Assessment of ideal ratio of mesh area to number of fixation tacks in laparoscopic ventral and incisional IPOM Plus hernia repair.

BACKGROUND: To clarify the optimum mesh-tack ratio MTR (mesh area in cm2 divided by the number of fixation tacks) in laparoscopic ventral and incisional hernia repair, we compared IPOM Plus procedures with more intensive mesh fixation to those with standard mesh fixation. METHODS: In a retrospective cohort study, 84 patients (mean hernia width 6.6 ± 4.4 cm) intraoperatively received an intensive mesh fixation I-IPOM Plus with MTR ≤ 4:1 (e.g. ,150 cm2 mesh fixed by 50 tacks) and 74 patients (mean hernia width 6.7 ± 3.4 cm) received a standard mesh fixation S-IPOM Plus with MTR > 4:1 (e.g., 150 cm2 mesh fixed by 30 tacks) at a community hospital between 2014 and 2017. Outcomes in recurrence rates, immediate and chronic postoperative pain, as well as long-term functionality of the abdominal wall were then evaluated. RESULTS: After a mean follow-up time of 34 months, a 2.3% recurrence rate in I-IPOM Plus patients and a 13.5% recurrence rate in S-IPOM Plus patients were recorded (p = 0.018). The recurrence was associated with large hernia > 10 cm (OR 3.7, 95% CI 1.3-5.4) and MTR > 5 (OR 2.4, 95% CI 1.1-3.8) in the multivariate analysis. There was a positive correlation between immediate postoperative pain intensity measured on day 7 and number of fixation tacks placed (I-IPOM Plus: mean 4.5 ± 2.5 VAS versus S-IPOM Plus: mean 2.7 ± 2.0 VAS, p = 0.001). However, there were no outcome differences in terms of length of immediate postoperative pain experience, sick leave duration, chronic pain rate and long-term abdominal wall functionality between these two groups. CONCLUSION: For ventral and incisional hernia patients with multiple recurrence risk factors, a mesh-tack ratio MTR ≤ 4:1 should be applied in laparoscopic IPOM Plus procedures.

Comparison of mesh fixation devices for laparoscopic ventral hernia repair: an experimental study on human anatomic specimens.

BACKGROUND: As there is a lack of clarity in terms of the tensile strength of mesh fixation for laparoscopic ventral hernia repair (LVHR), our aim was to investigate the immediate tensile strength of currently available mesh fixation devices on human anatomic specimens. METHODS: Sixteen recently deceased body donators (mean body mass index of 24.4 kg/m2) were used to test the immediate tensile strength (Newton) of 11 different LVHR mesh fixation devices. RESULTS: Each of the 11 different laparoscopic fixation devices was tested 44 times. Non-articulating tackers provided higher fixation resistance to tensile stress in comparison to articulating tackers (5.1-mm ReliaTack™: 16.9 ± 8.7 N vs. 12.2 ± 5.6 N, p = 0.013; 7-mm ReliaTack™: 19.8 ± 9.4 N vs. 15.0 ± 7.0 N, p = 0.007). Absorbable tacks with a greater length, i.e. ≥6 mm (7-mm ReliaTack™, 6-mm SorbaFix™ and 7.2-mm SecureStrap™) had significantly higher fixation tensile strength than tacks with a shorter length, i.e. < 6 mm (5.1-mm ReliaTack™ and 5.1-mm AbsorbaTack™) (p < 0.001). Furthermore, transfascial sutures (PDS 2-0 sutures 26.3 ± 5.6 N) provided superior fixation tensile strength than 5.1-mm AbsorbaTack™ (13.6 ± 7.3 N) and cyanoacrylate glues such as LiquiBand FIX8™ (3.5 ± 2.4 N) (p < 0.001, respectively). There was a significant deterioration in fixation capacity in obese body donators with a body mass index > 30 kg/m2 (13.8 ± 8.0 vs. 17.9 ± 9.7 N, p = 0.044). CONCLUSIONS: Although articulating laparoscopic tackers improve accessibility and facilitate the utilization of tacks within the fixation weak spot adjacent to the trocar placement, an articulating shaft that is not ergonomic to use may limit mechanisms of force transmission. For mesh fixation in LVHR, transfascial sutures and tacks with a longer length provide better immediate fixation tensile strength results.

Needlescopic Surgery Versus Single-port Laparoscopy for Inguinal Hernia.

