Summary
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.
Abstract
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.
Introduction
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.
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Protocol
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.
- Enroll patients based on the inclusion criteria (adult patients diagnosed with incisional hernias) and exclusion criteria (age ≤18 years or ≥80 years; emergency operation; strangulated incisional hernia; recurrent incisional hernia; the presence of severe organ dysfunction).
NOTE: The characteristics of the two groups, including the patient's age, sex, and body mass index (BMI), the length of time the hernia was present, and the maximum size of the hernia ring defect, are shown in Table 1. There were no significant differences in characteristics between the two groups (all P > 0.05). - All the operations were performed by the same group of surgeons, who received standardized training and had rich experience in laparoscopic surgery.
2. Necessary preparation and examination before the operation
- Carry out preoperative examinations, including routine blood tests, blood biochemistry tests, routine urine tests, a routine stool test, a chest X-ray, an electrocardiogram, and an abdominal CT.
- For a giant incisional hernia, use preoperative botulinum toxin A (BTA) and preoperative progressive pneumoperitoneum (PPP) for the surgical preparation11.
- Administer fentanyl at 4 µg/kg using another pump at a rate of 250 µg/min simultaneously with propofol administration. Intravenously inject cisatracurium (0.2 mg/kg) after the patient is anesthetized.
- Subsequently, intubate the patient with the help of an experienced anesthesiologist 4 min after the muscle relaxant injection. Next, mechanically ventilate the patient with sevoflurane 1% inhalation with the following respiratory parameters: tidal volume, 8 mL/kg; respiratory rate, 12 breaths per minute.
NOTE: The anesthetic maintenance drugs were sevoflurane 1%-3%, propofol 1-3 mg/kg/h, remifentanil 0.05-0.3 µg/kg/min, cisatracurium 0.15-0.2 mg/kg, and 1/5-1/3 of the additional induction amount every 0.5-1 h12.
- Subsequently, intubate the patient with the help of an experienced anesthesiologist 4 min after the muscle relaxant injection. Next, mechanically ventilate the patient with sevoflurane 1% inhalation with the following respiratory parameters: tidal volume, 8 mL/kg; respiratory rate, 12 breaths per minute.
- Use 0.5% PVP-I disinfectant to disinfect the surgical area. The upper part of the disinfection range should reach the nipple line on both sides, the lower part should reach the pubic symphysis, and both sides should reach the midaxillary line.
- After endotracheal intubation, place the trocars using the method of modelized trocar arrangement. Determine the locations of the trocar placement based on the preoperative computed tomography (CT) images and the assessment of the abdominal adhesions13.
NOTE: For example, the case in this video is a lower abdominal incision hernia, which requires a total of five puncture tubes. A 12 mm puncture device is placed 10 cm above the belly button, 12 mm and 5 mm puncture tubes are placed at the left and right clavicular midlines, and 5 mm puncture tubes are placed at the left and right axillary midlines. - Establish carbon dioxide pneumoperitoneum, and maintain the pneumoperitoneum pressure at 13 mmHg.
- Explore the whole abdominal cavity, evaluate the degree of abdominal adhesion around the hernia ring, and separate the adhesion.
- Close the defect of the hernia ring by continuous suture with a 1-0 barbed suture.
3. Measurement of the size of the hernia ring defect and anti-adhesion mesh marking
- Select an appropriate size anti-adhesion mesh (see Table of Materials) according to the size of the hernia ring defect, and then mark the mesh with a sterile marking pen as described below.
NOTE: A commercially available anti-adhesion mesh was used here, which contains a polypropylene mesh on the anterior side with an absorbable hydrogel barrier on the posterior side for laparoscopic hernia repair. The hydrogel barrier on the mesh prevents adhesion, and the mesh on this side should face the viscera.- Measure and mark the approximate range of the incisional hernia on the abdominal wall surface with a sterile ruler and marking pen (Figure 1A).The size of the hernia ring defect can also be measured by a preoperative CT examination.
- Place the ruler parallel to the longitudinal axis of the hernia defect, and measure the maximum longitudinal length of the defect (Figure 1B).
