Patent Publication Number: US-2022218458-A1

Title: Elastomeric auxetic membrane for urogynecological and abdominal implantations

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application is related to and claims the benefit of and priority to co-pending U.S. Provisional Application 63/205,849 filed on Jan. 11, 2021, the entire disclosure of which is hereby incorporated by reference in its entirety. 
    
    
     FIELD OF THE INVENTION 
     Embodiments relate to an elastomeric auxetic membrane, and particularly to an elastomeric auxetic membrane for urogynecologic and abdominal implantations. 
     BACKGROUND OF THE INVENTION 
     Urogynecologic surgical mesh is used to provide additional support when repairing damaged or weakened tissue. However, the pores of most current urogynecologic meshes contract and/or collapse in response to tensile loads. Pore collapse is problematic for surgical meshes, as meshes with small pores are associated with increased inflammation and fibrosis and have decreased tissue integration into the pores relative to meshes with large pores. Additionally, smaller pores increase the risk of bridging fibrosis (overlapping of the foreign body response to neighboring fibers resulting in a fibrous capsule), a process that can lead to encapsulation and pain. Clinically, pore collapse manifests as mesh contraction or “shrinkage” and is associated with vaginal pain that often does not resolve even with mesh removal resulting in poor patient outcomes. Pore collapse also changes the properties of the material, making it stiffer and resulting in stress shielding, the mechanism underlying mesh exposure. Most commercially available urogynecologic meshes are made from polypropylene, for which the minimal pore diameter for tissue integration has been shown to be 1 mm. Problematic areas for patients experiencing mesh complications are often located in areas where the pores of a mesh have collapsed well below this threshold of 1 mm with tensioning and loading. 
     Further, additional limitations of current meshes are material stiffness and permanent deformation with loading (i.e., permanent elongation of mesh). Propylene has a material stiffness that is orders magnitude stiffer than vaginal tissue, causing issues such as degeneration, decreased cellular response, and damage to underlying tissue. 
     Accordingly, there is a need for the development of a device with a stable pore geometry that does not collapse with tensioning and loading. Further, there is a need for a device that can complement the stiffness of native tissue, and a device that can withstand forces, both sudden and repetitive. 
     The present disclosure is directed toward overcoming one or more of the above mentioned problems, though not necessarily limited to embodiments that do. 
     SUMMARY OF THE INVENTION 
     Embodiments relate to the use of auxetic geometries to construct the pores of membranes. Auxetic geometries expand in the transverse direction when stretched along the longitudinal direction. This behavior is counterintuitive, as most materials contract in the transverse direction when stretched longitudinally. A membrane with pores that are auxetic has the potential to overcome the primary limitation of most prolapse meshes—pore collapse with tensile loading. 
     The disclosed device is referred to as a membrane as opposed to a mesh, as the term “mesh” implies a device manufactured via knitting or weaving. In contrast, the disclosed device is manufactured via molding or 3D printing. 
     In an exemplary embodiment, an elastomeric membrane for implantation in a human body, comprises a plurality of fibers, comprised of at least one polymer, and a plurality of pores, wherein each pore is defined by the plurality of fibers and has an auxetic shape such that a size of the pores expands in a direction transverse to a longitudinal axis when the membrane is subject to a tensile load along the longitudinal axis. 
     In some embodiments, the at least one polymer is polycarbonate urethane. 
     In some embodiments, the plurality of fibers have a material stiffness that is similar to a native tissue to which the membrane is attached. 
     In some embodiments, the plurality of fibers have a material stiffness of 6 to 35 MPa. 
     In some embodiments, the at least one polymer is a combination of at least two different types of fibers. 
     In some embodiments, the at least one polymer is a combination of at least two different grades of a single type of polymer. 
     In some embodiments, the plurality of fibers have an original length and are configured to return to a second length after tensile loading or unloading at 15 N, wherein the second length is less than or equal to 40% longer than the original length. 
     In some embodiments, the auxetic shape is a bowtie shape. 
     In some embodiments, the bowtie shape has horizontal edges and is oriented such that the horizontal edges are perpendicular to an axis of loading. 
     In some embodiments, the auxetic shape is a chiral hexagon shape. 
     In some embodiments, each pore has a minimum pore diameter of 0.5 to 5.0 mm. 
     In some embodiments, the membrane is manufactured using a technique that yields a membrane with no knots or interstices. 
     In some embodiments, the plurality of fibers have a width between 0.3 and 1 mm in an untensioned state. 