BACKGROUND AND OBJECTIVES: In recent years, 2 modifications of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair-needlescopic (nTAPP) surgery and single-port (sTAPP) surgery-have greatly improved patient outcomes over traditional approaches. For a comparison of these 2 modifications, we sought to investigate and compare the extent of surgical trauma and postoperative consequences for the abdominal wall in these two procedures. METHODS: In a retrospective study, 50 nTAPP and 35 sTAPP procedures occurring at a community hospital from November 1, 2009, through July 31, 2012 were reviewed. Intraoperative data, including length of the umbilical skin incision and operative time, were recorded. A follow-up evaluation included investigation of hernia recurrence, postoperative pain, abdominal wall mobility, cosmetic satisfaction, and period of sick leave. RESULTS: The mean umbilical skin incision was 13 ± 4 mm in nTAPP vs 27 ± 3 mm in sTAPP (P < .001). The nTAPP procedure required less operating time than the sTAPP procedure (54.8 ± 16.9 minutes vs 85.9 ± 19.7 minutes; P < .001). The mean immediate postoperative pain score on the visual analog scale was 2.7 ± 2.1 in the nTAPP group and 4.4 ± 1.9 in the sTAPP group (P = .016). In addition, patients who underwent nTAPP had a shorter period of sick leave (11.2 ± 8.4 days vs 24.1 ± 20.1 days; P = .02). At the follow-up evaluation after approximately 30 months, abdominal wall mobility and cosmetic satisfaction were equally positive, with no hernia recurrence. CONCLUSION: In patients with uncomplicated inguinal hernia, the nTAPP procedure, with less surgical trauma and operating time, has distinct advantages in reduction of immediate postoperative pain and sick leave time.

The application of the V-Loc closure device for gastrointestinal sutures: a preliminary study.

BACKGROUND: Leakage is one of the major complications in gastrointestinal surgery. This preliminary study compared a new barbed absorbable thread for gastrointestinal sutures with monofil suture material in a cadaver model. METHODS: In this study, mechanical experiments were performed in 20 recently deceased individuals. Incisions were made in the small intestine, colon, and stomach, and then sutures were created with the V-Loc closure device and monofil suture material. Intestinal bursting pressure was measured by inserting a balloon and slowly filling it with air until there was a dehiscence, or wall or suture rupture. RESULTS: The bursting pressures differed significantly between the two sutures in the small intestine, showing the advantage of the V-Loc closure device, which had a mean bursting pressure of 116.2 mmHg compared with 110 mmHg for the monofil suture (p = 0.003). The mean bursting pressure did not differ significantly between the two sutures in the colon and the stomach. The mean bursting pressures for the V-Loc closure device were 141.3 mmHg (stomach) and 137.2 mmHg (colon) compared with the monofil suture material bursting pressures of 133 mmHg (stomach) and 134.8 mmHg (colon). CONCLUSIONS: Because the bursting strength of the sutures created with monofil suture material differs significantly from that of the V-Loc closure device, the V-Loc suture material should be used for gastrointestinal sutures. Although the two sutures did not differ significantly in the colon or the stomach, the V-Loc closure device should be used for these as well because its advantages may overrule those of the monofil suture. No knot tying is required, and the operating time can be shorter. Especially for laparoscopic surgery, the V-Loc closure device is recommended.

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy--what to do?

BACKGROUND: Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects. METHODS: A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs. RESULTS: Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias. CONCLUSIONS: When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results.

Anatomical changes after inguinal hernia treatment: a reason for chronic pain and recurrent hernia?

BACKGROUND: Chronic pain and hernia recurrence are the most frequent long-term complications of treating inguinal hernia. One reason may be postsurgical changes in the anatomy of the groin. METHODS: In a retrospective investigation from 1994 to 2008, 1,194 patients undergoing 1,421 laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphies were studied. Anatomical structures in the groin, seen in 1,214 primary and 207 recurrent hernias, were charted by means of video analysis. Hernia orifices, myopectineal orifice (MPO), and Hesselbach's and Hessert's triangles were measured in their respective vertical and horizontal diameters in order to calculate the surface area. Other anatomical changes were also recorded. RESULTS: The mean surface area of hernial orifices was 3.00 +/- 2.01 cm(2) in primary hernias and 3.60 +/- 3.81 cm(2) in recurrent hernias. The mean surface area of Hesselbach's triangle was 4.23 +/- 2.21 cm(2) in the former group and 2.09 +/- 2.10 cm(2) in the latter (p < 0.0001). The mean surface area of Hessert's triangle in primary hernias (9.03 +/- 6.17 cm(2)) was significantly larger than that in recurrent hernias (3.11 +/- 3.67 cm(2); p < 0.0001). Further anatomical changes in suture-treated recurrent hernias included a dislocated spermatic cord, a raised inguinal ligament, and asymmetry in the region. CONCLUSION: The treatment of inguinal hernia by the suture technique is followed by significant anatomical changes such as reduction of the surface area and a subsequent increase of tension in the inguinal region. This could be one of the main reasons for chronic pain and hernia recurrence.

