Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.
Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A “contraposition and alignment” mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The “contraposition and alignment” mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.
Incisional hernia is a common complication after abdominal surgery and can be properly treated only with surgery1. Compared with traditional open incision herniorrhaphy, laparoscopic herniorrhaphy has the advantages of less surgical trauma, a lower infection rate, and faster postoperative recovery2,3. Currently, laparoscopic herniorrhaphy is the method of choice for the treatment of incisional hernia if there are no contraindications4.
However, laparoscopic herniorrhaphy is technically complex. Intraperitoneal onlay mesh (IPOM) is commonly used in laparoscopic incisional hernia repair, and this involves placing a mesh into the abdominal cavity laparoscopically to cover the hernia defect5. The mesh is a new type of medium-weight monofilament polypropylene mesh covered with a hydrogel barrier on the visceral side6. For laparoscopic incisional hernia repair using the IPOM method, it is necessary to master the placement of the trocars, the techniques to separate intra-abdominal adhesions, the techniques for suturing the incisional hernia, and the methods for placing and fixing the mesh in the abdominal cavity. In particular, if the mesh is not properly placed and fixed, this can result in the recurrence of the hernia, as well as potentially serious complications such as intestinal obstruction and mesh infection7,8. Therefore, mastering the correct mesh fixation technique is an important criterion for achieving a good surgical outcome.
The traditional method of mesh fixation for incisional hernia is to fix the mesh with a double-ring hernia nail. After the mesh is placed into the abdominal cavity, the edge of the mesh is fixed with a nail gun first, and then the edge of the hernia ring is fixed9. However, this method has poor spatial positioning, and the mesh is prone to displacement, leading to hernia recurrence. By reviewing and analyzing the various mesh fixation methods, a new “contraposition and alignment” method for mesh fixation is proposed and presented in this protocol10. In this method, the size and scope of the incisional hernia are measured in advance, after which the mesh fixation points can be marked in advance. When the mesh is placed into the abdominal cavity during the operation, nail gun fixation and suture fixation can be performed according to the previously marked locations. This method can reduce the difficulty of the operation, the operation time, the medical cost, and the occurrence of complications. In this study, this new method is compared with the conventionally used double-loop hernia nail fixation method for mesh fixation during laparoscopic incisional hernia repair surgery.
The protocol was carried out in accordance with the tenets of the Declaration of Helsinki and approved by the Ethics Review Committee of the Sixth Affiliated Hospital of Sun Yat-sen University.
The patients and families were informed of the purpose of shooting and making the surgical video, and informed consent was obtained.
1. Patient data and grouping
NOTE: From January 2018 to June 2020, laparoscopic incisional hernia repair using the IPOM method was performed during gastrointestinal, hernia, and abdominal surgery at the Sixth Affiliated Hospital of Sun Yat-sen University. After obtaining informed consent, a total of 84 patients with incisional hernias were included in the study.
2. Necessary preparation and examination before the operation
3. Measurement of the size of the hernia ring defect and anti-adhesion mesh marking
4. Mesh placement method
5. Follow-up
6. Statistical analysis
Either "contraposition and alignment" mesh fixation (experimental group) or traditional double-loop hernia nail fixation (control group) was performed for the patients in the study, with 42 patients in each group.
During the hernia repair surgery performed in this study, the anti-adhesion mesh was placed after the hernia ring was sutured. In the experimental group, the "contraposition and alignment" method was used to place the mesh, while the traditional double-loop fixation method was used to place the mesh in the control group.
Section 3 of the protocol details the specific mesh placement methods (Figure 1, Figure 2, and Figure 3). The mesh placement time, the frequency of seroma formation, mesh infection, hernia recurrence, chronic pain, the length of hospital stay, and the hospitalization costs were compared between the experimental and control groups. Figure 4 shows the comparison images before and after the operation. The mean mesh placement time of the experimental group was 32.5 min ± 11.6 min and of the control group was 44.7 min ± 12.5 min (P < 0.05), indicating a reduction in the time required for mesh placement with the "contraposition and alignment" method used in this study. There were only two cases of chronic pain in the experimental group, which was a significantly lower number than the eight cases observed in the control group (P < 0.05). In addition, there were no significant differences between the two groups in terms of seroma formation, mesh infection, recurrence of incisional hernia, the length of the postoperative hospital stay, and hospitalization expenses (Table 2).