     In some embodiments, the plurality of fibers have a thickness between 0.3 and 1 mm in an untensioned state. 
     In some embodiments, the membrane has an effective pore area that does not change in response to a tensile load up to 15 N. 
     In some embodiments, the at least one polymer is non-biodegradable. 
     In some embodiments, the at least one polymer is bioresorbable. 
     In some embodiments, the at least one polymer is configured to interact with a native tissue to enhance tissue integration. 
     In some embodiments, the membrane comprises a body section and at least one arm section, wherein the at least one arm section extends outwardly from the body section. 
     In some embodiments, the membrane has a porosity greater than or equal to 75%. 
     In an exemplary embodiment, a method of implanting a membrane in a human body comprises providing an elastomeric membrane for implantation in the human body. The elastomeric membrane comprises a plurality of fibers, comprised of at least one polymer, and a plurality of pores, wherein each pore is defined by the plurality of fibers and has an auxetic shape such that a size of the pores expands in a direction transverse to a longitudinal axis when the membrane is subject to a tensile load along the longitudinal axis. The method further comprises orienting the plurality of pores to maximize pore expansion when the membrane is subject to the tensile load along the longitudinal axis, and attaching the membrane to human tissue. 
     In some embodiments, the auxetic shape is a bowtie comprising horizontal edges, and the method further comprises orienting the plurality of pores such that the horizontal edges of the pores are perpendicular to the tensile load along the longitudinal axis. 
     In some embodiments, the auxetic shape is a bowtie comprising horizontal edges, and the method further comprises orienting the plurality of pores such that the horizontal edges of the pores are aligned with the tensile load along the longitudinal axis. 
     Additional features, aspects, objects, advantages, and possible applications of the present disclosure will become apparent from a study of the exemplary embodiments and examples described below, in combination with the Figures and the appended claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The above and other objects, aspects, features, advantages and possible applications of the present innovation will be more apparent from the following more particular description thereof, presented in conjunction with the following drawings. Like reference numbers used in the drawings may identify like components. 
         FIG. 1  shows a schematic view of an elastomeric auxetic membrane insertion by sacrocolpopexy. 
         FIG. 2A  shows a front view of stems and straps of elastomeric auxetic membrane for use in sacrocolpopexy. 
         FIG. 2B  shows a front view of a stem and straps of elastomeric auxetic membrane in a Y configuration for use in sacrocolpopexy. 
         FIG. 3  shows a schematic view of an anterior elastomeric auxetic membrane vaginal insertion. 
         FIG. 4  shows a schematic view of a posterior elastomeric auxetic membrane vaginal insertion. 
         FIG. 5  shows a schematic view of potential sites of an elastomeric auxetic membrane for hernia repair surgery. 
         FIG. 6A  is a front view of an elastomeric auxetic membrane with pores having an exemplary bowtie auxetic geometry. 
         FIG. 6B  is an isometric view of an elastomeric auxetic membrane with pores having an exemplary bowtie auxetic geometry. 
         FIG. 6C  is a side view of an elastomeric auxetic membrane with pores having an exemplary bowtie auxetic geometry. 
         FIG. 7A  is a front view of an elastomeric auxetic membrane with pores having an exemplary chiral hexagon auxetic geometry. 
         FIG. 7B  is an isometric view of an elastomeric auxetic membrane with pores having an exemplary chiral hexagon auxetic geometry. 
         FIG. 7C  is a side view of an elastomeric auxetic membrane with pores having an exemplary chiral hexagon auxetic geometry. 
         FIG. 8A  is a front view of a pore having an exemplary bowtie auxetic geometry demonstrating minimum pore diameter and fiber width. 
         FIG. 8B  is a front view of a pore having an exemplary bowtie auxetic geometry demonstrating internal angles. 
         FIG. 8C  is an isometric view of a pore having an exemplary bowtie auxetic geometry demonstrating fiber thickness. 
         FIG. 9A  is a front view of an elastomeric auxetic membrane with pores having an exemplary bowtie auxetic geometry demonstrating an orientation in which the horizontal edges of the bowtie auxetic geometry are perpendicular to the direction of loading. 
         FIG. 9B  is a front view of an elastomeric auxetic membrane with pores having an exemplary bowtie auxetic geometry demonstrating an orientation in which the horizontal edges of the bowtie auxetic geometry are aligned with the direction of loading. 
         FIG. 10  shows a front view of computational models of exemplary elastomeric auxetic membranes having pores with various types of auxetic geometries. 
         FIG. 11  shows a front view of computational models of exemplary elastomeric auxetic membranes having pores with standard geometries. 