Tensile strength and adhesion formation of mesh fixation systems used in laparoscopic incisional hernia repair.

BACKGROUND: Mesh tearoff from the tissue is the most common reason for hernia recurrence after hernia surgery involving the use of a synthetic mesh. Various fixation systems were critically compared in terms of their retention strength and the formation of adhesions. METHODS: In a prospective study with 25 Sprague-Dawley rats, two pieces of Parietex composite meshes measuring 2 x 3 cm were fixed intraperitoneally in a paramedian location. The randomized mesh fixation groups included transfascial fixed suture, ProTack, AbsorbaTack, and I-Clip. Of the 25 rats, 12 were killed and analyzed 1 week after implantation, with the remaining 13 rats killed and analyzed after 2 months. Adhesions observed at the time of mesh removal were measured according to an adhesion scoring system, and the fixation strengths of the individual fixation systems were tested. Additionally, the foreign body reaction to the mesh and fixation systems was measured as well as their potential degradation. RESULTS: After 1 week, the retention strength of transfascial fixed suture was significantly higher (8.7 N/cm(2)) than that of ProTack (5.6 N/cm(2)) or AbsorbaTack (5.7 N/cm(2)). After 2 months, the retention strength had increased to 13.2 N/cm(2) in the transfascial fixed suture group, which was significantly higher than in the ProTack (9.7 N/cm(2)) or AbsorbaTack (8.7 N/cm(2)) groups. In contrast, the mesh could be fixed with the I-Clip only in 56% of the cases, and then achieved rather poor retention strength. Adhesion was significantly greater in the ProTack group than in any of the other groups (p < 0.001). At 2 months, scanning electron microscopy showed only marginal degradation of the absorbable elements. CONCLUSIONS: Suture fixation led to satisfactory attachment of the prosthesis. Additional widespread anchorage of the mesh was achieved with ProTack or AbsorbaTack. The feasibility and retention strength of the I-Clip were poor.

Influence of a new self-gripping hernia mesh on male fertility in a rat model.

BACKGROUND: The number of mesh-based therapies of inguinal hernias is increasing compared with the classical suture techniques such as Shouldice and Bassini. Many different types of meshes with regard to material, pore size and surface coating are available. A recently offered mesh (Parietene Progrip) combines the properties of a standard lightweight polypropylene mesh with a whole surface fixation by incorporation of micro hooks. Therefore, additional fixation elements such as screws, tacks or clips become redundant when using this material. However, in treated male patients the micro hooks will also come into contact with the ductus deferens. As the sensitivity of this structure is known, the question arises of whether this new self-gripping mesh might damage susceptible tissue layers and impair male fertility. METHODS: Two different meshes, a standard lightweight polypropylene mesh (Parietene-Light) and a new self-gripping polypropylene mesh (Parietene Progrip) with absorbable micro hooks were wrapped surgically around the prepared ductus deferens of each of ten Sprague-Dawley rats. In five control rats ducts were only separated bluntly from adherent tissue. After 2 months rats were sacrificed and implants were recovered together with the ductus deferens for histology and electron microscopy. RESULTS: Samples from all animals showed an unrestricted lumen of the ductus deferens. Only minor inflammatory reactions with some infiltrating cells could be observed. Giant cells were present around the mesh fibres. Scanning electron microscopy revealed no degradation of the material surface after 2 months of implantation. CONCLUSION: The new self-gripping mesh showed no harmful influence on the ductus deferens in the rat model. Considering the larger dimensions of the ductus deferens in humans any detrimental effect on the exposed tissue can be excluded. The surface of the fibres was not subjected to material degradation.

Comparison of a new self-gripping mesh with other fixation methods for laparoscopic hernia repair in a rat model.

