Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

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 recovery^2,3. 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 infection^7,8. 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.

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.

1. 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).
2. 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

1. 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.
2. For a giant incisional hernia, use preoperative botulinum toxin A (BTA) and preoperative progressive pneumoperitoneum (PPP) for the surgical preparation¹¹.
3. 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.
   1. 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.
4. 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.
5. 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.
6. Establish carbon dioxide pneumoperitoneum, and maintain the pneumoperitoneum pressure at 13 mmHg.
7. Explore the whole abdominal cavity, evaluate the degree of abdominal adhesion around the hernia ring, and separate the adhesion.
8. 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

1. 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.
   1. 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.
   2. Place the ruler parallel to the longitudinal axis of the hernia defect, and measure the maximum longitudinal length of the defect (Figure 1B).
   3. 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).
   4. 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).
   5. Mark the nail gun fixation points evenly every 2-3 cm along the edge of the mesh, which pertains to the "contraposition" (Figure 1E).
   6. 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

1. 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).
2. Reduce the pneumoperitoneum pressure to 8-10 mmHg.
3. Ensure that the marked line of the unrolled mesh overlaps the longitudinal axis of the hernia ring defect (Figure 2C).
4. 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).
5. 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).
6. 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).
7. For the control group, flatten the mesh to cover the abdominal wall defect and fix the mesh using the double-loop mesh fixation method^9,14.
8. For the double-ring fixing method, do not mark the mesh.
   1. 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.
   2. 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

1. 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.
2. 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

1. 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.
2. 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.

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 m...

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...

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