         FIG. 12  shows a front view of computational models of exemplary elastomeric auxetic membranes having pores with various types of auxetic geometries and rotated 45°. 
         FIG. 13  shows a front view of computational models of exemplary elastomeric auxetic membranes having pores with various types of auxetic geometries and rotated 90°. 
         FIG. 14  shows images of the central regions of elastomeric auxetic membranes with pores having an exemplary bowtie auxetic geometry loaded longitudinally from 0.1 N to 2.5 N or 3 N and rotated at 0°, 45°, and 90° with respect to the longitudinal axis of the membranes. 
         FIG. 15  shows images of the central regions of elastomeric auxetic membranes with pores having an exemplary chiral hexagon auxetic geometry loaded longitudinally from 0.1 N to 3 N and rotated at 0°, 45°, and 90° with respect to the longitudinal axis of the membranes 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     The following description is of exemplary embodiments that are presently contemplated for carrying out the present invention. This description is not to be taken in a limiting sense, but is made merely for the purpose of describing the general principles and features of various aspects of the present invention. The scope of the present invention is not limited by this description. 
     Embodiments relate to an elastomeric auxetic membrane (EAM). The EAM  100  may be used in urogynecologic procedures including, but not limited to, transabdominal prolapse procedures (sacrocolpopexy) (see  FIGS. 1 and 2A-2B ), transvaginal prolapse repairs (see  FIGS. 3-4 ), and mid-urethral slings. It is contemplated that the EAM  100  may also be used in other surgical procedures including, but not limited to, abdominal hernia repairs (see  FIG. 5 ), inguinal hernia repairs (see  FIG. 5 ), diaphragmatic hernia repairs (see  FIG. 5 ), and other like surgical procedures. 
     The EAM  100  is a three-dimensional porous device that includes a plurality of open spaces (i.e., pores  102 ) that may be defined by polymeric fibers  104  with no knots (i.e., having no small spaces and interstices that are less than &lt;100 um). As used herein, pores  102  generally describes  102 ′,  102 ″, and/or  102 ″. It is contemplated that the EAM  100  is manufactured using 3D printing, molding, or other techniques that adequately yield a membrane with no knots or interstices. The EAM  100  may be in the form of any shape, and it is contemplated that the shape of the EAM  100  may complement a particular procedure or native tissue for which the EAM  100  is being used. In an exemplary embodiment, the EAM  100  may consist of a body section  106  only, or may consist of a body section  106  and either one or more arm sections  108  or a stem section  109 , wherein the arm sections  108  and stem sections  109  extend outwardly from the body section  106 . In an exemplary embodiment, the arm sections  108  may be used to tension the EAM  100  to ligaments  122  and other tissue. In another exemplary embodiment, the stem section  109  may be used to bridge two independent body sections  106 , one anterior and one posterior, to the sacrum  112 . For example, one or more arm sections  108  may be attached to a common body section  106  in a Y configuration (see  FIGS. 3-4 ), or a stem section  109  may connect two body sections  106  in a Y configuration (see  FIG. 2B ). It is further contemplated that the arm sections  108  or stem section  109  may have a larger surface area than the body section  106 . Additionally, the EAM  100  may have any dimensions, and it is contemplated that the dimensions of the EAM  100  may complement a particular procedure or native tissue for which the EAM  100  is being used. 
     In an exemplary embodiment, for a transabdominal prolapse procedure, the EAM  100  may be a rectangular shape and have overall dimensions of about 5 cm (width) and 15 cm (length). In another exemplary embodiment, for a transvaginal prolapse repair, the EAM  100  may have arm section  108  dimensions of about 1 to 3 cm (width) and about 5 to 15 cm (length), and a body section  106  dimension of about 5 to 7 cm (width) and 5 to 15 cm (length). 
     The width W and thickness T of the fibers  104  in an untensioned state may generally range between 0.3 mm and 1 mm (see  FIGS. 8A and 8C ). An untensioned state may be defined as a state in which the EAM  100  has no forces or loading acting upon it. However, as one skilled in the art will appreciate, it is contemplated that the fiber width W and/or fiber thickness T may vary depending on a number of factors including, but not limited to, the severity of the condition (e.g. the degree of prolapse) and/or the body mass index of the individual in whom the EAM  100  will be placed. 
