Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair

Summary

Here, we present a protocol to introduce a new peritoneal suture method. This method is called straight-needle, three-tailed, knot-free suture, and we will outline the manufacturing method and clinical application of this suture in detail.

Abstract

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is placed, the peritoneum must be resutured to avoid contact with the tissues and organs in the abdominal cavity. If the peritoneal suture time is too long, the operation and anesthesia time will be prolonged, increasing the burden on the patient. Moreover, improper suture methods cause serious consequences, such as intestinal obstruction and mesh infection.

The straight-needle suture method transforms the three-dimensional spatial configuration of the needle holder and the arc needle tip into a two-dimensional planar structure, which greatly reduces the difficulty of suturing. The three-tailed knot can be anchored at the beginning of the suture by its friction and button effect, which has an exact fixation effect. Thus, the suture does not easily slip, and the time to complete the suturing is shortened. Compared with the traditional suture method, the operator can suture the peritoneum more quickly, beginners can pass through the difficult learning curve faster, and skilled operators can also shorten the total operation time of TAPP to a certain extent. Thus, this suture method is extremely amenable to clinical application.

Introduction

Laparoscopic transperitoneal preperitoneal hernia repair is the main method of inguinal hernia repair¹. This approach has a short learning curve, allows complete observation of the inguinal anatomy, and is widely applied in the clinic^2,3. However, this operation requires a peritoneal incision, and after the placement of the mesh, the peritoneum must be sutured to prevent direct contact between the mesh and the organs in the abdominal cavity and avoid complications such as mesh erosion or adhesive intestinal obstruction^4,5.

There are many methods for peritoneal suture. At present, the traditional clinical method is to use absorbable sutures with continuous suturing. As the incised peritoneum is located in the anterior abdominal wall, the angle of the suture needle needs to be continuously adjusted during suture, and knots need to be tied at the beginning and end of each suture⁶. This suture method requires more time and more skilled endoscopic skills, and beginners require an extended practice period^7,8.

Thus, we designed a new method to improve the suturing process using straight-needle, three-tailed, knot-free sutures. The basic principle of this method is to use the two-dimensional structure of the straight needle and the anchoring effect of three knot-free tails in the process of suture to reduce the number of steps and the difficulty of suture. Having used this suture many times and compared it to the traditional method, we determined that this method is simple, easy to learn, safe and effective, with a low incidence of complications, and convenient for clinicians to use.

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.

1. Data and grouping

NOTE: From December 2018 to December 2020, laparoscopic TAPP was performed during gastrointestinal, hernia, and abdominal surgery at the Sixth Affiliated Hospital of Sun Yat-sen University. A total of 264 patients with inguinal hernia met the criteria and were included in the study.

1. Select adult and unilateral inguinal hernia patients for the surgery.
2. Apply the following exclusion criteria: recurrent hernia and bilateral hernia; incarcerated or strangulated hernia; other diseases such as ascites, connective tissue disease, heart/kidney failure, and hypoproteinemia; and the use of aspirin, clopidogrel, or other drugs that affect coagulation function.
3. Divide the patients randomly into an experimental group and a control group.
   NOTE: In this study, 134 cases were assigned to the experimental group and 130 cases to the control group. The general conditions of the two groups, including age, sex, BMI, hernia type, and hernia sac treatment, are shown in Table 1.
4. Assign two groups of surgeons from the same team who have received standardized training to perform the surgery.
   ​NOTE: In this study, the two groups of surgeons were experienced, laparoscopic surgeons. Ensure that there is no significant difference between the two groups (P > 0.05).

2. Method for generating the straight-needle, three-tailed knot

1. Straighten the needle of 3-0 VICRYL thread 1/2 round needle with an ordinary needle base.
2. Make the thread tail according to the sequence shown in Figure 1A-F.
   1. Overlap two threads to make a single knot and then tighten the knot.
   2. Pass one of the threads into the knot ring of the first knot.
   3. Lay the tail at both ends against the first knot and then make the second knot.
   4. Tighten the knot.
   5. Leave the tail at one end of the needle (~12 cm long); cut off the ring and the tail at the other end. Ensure that the length of the remaining three tails is ~0.8 cm.

3. Suture method

1. Suture the control group continuously with a 12 cm long, conventional 1/2 circle curved needle and 3-0 VICRYL absorbable suture.
2. In the experimental group, make three knot-free sutures as described above, and suture the peritoneum continuously.
3. Sew the three tails of the straight needle into the peritoneum (Figure 2A).
4. Hold and fix the straight needle using forceps grasped in the left hand.
5. Press the straight needle directly into the upper and lower abdominal membranes (Figure 2B; approximately 0.8 cm needle pitch).
6. Repeat the above actions and sew 8-10 stitches continuously (Figure 2C).
7. Repeating the joint actions of grasping the forceps and holding the needle, tighten the 8-10 needles (Figure 2D) until the whole peritoneal incision is closed.
8. Tighten the suture after sewing (Figure 2E).
9. Tie or fix the end of the suture with an absorbable clip (Figure 2F).

4. Follow-up

1. Complete the postoperative follow-up with outpatient visits and telephone conferences for 3-24 months.
   NOTE: The median follow-up time was 12 months in this study.
2. Record the occurrence of seroma, recurrence, and mesh infection.

5. Statistical analysis

1. Perform statistical analysis on peritoneal suture time, operation time, hernia recurrence, seroma, mesh infection, visual analog scale (VAS) score, length of hospital stay, and hospitalization expenses.
2. Express data as mean ± standard deviation (SD) and rates.
3. Compare the measurement data between groups using a t-test and the observation rate indices using a chi-square test.
4. Consider a difference to be statistically significant if P < 0.05.

Results

After the placement of the mesh, the incised peritoneum needs to be sutured again. Straight-needle, three-tailed, knot-free sutures were used for the peritoneal suture in the experimental group. The specific suture method has been described in detail in section 3 of the protocol (Figure 2). The control group was sutured with VICRYL suture or barbed suture with an arc needle. The two groups were compared with respect to suture times, operation times, hernia recurrence, mesh infection, seroma,...

Discussion

As the primary method of laparoscopic hernia repair, TAPP is widely used in the clinic. The main challenge in this operation is the suturing of the peritoneal incision. There is no standard suture method for the TAPP peritoneal incision. Some nonstandard methods lead to postoperative complications, such as inaccurate sutures and contact between the intestinal canal and mesh, resulting in postoperative intestinal adhesion and perforation; improper suturing or knotting; and intestinal canal invasion of the anterior periton...

Materials

Name	Company	Catalog Number	Comments
3-0 VICRYL suture	ETHICON	VCP316	absorbable suture
3D MAX MESH	BARD	117321	Inguinal hernia repair mesh
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