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Msc 11520 llw
Surgical Innovation, Vol 12, No 2 (June), 2005: pp xx–xx
T1
Mesh Fixation in Laparoscopic Repair of Ventral
Hernia: A New Method
S. S. Kumar, MD
During laparoscopic repair of ventral hernia,
optimal fixation of the prosthetic mesh to the abdominal wall
includes transfascial fixation with sutures in addition to
fixation with a stapling, clipping, or tacking device. With
the current methods, the intracorporeal passage and the grasping
and retrieval of sutures from the abdominal cavity are technically
difficult. The reason for this difficulty is the lack of three-dimensional
visual feedback during conventional laparoscopy. An easier
method is needed. A new method using T-shaped anchors (T-anchors)
is described. A T-anchor is a horizontal bar made of rigid
titanium that is attached to a vertical limb made of monofilament
suture. T-anchors are deployed in pairs, through a needle,
and are tied over a musculofascial bridge to achieve transfascial
fixation of the mesh to the abdominal wall. This method eliminates
the need for intracorporeal grasping and retrieval of the
sutures.
Key words:ventral hernia repair, laparoscopy,
visual feedback, T-anchor
 ith the rapid advances
in minimally invasive surgery, ventral and incisional hernias
of the abdominal wall are being increasingly repaired by the
laparoscopic approach that incorporates a prosthetic mesh.
Several studies have confirmed the success of this approach,
and the results appear to be better than the open repair of
these hernias.1 Major advantages of laparoscopic
repair of the ventral hernia include less postoperative pain,
a shorter hospital stay, less wound-related morbidity, and
an earlier return to normal activity.2
Briefly, in the present method of laparoscopic
ventral hernia repair, the fascial defect is defined by reduction
of the hernia sac contents and lysis of adhesions as needed.
At least a 5-cm area of the surrounding peritoneal surface
is also dissected free. A prosthetic mesh of proper size and
shape is affixed to the peritoneal surface of the abdominal
wall as
From the Department of Surgery, Vanderbilt University
School of Medicine, Nashville, and NorthCrest Medical Center,
Springfield, TN.
Address reprint requests to S. S. Kumar, MD,
FACS, 322 NorthCrest Drive, Springfield, TN 37172 (e-mail:
sskmd@ aol.com).
©2005 Westminster Publications, Inc., 708
Glen Cove Avenue, Glen Head, NY 11545, USA.
an onlay patch that extends beyond the edges
of the fascial hernia defect by 3 to 5 cm. The details of
the technique have been described previously. 3
Current Methods
The technique used for fixation of the prosthetic
mesh to the peritoneal surface of the abdominal wall is
of critical importance in avoiding recurrence of these hernias.3
Options in fixation of the prosthetic mesh to the
abdominal wall include sutures that achieve transfascial
fixation or one of the stapling, clipping, or tacking devices
that affix the mesh to the parietal peritoneum and possibly
to the posterior rectus sheath. A combination of these two
techniques appears to provide the best results.3 Placement
of the transfascial sutures for mesh fixation is crucial
but presents a technical challenge,4 as described
next.
In one common technique, sutures are pre-tied
to the perimeter of the prosthetic mesh. The mesh is then
rolled in to a cigar-shape and introduced into the abdomen
through a laparoscopic cannula. When the mesh is unrolled,
these sutures present a tangled bird’s nest appearance
during laparoscopy. Each suture end is grasped and retrieved
to the outside of the abdomen with a percutaneous suture-passer
device (eg, Gore Suture Passer, W.I. Gore and Associates,
Flagstaff, AZ, among others). The suture passer is introduced
and withdrawn at opposing angles to create a musculofascial
bridge over which the sutures are tied. Because of the tangled
appearance and lack of a three-dimensional (3D) visual feedback
during laparoscopy, it is cumbersome to trace each suture
and feed it into the suture passer.
In the alternative method, sutures are not pre-tied
to the mesh when it is introduced in to the abdomen. Instead,
the suture passer is used to carry each suture percutaneously
through the abdominal wall and to pierce the edge of the
mesh. The suture is grasped and held in a laparoscopic grasper.
The suture passer is withdrawn and reintroduced through
the same skin site but at a different angle. This creates
the musculofascial bridge over which the suture is to be
tied. The suture is then fed back into
the suture passer and withdrawn to the outside of the abdomen.
The two ends of the suture are tied, affixing the mesh to
the abdominal wall. In both methods, the suture knots lie
in the subcutaneous tissue.
The technical difficulties with both of these
methods lie in the intracorporeal grasping and feeding of
the sutures from and into the suture passer device. This
is because conventional laparoscopic visualization does
not provide 3D feedback. Technical difficulties of tasks
that require visually guided object grasping in video-assisted
surgery because of the loss of 3D vision have been previously
documented.4,5
The resulting lack of depth perception makes
grasping, retrieving, and feeding of each suture from and
into the prongs of the suture passer, a technically difficult
maneuver.
