The usage of grafts in reconstructive surgery

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Fah Che Leong, MD: “My name is Fah Che Leong. I’m from St. Louis, Missouri and at the St. Louis University School of Medicine.”

Mary McLennan, MD: “I’m Mary McLennan and I work with Fah Che Leong, we’re part of the Division of Urogynecology at St. Louis University.”

Willy Davila, MD: “I’m Willy Davila. I’m from the Cleveland Clinic, Florida in Ft. Lauderdale, Florida. We’re actually gathered today to discuss the usage of grafts in reconstructive surgery.

As urogynecologists we’re frequently faced with a patient with advanced prolapse and in particular patients with a weak fascia leading to the development of their prolapse. One of the big debates that are currently in place is the usage of grafts in reconstructive surgery. The three of use are very familiar, and regularly use, a graft called Veritas, which is a bovine pericardium matrix. So we would like to share our experiences with the Veritas graft material and hopefully will be able to share some of our insight into the application of this and the benefits of this, as compared to a synthetic mesh. So, maybe we’ll just each share our experiences with the audience.”

Fah Che Leong, MD: “Thank you. I had actually started using mesh in graft materials a number of years ago, only in response to repeated failures with prolapse repairs. In the beginning of course we started using whatever we had, and we still use occasionally things such as vicryl mesh for graft materials, but of course always looking for something better. We’ve also started using the biomaterials, most recently Veritas, which is a bovine pericardium. The way we’ve been using it, or I’ve been using it, is as an inner position graft to augment and supplement the lack of fascial or connective tissue strength; both anteriorly in the vagina or posteriorly, or as I tell my patients, the roof and the floor of the vagina. It’s a little bit easier to understand that way.

So what we’ve done is a number of different things, mostly just to give something where there is none, or where none has been for many, many years, in the back of the vagina or the floor. We lay in the material and use it as a separate and new floor, and on the roof of the vagina as nearly a hammock connecting up the arcus tendinous on both sides, which is where the vagina started.”

Mary McLennan, MD: “I have similar experiences. The idea of using graft material came out of, once again, the need or the perceived need, to do something better than what we were currently doing. I think one of the most frustrating things for us as surgeons, is that we, if we’re honest, see a consistent number of patients who come back with failures, both of our own and those of other physicians. So we were looking for something better, something that would give people longer-term success rates and that’s how the use of grafts came about.

For me, personally, I have used a variety of graft materials. I did not use any synthetic materials. I trained in an institution with a physician who had a lot of experiences with complications from synthetic material. So I really wasn’t keen to get on and use that type of material with the risk of anywhere from 25+ percent of having to remove those materials. So I was looking for something more biological. Cadaveric material came out initially and I found that a lot of patients were very uncomfortable with that. It was very inconsistent in quality and also the availability was often very difficult. And sizing was also an issue at times.

I was looking for other biological materials and I eventually settled on the Veritas really because it was so much easier for me, as a physician, to use. The thickness was fairly similar to human skin, the sutures held very well, and it was just a very nice material to put in place. And from that, from something that was to my satisfaction, we then looked to see if it made a difference in terms of the patients and we’ve been very, very happy.

I tell the patients it’s like a hammock. I actually do, and I think it is very important, to actually placate or use the patients’ own tissues initially, and lay this in as an extra layer. At least that’s the way that I do it. I suture this on top as an extra layer and extra hammock, both anteriorly and posteriorly.

Some people are just using it for patients who have recurrences rather than for initial therapy. I pretty much individualize it. If the patient really looks like they have very little tissue to put together themselves, or I can only identify a small amount of tissue and I need some bridging, it’s perfect for that application as well. I do use it on primary procedures as well as patients who’ve had previous failed procedures and it’s a very individual thing.

The other nice thing about this material is if I suddenly decide I need it, I don’t have to prepare the material. I can ask my OR staff. It doesn’t have to be refrigerated, it doesn’t have to be prepared, and it doesn’t really hold up any time in the operating room.”

Willy Davila, MD: “I agree. I think our practices are very similar. I think the application here has been either in somebody whose fascia is very deficient and you feel like you need to reinforce it, or in somebody who has a fascial defect and you repair the fascial defect, whether it’s lateral or central or ithical or whatever. Then you use this to reinforce that healing line of the fascial defect.

I think in particular I’ve found it useful with large cystoceles. I still think that is the big challenge to the reconstructive surgeon and it’s been so since the early 1900s, what is the permanent cure of a cystocele? I think this material has been very useful for that. As we follow our patients longitudinally, the other thing that I find is that it gets incorporated into the patient’s tissue very well. So unlike a synthetic material that you can actually palpate, and maybe feel during intercourse, and may cause some discomfort, this material becomes incorporated very well. Even if you feel where you place it, then six months or a year later it really feels soft and pliable, very much like the patient’s fascia. 

I don’t know about you two but I really haven’t had any healing difficulties with it. I agree with Fah Che, it is very, very easy to use. It takes sutures very well. It’s firm but not hard, that type of thing.”

Fah Che Leong, MD: “Patients have been very satisfied. We’ve not found any erosion problems or infection problems. So far, if we knock on wood, it’s been good.”

Willy Davila, MD: “Great, terrific. Well, hopefully this has been useful and you’ll consider using the collagen matrix from Veritas in your reconstructive surgeries. Thank you.”

  For another view point see: Surgical treatment of prolapse and incontinence