     The fibers  104  may be made from one or more polymers. The polymer(s) may include, but is not limited to, polycarbonate urethane (PCU). It is contemplated that the polymer(s) has a material stiffness that is similar to the native tissue for which the EAM is being used. In an exemplary embodiment, wherein the native tissue is vaginal tissue comprising an estimated tangent modulus or stiffness of 6 to 35 MPa, the material stiffness of the EAM may be similar to (i.e., 6 to 35 MPa), or one that is one or two orders in magnitude stiffer (i.e., 60 to 350 MPa, or 600 to 3,500 MPa), than vaginal tissue. The fibers  104  may comprise one polymer or of a combination of two or more different polymers, or of a combination of two or more different grades of a single type of polymer. For example, PCU is available in a range of durometers that are typically reported as Shore hardness ranging from 75 A, 85 A, 95 A, and 75D (also referred to as grades), and the fibers  104  may be comprised of one PCU grade or a combination of PCU grades depending on the application of the EAM  100 . Any polymer or combination of polymers that provide adequate strength, toughness, and durability while maintaining biocompatibility for soft tissue repairs is suitable. 
     It is contemplated that the polymer(s) may be non-biodegradable (i.e., permanent). Non-biodegradable may be defined as the ability of the polymer(s) to resist physical and/or chemical changes and to maintain its position within native tissue. It is further contemplated that the polymer(s) may be bioresorbable. Bioresorption may be defined as the ability of the polymer(s) to naturally degrade and/or dissolve over time. It is further contemplated that the polymer(s) may have a combination of both non-biodegradable and bioresorbable properties. 
     It is contemplated that the polymer(s) may have shape-memory properties (i.e., the polymer(s) may be elastomeric or exhibit elastomeric properties). Shape-memory may be further defined as the ability of the polymer(s) to minimize and potentially eliminate the amount that the EAM  100  permanently elongates in response to repetitive loading, and the EAM&#39;s  100  ability to return to its original configuration. Specifically, the polymer(s) may deform and return to an initial length with minimal permanent elongation. It is contemplated that a minimal permanent elongation after cyclic loading or unloading of 15 N is less than or equal to a 40% increase in the EAM&#39;s  100  initial length. The shape-memory characteristic mimics native soft tissues. 
     It is contemplated that the polymer(s) may be modified for the conjugation of proteins and other biomolecules of interest that promote interaction with native tissue to enhance tissue integration. Click chemistry is a popular technique for engineering bioactive polymers due to mild reaction conditions. Thus, motifs such as oximes or dialdehydes that facilitate crosslinking or attachment of peptides may be added. In an exemplary embodiment, the polymer(s) may be modified to provide for an RGD moiety for binding to integrins. In another exemplary embodiment, the one or more polymers may be modified to provide for a VAPG moiety for binding to elastin. 
     The pores  102  of the EAM  100  are in the form of an auxetic shape. An EAM  100  with auxetic pores  102  allows for adequate porosity and pore expansion for tissue integration. An auxetic shape expands in the transverse direction when stretched along the longitudinal direction, and is associated with a negative relative lateral contraction, which is analogous to a negative Poisson&#39;s ratio which describes deformation in the transverse axis relative to the longitudinal axis. This behavior (i.e., expansion of the pores  102  when loaded or elongated) is counterintuitive as most materials and shapes contract in the transverse direction when stretched longitudinally. Auxetic shapes that can be used include, but are not limited to bowtie (see  FIGS. 6A-6C ), chiral hexagon (see  FIGS. 7A-7C ), hexagon, spiral, triangle, square chiral, and square grid (see  FIG. 10 ). The pores  102  may have an auxetic shape that is either anisotropic of isotropic. Isotropic auxetic geometry may consist of any combination of polygons including, but not limited to, squares, circles, rectangles, hexagons, etc. Given that the pores  102  will expand independent of the orientation of the pores  102  with respect to the direction of loading Lx, the isotropic auxetic pore orientation is often negligible. The direction of loading Lx may be defined as the axis or axes in which force is applied to an object. It is contemplated that the auxetic geometry may be oriented to maximize pore expansion. 
     In an exemplary embodiment, the auxetic shape of the EAM  100 ′ is defined by fibers  104 ′ as a bowtie pore  102 ′ (see  FIGS. 6A-6C ), in which the bowtie pores  102 ′ consist of six sides (see  FIG. 8A ) and four congruent internal angles (α 1 , α 2 , α 3 , and α 4 ) (see  FIG. 8B ). The internal angles may be between 15° and 70°. The bowtie pores  102 ′ consist of two horizontal edges  110  opposite of one another, and two bent members  122  opposite of one another. The bent members  122  are directed inward toward the center of the bowtie. In use, the bowtie pore  102 ′ geometry will be oriented to maximize pore expansion, such that the horizontal edges  110  of the bowtie pore  102 ′ are perpendicular (see  FIG. 9A ) or aligned (see  FIG. 9B ) along the direction of loading Lx. As stated above, the direction of loading Lx may be defined as the axis or axes in which force is applied to an object. In another exemplary embodiment, the auxetic shape of the EAM  100 ″ is defined by fibers  104 ″ as chiral hexagon pores (see  FIGS. 7A-7C ), in which the pores consist of a combination of triangles  102 ″ and circles  102 ′″ oriented in a manner to maximize pore expansion. 
