fixing the mesh in ventral hernia3

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Title: A highly effective method of fixing the mesh in open ventral hernia repair

Running title: mesh fixing in ventral hernia

Authors: Anestis Ninos, Maria Vidali , Gerasimos Douridas, GeorgiosPapaioanou , Christos Iordanou, Stavros Maletsikopoulos, Farazi Christos, Stefanos

Pierrakakis

Affiliation: Thriassion General Hospital, Athens, Greece

Department of Surgery

Type: clinical study

Support or sponsorship: none

Corresponding Author:

Mr. Anestis Ninos MD FRCSEd18 Levidiou Str.,

13 121 Ilion,

Athens, Greece

Tel: +30210 5756832

Fax: +30210 8130621

E-mail: [email protected]

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mailto:[email protected]:[email protected]


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Abstract

BackgroundThe ideal method of ventral hernia repair is yet to be defined. We hereinpresent a method of intraperitoneal mesh fixation which is easy, fast and secure.

With this method we can achieve an open surgery for hernia repair with all its

advantages and with the minimal stress for the patient.Methods The skin incision is limited only over the hernia opening. No other

dissection in the subcutaneous layer is done. Adhesionlysis is performed and the

mesh is prepared by placing multiple sutures circumferentially at its edge and at one

to one and a half cm intervals. Small skin stab wounds with an 11 blade are made

corresponding to these points. The mesh is being introduced into the abdominal

cavity and each suture is pulled out using a suture-grasping device the and tied

subcutaneously, thus securing a full thickness abdominal muscular/fascial wall

fixation.

Results We have performed 106 incisional and ventral hernia mesh repairs using ourfixating technique between February 2003 and June 2007. Twenty-four patients

(22.6%) were being treated for recurrent hernias. The average age was 62 years

(range 27-84). The average time spent in the operating room was 52 minutes (range

28-112). There were no intraoperative complications. Of the 106 patients, 14

(13.2%) had a hernia defect up to 4 cm and the rest had a larger one. There were two

superficial minor wound infections that were managed conservatively. Twenty-eight

(35%) patients complained of pain at points corresponding to suture knots for more

than two months. All of them were successfully treated conservatively. To date none

has had a recurrence of his or her hernia.

Conclusions Open ventral hernia repair modified by the way of mesh fixation weproposed herein, is a safe effective quick and easy-learned method with a low

morbidity and low recurrence rate.

Key words

Ventral hernia, mesh, fixation method

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Discussion

The use of prosthetic material is now considered as a prerequisite for the repair of a

ventral hernia. Open and laparoscopic methods have been proposed.

Open techniques include the onlay, the Rives-Stopa sublay and the intaperitoneal

methods. Laparoscopicaly, the prosthesis is always placed intraperitonealy.

According to the hydrostatic law of Pascal, the abdominal forces that contribute to

hernia formation, will act to fix the mesh if that is placed in a pre or intraperitoneal

position(1). The onlay method has this great disadvantage apart from the high rate of

seromas and mesh infections. The underlay Rives-Stopa is a technique with low

recurrence rate but with a considerable mortality and morbidity (

2

).

The introduction of new materials and the construction of bilayer prosthesis in the

late 1990s made the intaperitoneal mesh hernioplasty a more commonplace method

for ventral hernia repair.

In our series we used the certain type of the aforementioned mesh, which is a light

polypropylene mesh with a three dimensional configuration. Although all types of

mesh have been used, an ideal one must at least be easily handled smoothly

positioned, without adhesion formation tendency and with the capacity to be quickly

incorporated into the abdominal wall tissues. A double face construction is of

paramount importance in order to be properly oriented, especially in laparoscopic

hernia repair. We have chosen a mesh according to the aforementioned properties.The intaperitoneal technique allows for the largest underlay of mesh and overlap on

the fascia or abdominal wall, which should reduce the recurrence (3).

The technique can be applied openly or laparoscopically (4). Fixation of the mesh

material is currently being debated in the literature. Fixing the mesh only to the

fascial edge, to the posterior abdominal wall laterally with partial thickness sutures,

or with full-thickness muscular/ fascial bites have been proposed. A 0% recurrence

rate has been reported using this latter method (5). Non absorbable monofilament

sutures are mostly used, as in our case. We used polypropylene sutures as these are

regarded more advantageous than the absorbable or threaded one. They are longer

lived, more secure and with the least infection rate.

Techniques involving suturing of a mesh to the edges of parietal defect have beensuggested but were associated with high recurrence rates, which were attributed to

weak anchoring of the prosthesis to the sides of the defects (6). This method of

fixation is now only rarely mentioned in the literature.

The failure of the aforementioned method has led to techniques that include a mesh

overlap of at least five cm beyond the edges of the defect (7).

Laparoscopic repair may offer lower complication rates and shorter length of

hospital stay compared with open repair. This is so because open repair involves an

extended wound trauma and dissection of wide areas of soft tissue for mesh

placement that may trigger regional or systematic complications (8) (9). It is therefore

very important to minimize the open wound trauma. This may be achieved by using

our fixation technique, which involves no dissection around the hernia opening andonly minimal adhysionlysis around the neck of the sac. This method is similar to the

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one proposed for laparoscopic repair (10), but has never been proposed for open

surgery.

The optimum number of sutures required is difficult to define but some kind of

suture fixation is mandatory for the long-term durability and good fascial fixation of

the mesh (11). In the laparoscopic method mattress sutures are spaced at 4 to 5 cm

intervals and additional staples or spiral tacks are placed at 1-cm interval ( 12). Othersargue that a 1.5cm placement interval between the sutures is an ideal distance ( 13).

With our similar open method sutures can easily be put at 1-cm intervals resulting in

a more stable anchoring because the tensile strength of sutures is 2.5 times greater

than the tensile strength of tackers (14).

In our series we present a considerable percentage of patients complaining of pain or

ache at the suture knot sites . Although in most of these cases the pain was

concentrated at a certain point only and in all of them it subsided with conservative

measures the fact drove our attention. The topic was debated recently in the 2006

Suvretta expert workshop. One of the conclusions of the meeting was that

slowly absorbable sutures seem to reduce the incidence of would pain(15). If that

holds true for the closure of abdominal incisions it will probably be true for the meshfixation. We have recently changed our suture preference in favor of the slowly

absorbable materials and our first results are pending.

Conclusions

Intraperitoneal mesh technique for ventral hernia repair modified by the way of mesh

fixation we proposed herein, is a safe effective quick and easy-learned method with

at least the same morbidity and the same or better recurrence rate.

Conflict of interest

The authors declare that they have no conflict of interest.

Figures

Fig.1 multiple sutures are placed circumferentially at one to one and a half cmintervals

Fig.2 a suture-grasping device is introduced through the stab wounds and the two

threads are pulled out and tied subcutaneously

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fixing the mesh in ventral hernia3

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