Figure 1: Measurement of the hernia ring defect size and marking the anti-adhesion mesh. (A) The size of the incisional hernia defect on the abdominal wall is measured. (B) The longitudinal axis length of the hernia ring defect is measured under laparoscopy. (C) The appropriate mesh size is selected. (D) The range of the vertical axis is marked on the mesh. (E) The fixation positions of the nails are marked on the edge of the mesh. (F) The fixation positions of the nails are marked in the middle of the mesh. This figure is reprinted with permission from Ning et al.10. Please click here to view a larger version of this figure.
Figure 2: Steps of mesh placement under laparoscopy. (A) The layout of the puncture holes for an incisional hernia. (B) The mesh is placed into the abdominal cavity through the puncture hole. (C) The longitudinal axis of the mesh overlaps the longitudinal axis of the hernia ring defect (red dotted line). (D) The marked positions on the mesh longitudinal axis are fixed on the abdominal wall with non-absorbable nails (indicated by a red arrow). (E) The mesh is fixed to the abdominal wall along the marked points on the edge of the mesh (red arrow) with non-absorbable nails. (F) The mesh is fixed on the abdominal wall along the marked points in the middle of the mesh (red arrow) with absorbable nails. This figure is reprinted with permission from Ning et al.10. Please click here to view a larger version of this figure.
Figure 3: Steps of the double-loop mesh fixation method. (A)After closing the hernia ring, the extent of the hernia ring defect is measured with a ruler under laparoscopy. (B) The appropriate mesh is selected according to the size of the hernia ring defect. (C) Fixation of the outer ring: the fixing nails are placed along the edge of the mesh to ensure that the distance between the hernia nail and the edge of the mesh is about 2-4 mm and the distance between the nails is about 2-3 cm. (D) Fixation of inner ring: the mesh is fixed about 2 cm along the outer edge of the hernia ring defect, and the distance between the nails is 3-5 cm. This figure is reprinted with permission from reference Ning et al.10. Please click here to view a larger version of this figure.
Figure 4: Comparison of the condition before and after the operation. (A)Photos of the incisional hernia of the abdominal wall before the operation. (B) A color ultrasound image of the abdominal wall before the operation. (C) A CT image of the abdominal wall before the operation. (D) Photos of the abdominal wall 3 months after the operation. (E) A color ultrasound image of the abdominal wall 1 month after the operation. (F) A CT image of the abdominal wall 3 months after the operation. Please click here to view a larger version of this figure.
experimental group n=42 |
control group n=42 |
P-value | |
Age (years) | 52.5±3.4 | 53.2±4.2 | 0.4 |
Gender (n) Men Women |
26 16 |
27 15 |
0.82 |
BMI (kg/m2) | 24.0±3.3 | 23.5±2.7 | 0.45 |
Disease time(yr) | 2.73±0.51 | 2.56±0.64 | 0.18 |
Maximum defect of hernia ring(cm) |
0.35 | ||
≥10cm | 11 | 15 | |
<10cm | 31 | 27 |
Table 1: Comparison of the baseline data of the experimental and control groups. The baseline characteristics compared included the patients' age, sex, body mass index (BMI), the length of time of the hernia defect, and the maximum defect size of the hernia ring.
experimental group n=42 |
control group n=42 |
P-value | |
Mesh placement time (min) | 32.5±11.6 | 44.7±12.5 | <0.05 |
Seroma | 3 | 4 | 1.00 |
Mesh infection Recurrence of hernia |
1 1 |
2 3 |
1.00 1.00 |
Chronic pain | 2 | 8 | <0.05 |
Postoperative hospital stay (days) | 5.8±1.3 | 5.5±1.1 | 0.26 |
Hospitalization cost (ten thousand ) | 4.9±0.6 | 4.7±0.5 | 0.1 |
Table 2: Comparison of the intraoperative and postoperative data between the experimental and control groups. The indices compared between the two groups included placement time, seroma formation, mesh infection, hernia recurrence, chronic pain, the length of thepostoperative hospital stay, and the hospitalization costs.
