HOW I DO IT DIFFERENTLY
|Year : 2018 | Volume
| Issue : 2 | Page : 168-170
Sewing machine technique for laparoscopic mesh fixation in intra-peritoneal on-lay mesh
Khojasteh Sam Dastoor1, Kaiomarz P Balsara2, Asif Y Gazi3
1 Department of GI & Laparoscopic Surgery, Bhatia Hospital, Mumbai, Maharashtra, India
2 Department of GI & Laparoscopic Surgery, Breach Candy Hospital, Mumbai, Maharashtra, India
3 Department of GI & Laparoscopic Surgery, Saifee Hospital, Mumbai, Maharashtra, India
|Date of Submission||19-Jun-2017|
|Date of Acceptance||29-Aug-2017|
|Date of Web Publication||12-Mar-2018|
Dr. Khojasteh Sam Dastoor
Bhatia Hospital, Tardeo, Mumbai - 400 007, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Mesh fixation in laparoscopic ventral hernia is accomplished using tacks or tacks with transfascial sutures. This is a painful operation and the pain is believed to be more due to transfascial sutures. We describe a method of transfascial suturing which fixes the mesh securely and probably causes less pain.
Method: Up to six ports may be necessary, three on each side. A suitable-sized mesh is used and fixed with tacks all around. A 20G spinal needle is passed from the skin through one corner of the mesh. A 0 prolene suture is passed through into the peritoneum. With the prolene within, the needle is withdrawn above the anterior rectus sheath and passed again at an angle into the abdomen just outside the mesh. A loop of prolene is thus created which is tied under vision using intra-corporeal knotting.
Conclusion: This method gives a secure mesh fixation and causes less pain than conventional methods. This technique is easy to learn but needs expertise in intra-corporeal knotting.
Keywords: Intra-peritoneal on-lay mesh, laparoscopic ventral hernia, mesh, pain, sewing machine, transfascial sutures
|How to cite this article:|
Dastoor KS, Balsara KP, Gazi AY. Sewing machine technique for laparoscopic mesh fixation in intra-peritoneal on-lay mesh. J Min Access Surg 2018;14:168-70
| ¤ Introduction|| |
Laparoscopic intra-peritoneal on-lay mesh (IPOM) has gained acceptance as the preferred method for repair of incisional hernia., Being minimally invasive, it has the advantage of forming less post-operative adhesions, less wound infection and shorter hospital stay as compared to open surgery. The recurrence rates are also low, about 10% or less, and patient satisfaction scores are high.
Pain, however, still remains a problem post-operatively. The pain is usually self-limiting and is said to be chronic pain if it goes beyond 8 weeks. The most standard method of mesh fixation involves tacks and transfascial sutures. Both these cause pain., Probably, transfascial sutures cause more pain than the tacks, due to nerve entrapment or ischaemia of the entangled muscles and sutures pulling on the abdominal wall when patients move from side to side. In addition, transfascial sutures can cause puckering of skin and knot placement is unpredictable, especially in obese patients.
There are various methods of taking transfascial sutures. The technique we describe herein gives a secure fixation and probably causes less pain than other conventionally described techniques.
| ¤ Methods|| |
Sixteen primary ventral hernias (11 para-umbilical and 5 epigastric) and 34 incisional hernias were repaired using laparoscopic IPOM technique. All incisional hernias were vertical mid and lower abdominal incisions. Hernias larger than 8 cm × 8 cm were not done by laparoscopy. Thirty-two were females and 18 were males; age range was 25–71 years. Mean body mass index was 28. The thickness of the rectus muscle and the musculoaponeurotic layer lateral to the rectus was measured by a computed tomography scan or a sonography in all patients. Informed consent of all patients was taken, after explaining to them that a different method of transfascial suturing would be used.
Three ports were used on the one side and an additional two or three on the opposite side. One port was 10 mm or 12 mm and all others 5 mm. The addition of 2 or 3, 5 mm ports do not significantly add to the pain in our experience. A composite mesh was used, either Ventralight ST by Bard Davol Inc. or Parietex by Covidien Surgical. The mesh size was chosen to accomplish a 4–5 cm overlap as assessed by imaging and intra-operative in a partially deflated abdomen at 8 mmHg. If possible, we used a central fixation stitch, which was drawn out through the defect to correctly place the mesh. The mesh was first fixed in position with tacks, 1.5–2 cm apart. The following describes the steps of suture placement.