     As a result of the auxetic shape of the pores  102 ′, it is contemplated that the pores  102 ′ may have a minimal diameter D between 0.5 mm and 5.0 mm, with a preferable minimal diameter of 1 mm, regardless of whether the pores  102 ′ are in a tensioned or untensioned state. One skilled in the art will appreciate that the minimal diameter D will increase as the pores  102 ′ expand. However, as one skilled in the art will appreciate, it is contemplated that the minimal diameter D may vary depending on a number of factors including, but not limited to, the severity of the condition (e.g. the degree of prolapse) and/or the body mass index of the individual in whom the EAM  100  will be placed. An untensioned state may be defined as a state in which the EAM  100  has no forces or loading acting upon it. Pores  102 ′ of an auxetic shape also result in an EAM  100  with an increased overall pore area, an increased porosity (i.e., greater than or equal to 75%), and an effective porosity greater than 80% in response to tension and elongation. The effective porosity is defined by the percentage of pores  102 ′ greater than 1 mm in diameter. 
     In response to tensile loading or elongation, the pores  102 ′ of the EAM  100  will remain open (i.e. pore size will be greater than or equal to the unloaded pore size) when implanted along the intended direction of loading Lx or irrespective of the orientation with respect to the direction of loading Lx for the isotropic auxetic pore geometry. The EAM  100  will also experience increased porosity (greater than or equal to 75%) and an effective porosity greater than 80% in response to tension and elongation. It is further contemplated that due to the inherent nature of the auxetic geometry, the polymer(s) used, and the method of manufacture using 3D printing or molded technology (i.e., absence of knots) the EAM  100  will experience minimal wrinkling in response to tension and elongation. 
     Moreover, the EAM has an effective pore area that does not change in response to tensile loading or elongation within the physiologic range (i.e., loads up to 15 N). Specifically, in an exemplary embodiment, the effective pore area of an EAM manufactured using polydimethylsiloxane, a relatively weak polymer, did not change in response to tensile loads up to 3 N, and it is contemplated that the effective pore area of an EAM manufactured using a stronger polymer (i.e., PCU), will remain unchanged in response to tensile loads up to 15 N. 
     In reference to  FIG. 1 , in an exemplary method of use, the EAM  100  is inserted by sacrocolpopexy, a procedure performed via minimally invasive laparoscopy, laparoscopy assisted robotic surgery, or laparotomy. In all 3 approaches, a dissection is carried down to the sacrum  112  extending to the site of the EAM  100  attachment and tensioning. The bladder  114  is dissected off of the anterior vagina  116  and the rectum  118  dissected off of the posterior vagina  116 . A strap of the EAM  100  (typically 5 by 15 cm) is placed between the bladder  114  and the vagina  116 , and a second strap of the same size between the rectum  118  and the vagina  116 . The two straps are then pulled up to the longitudinal ligament of the spine  120  at the level of the sacrum  112  and attached to it; thereby lifting the vagina  116  back into its physiological position. For the membrane bridge to the sacrum  112 , the two straps of EAM  100  can be attached individually or through a common stem section  109  in a Y configuration at attachment site  121 . For an auxetic EAM  100 , the orientation would be such that when the EAM  100  is tensioned longitudinally, the pores  102  open in that direction. Typically, 8 to 10 cm of an arm section  108  is used posteriorly and 4 to 6 cm anteriorly. The stem section  109  can range from 3 to 8 cm. For this invention, the amount of material in the body section  106  of the EAM  100  in contact with the vagina  116  may differ from that of the bridge to the sacrum  112 . 
     Specifically, in reference to  FIG. 2A , sacrocolpopexy EAMs can be configured from two straps of membrane, each containing (i) a body section  106  that is sutured over the vagina, and (ii) a stem section  109  from each strap that forms a bridge between the vagina and the sacrum. Alternatively, in reference to  FIG. 2B , the EAM can also be configured into a Y in which a posterior body section  106 ″ is attached to an anterior body section  106 ′, which has a stem section  109 ′, at the interface with the stem section  109 ′. In this case, the single stem section  109 ′ forms the bridge between the vagina and the sacrum. The stem section  109  may have different textile and mechanical properties than the body section. 
     In reference to  FIGS. 3 and 4 , in another exemplary method of use, the EAM  100  is used during transvaginal prolapse repairs. During this procedure, the EAM  100  is used to reinforce the anterior wall, the vaginal apex or uterus, and the posterior vaginal wall. A full thickness incision is made in the vagina  116  and the associated organ (i.e., bladder, small bowel, or rectum) dissected away. The dissection is carried down to the sacrospinous ligament or the uterosacral ligament. The membrane is placed over the vaginal wall and then tensioned to the ligaments  122  via arm sections  108  or a suture attachment. The amount of material may vary along the EAM&#39;s  100  length. It is contemplated that the arm sections  108  of the EAM  100  that insert into the ligaments  122  may have more material than that the body section  106  in contact with the vagina  116 . The pore geometry may be chosen such that the pores  102  will remain open along the direction of loading. The vaginal incision  116  will be closed over the EAM  100 . 