A New Method
The new method consists of modified T-shaped
anchors (T-anchors, Nashville Surgical Instruments, Springfield,
TN). The horizontal bar of the T is made of titanium and
is about 1.0 × 0.1 cm in size, and the vertical part
consists of an attached 2-0 nonabsorbable monofilament suture
of standard length. Each T-anchor is delivered through a
15-cm-long, 16-gauge needle (Figure1) and can be deployed
by advancement of a stylet through this needle (Figure 2).
After the ventral hernia defect has been dissected,
the prosthetic mesh is positioned within the peritoneal
cavity for fixation to the anterior abdominal wall. The
sites for transfascial suture fixation of the mesh to the
abdominal wall are marked at the skin level, and a 3-mm
incision is made at each site. A T-anchor is loaded into
the 16-gauge needle (Figure 1).
The needle is introduced in to the abdomen at
an approximately 60° angle through the incision site.
The tip of the needle is visualized as it enters the abdominal
cavity and its position is monitored laparoscopically at
all times. The needle is advanced to puncture the mesh approximately
1 cm away from the edge of the mesh. To maintain careful
needle tip monitoring, the needle should enter from the
posterior surface of the mesh and exit at the anterior surface
during placement of the first row of the T-an-chors (Figure
3). When the mesh has been pulled up to the anterior abdominal
wall, this order may be reversed to maintain needle tip
visualization.
Figure 1. The T-anchor is inserted into
a 15-cm-long, 16-gauge needle.
Figure 2. The T-anchor is advanced by
a stylet through the 16-gauge needle.
Mesh Fixation
in Laparoscopic Repair of Ventral Hernia: A New Method
The T-anchor is deployed by advancement of the stylet, as
already described (Figure 2). The needle is withdrawn. A
second T-anchor is loaded into the needle. The needle is
reintroduced through the same skin site, again at an approximately
60° angle to the abdominal wall, but in the opposite
direction (Figure 3). This creates a musculofascial
bridge over which the suture will be tied (Figure3). The
needle again enters the mesh one cm away from the edge of
the mesh and 1 to 2 cm away from the first T-anchor. The
second T-anchor is now deployed, and the needle is withdrawn.
The titanium bars are aligned parallel to the border of
the mesh to avoid protrusion through the mesh.
The T-anchors are thus applied in pairs at 5-cm
intervals along the perimeter of the mesh (Figure 3). When
the paired sutures are tied together, the mesh attaches
to the abdominal wall (Figure 4). Suture knots lie in the
subcutaneous tissue. Additional tacks, clips, or staples
are placed 1 cm apart along the perimeter and the surface
of the mesh.
Surgeons may choose to place the tacks, clips,
or staples first, followed by the transfascial fixation
with T-anchors.
Discussion
A device similar to the T-anchors has been in
extensive clinical use for fixation of the stomach to the
anterior abdominal wall during percutaneous endoscopic gastrostomy
tube placement (T-fasteners, Ross Laboratories, Columbus,
OH). Clinical trials of the new modified technique for laparoscopic
mesh fixation in ventral hernia repair await approval from
the United States Food and Drug Administration.
Postoperative recurrence of ventral hernia after
laparoscopic repair is reported to be as high as 13% when
only a stapling, clipping, or the tacking device is used
for mesh fixation.2 Proper use of the transfascial
fixation sutures in combination with a stapling, clipping,
or tacking device decreased the postsurgical recurrence
rate to as low as 2%.3 Therefore, the current
recommendation for mesh fixation is that a transfascial
suture should be placed at a distance of 5 cm each along
the perimeter of the prosthetic mesh. In addition, a tacking,
clipping, or stapling device should be used to affix the
edge of the mesh to the abdominal wall at 1-cm intervals.3
The lack of a 3D visual feedback and the consequent
lack of depth perception during la-paroscopy4,5 make
conventional suture placement for prosthetic mesh fixation
a technical challenge. The new method with the use of T-anchors
resolves the difficulties. In addition, placement of each
pair of T-anchor in a direction parallel to the nerve pathways
may decrease the possibility of nerve entrapment.
Figure 3. The
T-anchors are deployed through the abdominal wall and the
edge of the mesh. The needle enters posterior surface of mesh
and exits at anterior surface.
Figure
4. The suture ends of theT-anchors are tied over a musculofascial
bridge.
The new method has the
potential of enhancing the technical ease and safety of
this operation. Operating-room time-savings and cost-effectiveness
of this method will need further evaluation.
References
1. Ben-Haim
M, Kuriansky J, Tai R, et al: Pitfalls and complications
with laparoscopic polytetrafluoroethylene patch repair
of postoperative ventral hernia. Surg Endosc 16: 785-788,
2002.
2. LeBlanc KA: The critical technical
aspects of laparoscopic repair of ventral and incisional
hernias. Am Surg 67: 809812, 2001.
3. Heniford BT, Park A, Ramshaw
BJ, Voeller G: Laparoscopic ventral and incisional hernia
repair in 407 patients. J Am Coll Surg 190: 645- 650,
2000.
4. Marotta J, Goodale M: The role
of learned pictorial cues in the programming and control
of grasping. Exp Brain Res 121:465-470, 1998.
5. Servos P, Goodale M, Jakobson LS: The
role of binocular vision in comprehension: a kinetic analysis.
Vision Res 32: 1513-21, 1992.
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