- A 21G or a 20G spinal needle was inserted from the skin down through the corner of the mesh. A 2-0 or 0 polypropylene suture, 25 cm long, was introduced through the needle into the abdomen and held within the abdomen with a Maryland forceps [Figure 1]
- The spinal needle is then withdrawn about 1–2 cm, depending on the muscle thickness, as assessed by prior imaging so that it lies just anterior to the rectus sheath. The intra-abdominal end of the suture is kept in position by the Maryland [Figure 2]
- Keeping the outer end of the prolene lax, the spinal needle is re-introduced into the abdominal cavity with a slight angulation, so as to puncture the posterior sheath and peritoneum just outside the mesh and carry a loop of the suture with it [Figure 3]
- The loop is pulled with a needle holder and undone so that both ends of the suture are in the abdomen. The ends of the polypropylene suture are tied using intra-corporeal knotting, just adequately to fix the mesh, yet not cause strangulation. Before knotting, the pressure is reduced to 8 mm, so the knots do not come loose [Figure 4].
|Figure 1: A 20G spinal needle is inserted at the edge of the mesh with a 25 cm, 0 polypropylene suture along with it|
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|Figure 2: Keeping the polypropylene suture held within the abdomen, the spinal needle is withdrawn above the anterior sheath|
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|Figure 3: The spinal needle is re-introduced into the abdomen just outside the mesh, taking a loop of the polypropylene suture along with it. The loop is then undone so that both the ends of the suture are within the abdomen|
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|Figure 4: The two ends of the suture are then tied intra-corporeally so that the mesh is fixed in position|
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The procedure is repeated in all four corners and two additional sutures in the centre of the mesh, depending on the size of the mesh used.
Paracetamol intravenous 1 g 8th hourly was used for the first 24 h. From the next day, oral paracetamol 1 g thrice a day was used for 3 days and then as needed. When VAS pain scores were >5, intravenous diclofenac 75 mg was added up to 12 hourly.
| ¤ Results|| |
All patients had the procedure done by laparoscopy. The mean VAS pain score on day 1, 2 and 3 was 3.8 (range 2–6). Side-to-side movement was also comfortable in all patients. There was a patient with seroma formation at the umbilicus not requiring any intervention, 2 patients with paralytic ileus which settled conservatively in 5–6 days and no port site infections, bowel perforations or fistulisations. At the end of 1 week, all patients were free of pain and did not need analgesics. Patients were usually discharged on the 3rd post-operative day. None of the patients had chronic pain (i.e. beyond 8 weeks).
| ¤ Discussion|| |
Laparoscopic ventral hernia repair has advantages over open surgery though post-operative pain is a major drawback. The pain is most intense during the first 72 h of surgery and occasionally requires strong analgesia, but it subsides in 1 week. The cause of the pain is more likely due to the sutures than the tacks. We have described a method of mesh fixation which is akin to a sewing machine stitch, hence the title.
The advantages of this method are as follows.
- The sutures help fix the mesh with the anterior rectus sheath as desired. The certainty of the suture being at the level of the anterior sheath is more, unlike the conventional method where the suture is arbitrarily tied down to the fat or the sheath. In obese patients too, our method ensures that the fixation is to the rectus sheath, unlike in prior described methods where the knot may just lie within the fat and allow the mesh to move
- There is no dimpling at the entry sites
- The ends of the suture do not hurt the patient as they are within the abdominal cavity
- Knotting is under vision and can be controlled to be just adequate
- Spinal needles 21G and 20G are less traumatic and therefore less likely to cause haematoma.
The disadvantages of this technique are as follows:
- Up to six ports are required
- The surgeon should be adept at intra-corporeal knotting.
Our observation has been that these patients suffer less pain though, at present, we do not have any comparative study. This method also ensures good mesh fixation and prevents mesh migration.
| ¤ Conclusion|| |
We have described a method of transfascial suturing of the mesh in anterior abdominal wall hernias which causes less trauma, has better fixation, prevents mesh shrinkage and causes less pain. A larger comparative trial would be of value in evaluating this form of suturing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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Postoperative pain after laparoscopic ventral hernia repair: A prospective comparison of sutures versus tacks. JSLS 2008;12:113-6.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]