How Is Mesh Sewn In For Hernia Repair

J Minim Access Surg. 2018 Apr-Jun; 14(ii): 168–170.

Sewing machine technique for laparoscopic mesh fixation in intra-peritoneal on-lay mesh

Khojasteh Sam Dastoor

Department of GI & Laparoscopic Surgery, Bhatia Hospital, Bombay, Maharashtra, India

Kaiomarz P. Balsara

¹Department of GI & Laparoscopic Surgery, Breach Candy Hospital, Mumbai, Maharashtra, India

Asif Y. Gazi

²Department of GI & Laparoscopic Surgery, Saifee Hospital, Mumbai, Maharashtra, Bharat

Received 2017 Jun 19; Accepted 2017 Aug 29.

Abstract

Introduction:

Mesh fixation in laparoscopic ventral hernia is accomplished using tacks or tacks with transfascial sutures. This is a painful performance and the pain is believed to be more than due to transfascial sutures. We describe a method of transfascial suturing which fixes the mesh deeply and probably causes less pain.

Method:

Up to six ports may exist necessary, three on each side. A suitable-sized mesh is used and fixed with tacks all around. A 20G spinal needle is passed from the skin through i corner of the mesh. A 0 prolene suture is passed through into the peritoneum. With the prolene within, the needle is withdrawn to a higher place the anterior rectus sheath and passed over again at an angle into the abdomen only exterior the mesh. A loop of prolene is thus created which is tied under vision using intra-corporeal knotting.

Conclusion:

This method gives a secure mesh fixation and causes less pain than conventional methods. This technique is piece of cake to acquire but needs expertise in intra-corporeal knotting.

Keywords: Intra-peritoneal on-lay mesh, laparoscopic ventral hernia, mesh, hurting, sewing machine, transfascial sutures

INTRODUCTION

Laparoscopic intra-peritoneal on-lay mesh (IPOM) has gained credence as the preferred method for repair of incisional hernia.[1,two] Being minimally invasive, information technology has the advantage of forming less post-operative adhesions, less wound infection and shorter hospital stay as compared to open surgery.[3] The recurrence rates are besides low,[three] well-nigh 10% or less, and patient satisfaction scores are high.[2]

Hurting, however, however remains a problem mail-operatively. The hurting is usually self-limiting and is said to be chronic pain if it goes across 8 weeks.[four] The most standard method of mesh fixation involves tacks and transfascial sutures. Both these cause hurting.[1,4] Probably, transfascial sutures crusade more pain than the tacks,[5] due to nerve entrapment or ischaemia of the entangled muscles and sutures pulling on the abdominal wall when patients move from side to side. In addition, transfascial sutures can cause puckering of skin and knot placement is unpredictable, particularly in obese patients.

There are diverse methods of taking transfascial sutures. The technique we describe herein gives a secure fixation and probably causes less pain than other conventionally described techniques.

METHODS

Sixteen primary ventral hernias (xi para-umbilical and 5 epigastric) and 34 incisional hernias were repaired using laparoscopic IPOM technique. All incisional hernias were vertical mid and lower intestinal incisions. Hernias larger than 8 cm × 8 cm were not done by laparoscopy. Thirty-2 were females and eighteen were males; age range was 25–71 years. Mean body mass index was 28. The thickness of the rectus muscle and the musculoaponeurotic layer lateral to the rectus was measured past a computed tomography scan or a sonography in all patients. Informed consent of all patients was taken, afterward explaining to them that a different method of transfascial suturing would be used.

Three ports were used on the 1 side and an boosted two or 3 on the opposite side. I port was 10 mm or 12 mm and all others 5 mm. The add-on of two or 3, 5 mm ports do not significantly add to the pain in our experience. A composite mesh was used, either Ventralight ST by Bard Davol Inc. or Parietex by Covidien Surgical. The mesh size was chosen to accomplish a iv–5 cm overlap every bit assessed by imaging and intra-operative in a partially deflated abdomen at 8 mmHg. If possible, we used a fundamental fixation stitch, which was drawn out through the defect to correctly place the mesh. The mesh was first stock-still in position with tacks, one.5–2 cm apart. The post-obit describes the steps of suture placement.