     In another exemplary method of use, the EAM  100  is used as a mid-urethral sling. An incision will be made into the vagina  116  over the mid-urethra and extended laterally toward the ischiopubic ramus. An EAM  100  with dimensions of 1.5 by 6.25 cm will be placed over the mid-urethra and pulled through the retropubic space, or the transobturator space, or through the fascia overlying the obturator externus. After a cystoscopy to verify that the membrane had not entered the urethra or bladder, the EAM  100  will be tensioned over the urethra. The vagina  116  will then be closed over the EAM  100 . 
     In another exemplary method of use, the EAM is used for inguinal hernia repair. After incising the skin, subcutaneous tissue, and external oblique aponeurosis, the spermatic cord (males) is elevated from the posterior wall of the inguinal canal. In indirect hernias, the hernial sac is identified, dissected to the internal ring and opened to allow examination of its contents. The sac is ligated and its distal portion is usually excised. In this context, an appropriately sized EAM is prefabricated or trimmed to fit the floor of the inguinal canal. The apex is first sutured to the public tubercle using 3-0 Prolene suture. The same continuous suture is then used to suture the lower border of the membrane to the free edge of the inguinal ligament after an opening is made into its lower edge to accommodate the spermatic cord. The continuous suture extends up just medial to the anterior superior iliac spine. Interrupted Prolene sutures then suture the two cut edges of the membrane together around the spermatic cord. The inferomedial corner of the membrane is then attached while overlapping the pubic tubercle. The membrane is then anchored to the conjoined tendon by metal staples (i.e., titanium) or by interrupted sutures (i.e., Prolene 3-0). The aponeurosis of external oblique is closed using absorbable sutures (i.e., Vicryl No  2 ). The skin is then closed. 
     In another exemplary method of use, the EAM is used for abdominal wall or ventral hernia repair. Surgical repair technique can be performed minimally invasively or open. In some instances, an EAM can be placed over a suture repair of the fascial defect while in others in which a suture repair is not possible, the EAM is used to cover the defect and fixed in place by sutures or alternatively via a tack device. Typically, the EAM is placed over a fascial defect such that 5 cm of the membrane spans all sides of the defect. 
     In another exemplary method of use, the EAM is used for hiatal or diaphragmatic hernia repairs. Hiatal hernias can effectively be repaired via a transabdominal or transthoracic approach. More recently, a laparoscopic approach has gained popularity as it is markedly less morbid than an open approach. The use of surgical mesh for reinforcement of large hiatal hernia repairs has been shown to lead to decreased recurrence rates. Surgical repair may be a primary suture closure reinforced by the EAM or an EAM closure alone (larger defects). In both cases, the defect of the diaphragm is closed by placing the EAM over the space between the diaphragm and the esophagus after reduction of the herniated contents. 
     EXAMPLES 
     The following examples serve to illustrate certain aspects of the disclosure and are not intended to limit the disclosure. 
     Example 1 
     Computational models of membranes with different auxetic geometries intended for use via a sacrocolpopexy, in which the forces along the membrane in vivo are predominantly uniaxial, were constructed. The deformation of the models was assessed via simulated uniaxial tensile tests using finite element analysis (FEA). A simulated load of 3 N was applied along the longitudinal axis of the models. The pore geometries for the auxetic models included (1) bowtie, (2) chiral hexagon, (3) hexagon(b), (4) spiral, (5) triangle, (6) square chiral(a), (7) square chiral(b), and (8) square grid (see  FIG. 10 ). For comparison purposes, computational models with standard pore geometries mimicking current commercially available prolapse meshes were also created. The standard models included (1) square, (2) diamond, and (3) hexagon(a) (see  FIG. 11 ). Quantitative measurements of the following parameters were used to characterize the deformation of the pore geometries and models overall: minimal pore diameter, effective pore area (defined by the area of the pores with widths greater than 1 mm), porosity (defined by the amount of pore space within the mesh), effective porosity (defined by the amount of void space within the membrane from the pores that are greater than 1 mm), and relative lateral contraction (representative of the degree of contraction of the model with a positive value indicating model contraction (i.e., pore collapse) and a negative value indicating expansion (i.e., pores remaining open/enlarging)). 
     