- Select an appropriately sized anti-adhesion mesh according to the size of the hernia ring defect. Ensure that the coverage of the mesh exceeds the edge of the defect by at least 5 cm. For example, for an incisional hernia defect of size 7 cm x 5 cm, use a mesh approximately 20 cm x 15 cm in size (Figure 1C).
- Mark the longitudinal length of the defect on the mesh, and mark the nail gun fixation points at intervals of 5 cm on the longitudinal axis. Then, extend the fixation points more than 5 cm along the marked line to the edge of the mesh, which pertains to the "alignment" (Figure 1D).
- Mark the nail gun fixation points evenly every 2-3 cm along the edge of the mesh, which pertains to the "contraposition" (Figure 1E).
- Finally, ensure that the fixing points of the nail gun are uniformly marked 2 cm from the longitudinal axis of the defect on both sides, with an interval of 3 cm (Figure 1F).
4. Mesh placement method
- Roll the mesh such that the anti-adhesion surface will face the abdominal wall. Place the rolled mesh into the abdominal cavity through the 12 mm puncture hole, and then unfold the mesh under laparoscopic guidance (see Table of Materials, (Figure 2B).
- Reduce the pneumoperitoneum pressure to 8-10 mmHg.
- Ensure that the marked line of the unrolled mesh overlaps the longitudinal axis of the hernia ring defect (Figure 2C).
- Fix the marked points on the longitudinal axis of the mesh to the abdominal wall with non-absorbable nails using a nail gun (see Table of Materials; (Figure 2D).
- Fix the edge of the mesh to the abdominal wall along the marked points on the edge of the mesh with non-absorbable nails using a nail gun (Figure 2E).
- Fix the mesh on the abdominal wall along the marked points on both sides of the longitudinal axis of the mesh with absorbable nails using a nail gun (Figure 2F).
- For the control group, flatten the mesh to cover the abdominal wall defect and fix the mesh using the double-loop mesh fixation method9,14.
- For the double-ring fixing method, do not mark the mesh.
- First, place the fixing nails along the edge of the mesh to ensure that the distance between the nails and the edge of the mesh is about 2-4 mm and that the distance between the nails is about 2-3 cm.
- Then, fix the mesh along the outer edge of the hernia ring defect about 2 cm away from it, with a distance between the nails of 3-5 cm
NOTE: See Figure 3A-D for this method.
5. Follow-up
- Perform postoperative follow-up, including outpatient visits and telephone consultations, for 3 months to 24 months.
NOTE: In this study, the median follow-up time was 12 months. A physical examination and abdominal wall color ultrasound were performed in the first month after the operation, and an abdominal CT was performed at 3 months, 12 months, and 24 months after the operation.The follow-up time was 24 months after the operation.After all the follow-ups, the case data were collected and compared. - Record the occurrence of seromas, hernia recurrence, chronic pain, and mesh infection.
Seroma can be diagnosed by an abdominal wall color ultrasound, hernia recurrence and mesh infection by an abdominal CT, and chronic pain by a pain rating scale.In particular, carry out an abdominal CT examination with patients 3 months after surgery, and then compare the results with the preoperative abdominal CT images to evaluate the surgical treatment effects and whether there is a recurrence of the incisional hernia (Figure 4A-F).
6. Statistical analysis
- Compare the time required for mesh placement, seroma formation, mesh infection, hernia recurrence, chronic pain, the length of hospital stay, and the hospital costs between the two groups.
NOTE: In this study, the measurement data (age, BMI, disease time, mesh placement time, length of hospital stay, and hospitalization costs) were expressed as mean ± standard deviation, and the count data (gender, maximum defect of the hernia ring, seroma, mesh infection, hernia recurrence, and chronic pain) were expressed as a count and percentage. - Compare the measurement data between the groups using a t-test, and compare the count data using a chi-square test. A value of P < 0.05 was considered to indicate a statistically significant difference in this study.
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Representative Results
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.
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Discussion
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.
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Disclosures
The authors have no conflicts of interest to disclose.
Acknowledgments
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).
Materials
| Name | Company | Catalog Number | Comments |
| 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 |
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