A 21G or a 20G spinal needle was inserted from the skin downwardly through the corner of the mesh. A 2-0 or 0 polypropylene suture, 25 cm long, was introduced through the needle into the abdomen and held inside the abdomen with a Maryland forceps [Figure 1]

A 20G spinal needle is inserted at the border of the mesh with a 25 cm, 0 polypropylene suture along with information technology
The spinal needle is then withdrawn about 1–two cm, depending on the muscle thickness, equally assessed past prior imaging then that it lies but inductive to the rectus sheath. The intra-abdominal stop of the suture is kept in position by the Maryland [Effigy 2]

Keeping the polypropylene suture held within the abdomen, the spinal needle is withdrawn above the anterior sheath
Keeping the outer stop of the prolene lax, the spinal needle is re-introduced into the abdominal cavity with a slight angulation, so as to puncture the posterior sheath and peritoneum just exterior the mesh and deport a loop of the suture with it [Figure 3]

The spinal needle is re-introduced into the belly but outside the mesh, taking a loop of the polypropylene suture forth with it. The loop is and so undone so that both the ends of the suture are within the belly
The loop is pulled with a needle holder and undone and then that both ends of the suture are in the abdomen. The ends of the polypropylene suture are tied using intra-corporeal knotting, simply adequately to fix the mesh, notwithstanding not cause strangulation. Before knotting, the force per unit area is reduced to 8 mm, so the knots exercise not come loose [Figure 4].

The two ends of the suture are and so tied intra-corporeally and then that the mesh is fixed in position

The procedure is repeated in all 4 corners and 2 additional sutures in the heart of the mesh, depending on the size of the mesh used.

Paracetamol intravenous i one thousand 8^thursday hourly was used for the first 24 h. From the next day, oral paracetamol one g thrice a day was used for 3 days so equally needed. When VAS pain scores were >5, intravenous diclofenac 75 mg was added up to 12 hourly.

RESULTS

All patients had the procedure done by laparoscopy. The hateful VAS pain score on solar day 1, 2 and 3 was 3.viii (range 2–6). Side-to-side move was likewise comfortable in all patients. There was a patient with seroma germination at the umbilicus not requiring any intervention, 2 patients with paralytic ileus which settled conservatively in five–half dozen days and no port site infections, bowel perforations or fistulisations. At the end of 1 week, all patients were free of pain and did not need analgesics. Patients were ordinarily discharged on the 3^rd post-operative solar day. None of the patients had chronic pain (i.due east. beyond 8 weeks).

DISCUSSION

Laparoscopic ventral hernia repair has advantages over open surgery though post-operative pain is a major drawback. The pain is most intense during the first 72 h of surgery and occasionally requires strong analgesia, merely it subsides in 1 week. The cause of the hurting is more likely due to the sutures than the tacks. We accept described a method of mesh fixation which is alike to a sewing machine sew, hence the title.

The advantages of this method are as follows.

The sutures help fix the mesh with the anterior rectus sheath as desired. The certainty of the suture being at the level of the inductive sheath is more, unlike the conventional method where the suture is arbitrarily tied downwards to the fat or the sheath. In obese patients too, our method ensures that the fixation is to the rectus sheath, unlike in prior described methods where the knot may but lie within the fat and allow the mesh to motion
There is no dimpling at the entry sites
The ends of the suture do not hurt the patient as they are within the abdominal cavity
Knotting is under vision and can be controlled to be just adequate
Spinal needles 21G and 20G are less traumatic and therefore less likely to crusade haematoma.

The disadvantages of this technique are as follows:

Up to six ports are required
The surgeon should exist good at intra-corporeal knotting.

Our observation has been that these patients suffer less hurting though, at present, we do non have any comparative study. This method as well ensures good mesh fixation and prevents mesh migration.

Conclusion

Nosotros have described a method of transfascial suturing of the mesh in anterior abdominal wall hernias which causes less trauma, has better fixation, prevents mesh shrinkage and causes less pain. A larger comparative trial would be of value in evaluating this course of suturing.

Financial support and sponsorship

Nix.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869981/

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