       
         
           
               
               
               
               
               
               
             
               
                 TABLE 1 
               
               
                   
               
               
                   
                   
                   
                   
                   
                 Relative  
               
               
                   
                 Minimal  
                 Effective  
                   
                   
                 Lateral  
               
               
                   
                 Pore  
                 Pore  
                 Porosity  
                 Effective  
                 Con-  
               
               
                   
                 Diameter  
                 Area  
                 (%  
                 Porosity  
                 traction  
               
               
                 Geometry  
                 (% Change)  
                 (% Change)  
                 Change)  
                 (% Change)  
                 at 3N 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 Bowtie  
                 +113.0%  
                 No  
                 +25.9%  
                 +25.9%  
                 −0.47  
               
               
                   
                   
                 change  
                   
                   
                   
               
               
                 Chiral  
                 −18.9%  
                 −10.7%  
                 +6.9%  
                 −5.2%  
                 0.19  
               
               
                 Hexagon  
                   
                   
                   
                   
                   
               
               
                 Hexagon  
                 +125.0%  
                 No  
                 +21.4%  
                 +21.4%  
                 −0.02  
               
               
                 (b)  
                   
                 change  
                   
                   
                   
               
               
                 Spiral  
                 −2.0%  
                 No  
                 +12.9%  
                 +12.9%  
                 −0.13  
               
               
                   
                   
                 change  
                   
                   
                   
               
               
                 Triangle  
                 −30.2%  
                 No  
                 +14.5%  
                 +14.5%  
                 0.34  
               
               
                   
                   
                 change  
                   
                   
                   
               
               
                 Square  
                 −32.0%  
                 −13.0%  
                 +15.0%  
                 No  
                 −0.15  
               
               
                 Chiral(a)  
                   
                   
                   
                 change  
                   
               
               
                 Square  
                 −32.7%  
                 −12.3%  
                 +15.3%  
                 No  
                 −0.09  
               
               
                 Chiral(b)  
                   
                   
                   
                 change  
                   
               
               
                 Square  
                 +443.0%  
                 No  
                 +40.3%  
                 +40.3%  
                 −0.34  
               
               
                 Grid  
                   
                 change  
                   
                   
                   
               
               
                 Square  
                 −3.9%  
                 No  
                 +2.7%  
                 +2.7%  
                 0.14  
               
               
                   
                   
                 change  
                   
                   
                   
               
               
                 Diamond  
                 −81.6%  
                  −100%  
                 −33.3%  
                 −100.0%  
                 1.65  
               
               
                 Hexagon  
                 −43.5%  
                 No  
                 −12.5%  
                 −12.5%  
                 2.32  
               
               
                 (a)  
                   
                 change 
               
               
                   
               
            
           
         
       
     
     Regarding effective pore area, the effective pore area for all models was 100%. No change means that the effective pore area at 3 N was maintained at 100%. Regarding effective porosity, no change means that the effective porosity before (0 N) and after loading (3 N) are the same. Regarding relative lateral contraction, a positive value indicates model contraction and a negative value indicates model expansion/pore expansion. 
     As seen in Table 1, the results show that, generally, auxetic pore geometries expand in response to uniaxial loading. As anticipated, the models with standard pore geometries contracted and/or their pores collapsed with loading consistent with ex vivo testing of commercial polypropylene meshes with similar pore geometries. 
     Example 2 
     Computational models of membranes with different auxetic geometries intended for use via transvaginal prolapse repairs, in which the forces along the membrane are oriented in a variety of directions, were constructed. For transvaginal membranes, it was important to assess how pore orientation impacts the ability of auxetic pores to expand in multiple directions. Accordingly, the deformation of the models was assessed via simulated tensile tests FEA with the auxetic pores rotated 45° (see  FIG. 12 ) and 90° (see  FIG. 13 ) with respect to the longitudinal axis of the membranes. A simulated load of 3 N was applied along the longitudinal axis of the models. For 3 of the 8 auxetic geometries, a 90° rotation resulted in the same pore orientation as the respective model created in the previously mentioned FEA study; hence, there were only five models with the pores rotated 90°: (1) bowtie, (2) triangle, (3) chiral hexagon, (4) hexagon (b), and (5) square chiral (b). All of the auxetic geometries were tested with a 45° degree rotation. 
     In response to 3 N, the pores of all of the models with the pores rotated at 45° contracted and only two of the auxetic geometries were able to maintain its ability to expand when rotated 90°, the bowtie and triangle. Collectively, these results suggest that, in addition to load dependence, the ability of an auxetic geometry to expand is also dependent on the orientation of the auxetic geometry with respect to the direction of loading. The chiral hexagon geometry demonstrated the least sensitivity to pore orientation relative to the other auxetic geometries. 
     Example 3 
     Synthetic membranes with the bowtie and chiral hexagon pore geometries at 0°, 45°, and 90° were manufactured (see  FIGS. 14-15 ). Membranes were manufactured from polydimethylsiloxane (PDMS), an elastomer with a material stiffness (9.9 MPa) similar to that of a vagina. 3 N of force were applied along the longitudinal axis of the membranes. Quantitative measurements of the following parameters were used: minimal pore diameter, effective pore area (defined by the area of the pores with widths greater than 1 mm), porosity (defined by the amount of pore space within the membrane), effective porosity (defined by the amount of void space within the mesh from the pores that are greater than 1 mm), and relative lateral contraction (representative of the degree of contraction of the model with a positive value indicating model contraction (i.e., pore collapse) and a negative value indicating expansion (i.e., pores remaining open/enlarging)). 
     