Laparoscopic incisional hernia repair is primarily performed using the IPOM method5, for which the placement and fixation of the mesh are key to achieving good outcomes. If the placement and fixation of the mesh are improper, the mesh will not adhere tightly to the abdominal wall and may be wrinkled or displaced. Improper mesh fixation is associated with seroma formation, abdominal infection, chronic pain, and hernia recurrence. Specifically, the treatment for mesh infections involves puncture and drainage. Postoperative pain associated with mesh infection is often treated conservatively, and poor treatment may necessitate further surgery to remove part or all of the mesh15,16. In order to avoid these complications, it is crucial to master the correct mesh placement and fixation technique. The mesh fixation methods commonly used in laparoscopic incisional hernia repair include hernia nail fixation, suture fixation, and medical adhesive fixation17,18,19. Nail fixation has the advantage of being a simple procedure with a short operation time, and this is the most commonly used method of mesh fixation20. However, the use of hernia nails, especially non-absorbable nails, and the number of nails placed are closely related to the risk of postoperative pain21,22. The use of hernia screws to fix the mesh in certain areas, such as near the external iliac artery and vein in the inguinal region or in the pericardial area of the diaphragm, is associated with an increased risk of massive bleeding23,24. Suture fixation methods include crochet puncture suture fixation, simple suture fixation, and other improved methods25. The main advantages of suture fixation with full abdominal wall suspension are that, with this technique, it is easy to flatten the mesh, and the cost is much lower than that of nail gun fixation. However, using non-absorbable sutures placed through the fascia to fix the mesh is associated with a higher incidence of postoperative pain than hernia nail fixation26. With crochet puncture suture fixation, the crochet needle needs to penetrate the skin into the abdominal cavity, which significantly increases the risk of mesh infection. The use of medical adhesive for mesh fixation is simpler and less expensive, but the fixation with medical adhesive alone is not strong enough, which increases the risk of hernia recurrence27. In addition, the glue block formed during the application of the chemical medical adhesive can affect the process of cell growth and peritoneal mesh formation28. As such, the use of medical adhesive for fixation is only recommended in areas for which the use of nails or sutures may increase the risk of bleeding or pain, such as near blood vessels.
Currently, the most commonly used mesh fixation method is double-loop mesh fixation with hernia nails9,14. However, there are shortcomings to this method. First, it is difficult to accurately locate the spatial axial position of the mesh when placing the mesh, especially for inexperienced surgeons. The mesh center can shift and not completely cover the defect area, which increases the risk of hernia recurrence. Second, the number of hernia nails needed cannot be accurately calculated when placing the mesh, and nail guns typically contain 15 or 30 nails. If the estimated number of hernia nails required is not accurate, some nails may be wasted, thus increasing the medical costs. Third, after the mesh is placed, the blood vessels and nerves cannot be accurately located, which may lead to blood vessel or nerve injury when nailing the mesh.
