume, including but not limited to advertising, publicity, and direct mail, or other similar uses, but excluding use as a cover illustration. I ask that you grant nonexclusive world rights for the reproduction, as part of this thesis only, in all languages and for all editions (including ebook).

Please sign and return this letter to me along with the image in question. Please contact me if you have any questions regarding this request.

Sincerely yours,

Hummad Tasneem

Approved:

_________________________________ (signature)

Date: ____________

98