BACKGROUND: Microhooks are small structures on the surface of the Progrip (PG; Sofradim Corp) mesh to ensure its anchorage in tissue. Additional fixation is not required. The aim of this animal study was to compare the strength of incorporation, foreign body reaction, and changes in material after implantation of this novel mesh with the current fixation alternatives, namely the hernia stapler (HS) and fibrin glue (FG). STUDY DESIGN: Forty Sprague-Dawley rats were used in this two-phase, prospective randomized study. Polypropylene meshes (Parietene light; Sofradim Corp) were positioned bilaterally on the abdominal muscle. The randomized mesh fixation groups were named HS, FG, PG, and UM (unfixed mesh). Half of the rats in each group were sacrificed and analyzed 5 days after implantation, and the second half were sacrificed and analyzed after 2 months. Measured parameters were strength of incorporation, foreign-body reaction to, and potential degradation of, mesh and fixation systems. RESULTS: After 5 days, strength of incorporation was substantially higher for PG (3.2 N/cm(2)) and HS (2.7 N/cm(2)) compared with FG (0.9 N/cm(2)) or UM (1.5 N/cm(2)). After 2 months, PG had a much greater strength of incorporation (14.8 N/cm(2)) compared with all other groups (HS 11.7 N/cm(2); FG 11.4 N/cm(2); UM 8.7 N/cm(2)). Inflammatory reactions were considerably more severe after 5 days than after 2 months. No significant differences in foreign-body reactions were found between groups. At neither time point were signs of degradation detected by scanning electron microscopy. CONCLUSIONS: PG demonstrated a substantially stronger strength of incorporation in muscle tissue compared with other fixation systems and is an economic alternative to HS or FG. Laparoscopic mesh placement of PG requires some practice because of the microhooks. Clinical studies will have to be performed before the value of this mesh can be established for laparoscopic application.

Biomechanical properties of lightweight versus heavyweight meshes for laparoscopic inguinal hernia repair and their impact on recurrence rates.

BACKGROUND: Laparoscopic inguinal hernia repair can be performed using light- or heavyweight meshes. Apart from the size of the mesh, its friction coefficient (mu(0)) and flexural stiffness are of crucial importance to avoidance of hernia recurrence. METHODS: In the current biomechanical study, tensile tests were performed to determine the ultimate tensile strength and modulus of elasticity of six lightweight meshes and six heavyweight meshes for laparoscopic inguinal hernia repair. To determine their friction coefficient (mu(0)), the meshes were placed between a resected peritoneum and groin muscles during an autopsy. Meshes measuring 15 x 10 cm in size then were used in a hernia model with an opening size of 1.5, 3, or 5 cm. RESULTS: The ultimate tensile strength and modulus of elasticity were significantly lower in the lightweight mesh group than in the heavyweight mesh group. The mean friction coefficient (mu(0)) of the meshes was 0.4. Given an opening of 1.5 cm, all meshes remained adequately stable. At opening sizes of 3 and 5 cm, the lightweight meshes flexed on the average by 3.16 +/- 0.4 mm and 10.40 +/- 2.5 mm, respectively. Heavyweight meshes, on the other hand, were significantly less flexible. Their mean flexure was, respectively, 0.34 +/- 0.2 mm and 3.97 +/- 0.7 mm (p < 0.001). CONCLUSION: Stable meshes are characterized by a small degree of flexure and do not slide into the gap even when subjected to repetitive loads. Therefore, in terms of hernia recurrence, meshes with greater flexural stiffness or well-fixed lightweight meshes that adequately overlap the hernia defect can be used for laparoscopic treatment of large inguinal hernias.

Preliminary results with the reinforced tension line: a new technique for patients with ventral abdominal wall hernias.

BACKGROUND: After median laparotomy, excessive horizontal tensile forces on the suture base or scar tissue lead to incisional hernias or recurrent hernias. Our new suture technique, known as reinforced tension line (RTL), allows peak tensile forces to be distributed from the suture base to the surrounding tissue through a longitudinal suture, thereby preventing the suture from cutting through the tissue. METHODS: From April 2002 to April 2005, the RTL technique was used to treat 103 patients with ventral abdominal wall hernias > or = 3 cm in size. In patients with larger hernias, tensile forces were measured intraoperatively. Patients with tensions > or = 40 N during fascial closure were excluded from the study. Comorbidities, as well as intraoperative and postoperative complications, were recorded. Early and late complications were monitored during a follow-up period of 12 to 48 months. RESULTS: Tensile loads > or = 40 N in the fascia were recorded in 7 of 103 patients. The 7 patients were treated with mesh prostheses and excluded from the study. The mean age of the remaining 96 patients was 64 years, and the mean size of the hernial orifice was 58 cm2 (range 7-211 cm2). Twenty-eight patients with hernias underwent acute surgery. No intraoperative complications were encountered. After surgery, 5 patients developed hematomas that did not require revision surgery. Five asymptomatic recurrences (5.5%) were diagnosed during a mean follow-up period of 32 months. CONCLUSIONS: The use of RTL allows the loads impinging on the suture base to be distributed over the surrounding tissue. Rupture of the thread from the suture base is prevented, and abdominal wall hernias can be treated effectively. Particularly in cases of acute surgery or contamination of the surgical area, or in the presence of other contraindications for using mesh, the RTL technique is an excellent alternative to mesh repair. These favorable preliminary results must be evaluated in further investigations.