In view of the shortcomings of the double-loop fixation method, the "contraposition and alignment" mesh fixation method was designed in this study. The results of this study showed that the incidence of seroma and mesh infection, the hernia recurrence rate, the length of postoperative hospital stay, and the hospital costs were similar between the "contraposition and alignment" mesh fixation method and the double-loop fixation method. However, the "contraposition and alignment" mesh fixation method simplifies the surgical procedure by allowing for the mesh to be designed, positioned, and marked in advance, which only takes 1-2 min. After being placed into the abdominal cavity, the mesh is fixed according to the pre-marked positions, which can simplify the placement and reduce the operation time. In addition, marking the areas that overlay vessels and nerves in advance and using absorbable sutures for fixation in these areas can reduce the risk of vascular and nerve injury. It has been reported that in special areas such as the costal margin, the use of a nail gun to fix the mesh or the use of a crochet needle for a full thickness abdominal wall suture can lead to intercostal nerve compression and local muscle ischemia, which may cause chronic pain29. Through a retrospective study, it was found that the "contraposition and alignment" mesh fixation method can significantly shorten the placement time of the mesh. Simultaneously, through the postoperative follow-up, this method was found to reduce the incidence of postoperative chronic pain.
Nevertheless, the "contraposition and alignment" mesh fixation method suffers from a few limitations. This method can only be used with medium or heavyweight anti-adhesion mesh. Lightweight and large anti-adhesion meshes, especially those that are transparent or translucent, are not easy to mark, and it may not be easy to see the marks when placing the mesh. It is also unclear if marking the mesh with a sterile marking pen damages the anti-adhesion coating and, thus, affects mesh adhesion. Additional studies are required to address these issues. Marking in advance when designing and manufacturing the anti-adhesion mesh may help overcome the potential issues arising from using a pen.
There are several key points that should be taken into account when using the "contraposition and alignment" mesh fixation method. When placing the mesh, the length and position of the mesh centerline and the longitudinal axis of the incisional hernia defect should coincide. The longitudinal axis of the defect is the position where the abdominal wall tension is greatest after the hernia ring is closed. The best abdominal wall repair effect can be achieved by fixing the midline based on fixation points that have been designed and marked in advance. Second, the mesh should be fixed according to the nail points marked in advance. When placing the nails, the nail gun, the mesh, and the abdominal wall should be aligned in the same direction to achieve the best fixation effect. Finally, nail gun fixation should not be used in areas containing blood vessels or nerves, and suture fixation can be used to replace nails when necessary to reduce the occurrence of postoperative chronic pain. The ideal effect of the operation is achieved when the mesh is fixed firmly and the use of hernia nails, especially non-absorbable nails, is reduced as much as possible. The mesh edge needs to be fixed with high-strength non-absorbable nails, while absorbable nails can be used on both sides of the longitudinal axis of the mesh to ensure good fixation and reduce postoperative complications.
To achieve the best effect of the mesh placement, the mesh should be completely flattened, the edges should not be curled, and the fixation should be firm such that displacement will not occur. When these conditions are met, the mesh integrates into the peritoneum and abdominal wall tissue rapidly. During the operation, due to the influence of various factors, it is difficult to achieve a rational mesh fixation effect, which requires certain surgical skills. This study shows that the "contraposition and alignment" mesh fixation method offers the advantage of reliable mesh fixation, the technique is easy to learn and master, and the method is associated with a lower risk of chronic pain. Further studies with larger numbers of patients are necessary to confirm the results of this study.
The authors have nothing to disclose.
This research was supported by the Guangdong Science and Technology Plan Project (grant number: 2021A1515410004) and the National Key Clinical Discipline (grant number: [2012]649).
1-0 Stratafix Symmetric PDS Plus Violet 45cm PS-1 | ETHICON | sxpp1a401 | STRATAFIX Symmetric PDS Plus |
3-0 VICRYL suture | ETHICON | VCP316 | absorbable suture |
AbsorbaTack Fixation | Covidien llc | ABSTACK15 | absorbable nail gun |
Laparoscopic needle holder | KARL-STORZ | 26173KL | needle holder |
Laparoscopic separating forceps | KARL-STORZ | 38651ON | separating forceps |
Laparoscopic system (OTV-S400) | Olympus | CLV-S400_WA4KL530 | 4K HD image large screen surgical laparoscope |
ProTack Fixation | Covidien llc | 174005 | Non absorbable nail gun |
VENTRALIGHT ST | BARD | 5954810 | Biological anti-adhesion mesh |