       
         
           
               
               
               
               
               
               
             
               
                 TABLE 2 
               
               
                   
               
               
                   
                   
                   
                   
                   
                 Relative  
               
               
                   
                 Minimal  
                 Effective  
                   
                   
                 Lateral  
               
               
                   
                 Pore  
                 Pore  
                 Porosity  
                 Effective  
                 Con-  
               
               
                   
                 Diameter  
                 Area  
                 (%  
                 Porosity  
                 traction  
               
               
                 Geometry  
                 (% Change)  
                 (% Change)  
                 Change)  
                 (% Change)  
                 at 3N 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 Bowtie  
                 +13.6%  
                 No  
                 +33.3%  
                 +33.3%  
                 −25.5%  
               
               
                  0° 
                   
                 change  
                   
                   
                   
               
               
                 Bowtie  
                 −49.0%  
                 −100.0%  
                 −27.4%  
                 −100.0%  
                 +14.4%  
               
               
                 45° 
                   
                   
                   
                   
                   
               
               
                 Bowtie  
                 +72.5%  
                 No  
                 +33.6%  
                 +33.6%  
                 −30.9%  
               
               
                 90° 
                   
                 change  
                   
                   
                   
               
               
                 Chiral  
                 −28.8%  
                 N/A  
                 +37.6%  
                 N/A  
                 −9.6%  
               
               
                 Hexagon  
                   
                   
                   
                   
                   
               
               
                  0° 
                   
                   
                   
                   
                   
               
               
                 Chiral  
                 −26.4%  
                 N/A  
                 +38.1%  
                 N/A  
                 −10.5%  
               
               
                 Hexagon  
                   
                   
                   
                   
                   
               
               
                 45° 
                   
                   
                   
                   
                   
               
               
                 Chiral  
                 +96.8%  
                 N/A  
                 +40.6%  
                 N/A  
                 −11.8%  
               
               
                 Hexagon  
                   
                   
                   
                   
                   
               
               
                 90° 
               
               
                   
               
            
           
         
       
     
     Regarding effective pore area, the effective pore area for all models was 100%. No change means that the effective pore area at 3 N was maintained at 100%. Regarding a result of “N/A,” a parameter was not calculated. 
     As seen in Table 2 and  FIG. 14 , the minimal pore diameter, porosity, and effective porosity all increased for the bowtie 0° membranes while mesh burden decreased. There was no change in the effective pore area (i.e. the minimal pore diameter of pores was &gt;1 mm). These results are similar to the results for bowtie 90° membranes in which the minimal pore diameter, porosity, and effective porosity all increased while mesh burden decreased and the effective pore area was unchanged. The observed pore collapse with the bowtie 45° membranes was associated with a decrease in the minimal pore diameter and porosity, and there was a complete loss (i.e. 100% decrease) in the effective pore area and effective porosity. Mesh burden however was increased for the bowtie 45° membranes, and this result was anticipated given that pore collapse results in an increased amount of material. 
     As seen in Table 2 and  FIG. 15 , the minimal pore diameter decreased for the chiral hexagon 0° and 45° membranes while it increased for the 90° membranes. The porosity for all of the chiral hexagon membranes increased while mesh burden decreased for all of them. The effective pore area and effective porosity was not calculated for the chiral hexagon membranes given that the minimal pore diameter for all pores within these membranes was less than 1 mm prior to the application of loading (this was a result of our manufacturing process). Thus, calculations of these two parameters would not accurately reflect how the effective pore area and effective porosity changes with loading and we therefore did not analyze these two parameters for the chiral hexagon membranes. 
     Collectively the results from this mechanical testing of the bowtie and chiral hexagon 0°, 45°, and 90° membranes demonstrate that auxetic pores have the ability to expand; however, expansion is dependent on the orientation of the pore with respect to the direction of loading. 
     It should be understood that modifications to the embodiments disclosed herein can be made to meet a particular set of design criteria. For instance, the number of or configuration of components or parameters may be used to meet a particular objective. 
     It will be apparent to those skilled in the art that numerous modifications and variations of the described examples and embodiments are possible in light of the above teachings of the disclosure. The disclosed examples and embodiments are presented for purposes of illustration only. Other alternative embodiments may include some or all of the features of the various embodiments disclosed herein. For instance, it is contemplated that a particular feature described, either individually or as part of an embodiment, can be combined with other individually described features, or parts of other embodiments. The elements and acts of the various embodiments described herein can therefore be combined to provide further embodiments. 
     It is the intent to cover all such modifications and alternative embodiments as may come within the true scope of this invention, which is to be given the full breadth thereof. Additionally, the disclosure of a range of values is a disclosure of every numerical value within that range, including the end points. Thus, while certain exemplary embodiments of the device and methods of making and using the same have been discussed and illustrated herein, it is to be distinctly understood that the invention is not limited thereto but may be otherwise variously embodied and practiced within the scope of the following claims, which is to be given the full breath thereof.