Laparoscopic Ventral Hernia –

Suturing With Onlay Mesh

Repair
 BACKGROUND

• Laparoscopic repair of incisional abdominal hernias was

first reported in 19931 – “tension-free” technique
• We started laparoscopic ventral hernia repair in 1995
• First 254 cases by the “tension-free” technique.
• 10 (3.9%) recurrences and 33 (13%) seroma formation

LeBlanc KA, Booth WV. Surg Laparosc Endosc 1993.

 ETHNIC POPULATION

• Physiognomy of Indian population, especially women:

– Pendulous lower abdomen.
– Poor abdominal muscle tone.

• Thus, two problems manifested themselves post-op.:

1. Poor contour of the lower abdomen.
2. Poor abdominal muscle functioning – c/o difficulty in
getting up from supine position ; abdominal
muscular pain on exertion.
 SUTURED CLOSURE

• From 2000 onwards, we started suturing the

defect with non-absorbable material before fixing
a mesh with intra-corporeal suturing techniques.
Total number of incisional hernias 721
Recurrent incisional hernias 185 (25.7%)
Previous meshplasty 93 (12.9%)
More than one prior hernia repairs (range: 2-7) 23 (3.2%)
Supra-umbilical: Infra-umbilical 138:583
Multiple fascial defects 159 (22.1%)
Single fascial defect 562 (77.9%)
Hernia contents
265 (36.8%)
Nil
384 53.3%)
Omentum
72 (9.9%)
Bowel

Incarcerated hernias 22 (3.1%)

 RATIONALE

1. 4-5 cm. overlap can be achieved on either side of the

defect by using 9-10 cm. wide mesh.

2. Potential dead space decreased & segregated from

peritoneal cavity, decreasing chances of seroma
formation.

3. In case abdominoplasty/ mini-lap for adhesiolysis

required, mesh is separated from abdominal incision
by closure of defect, thus decreasing risk of mesh
infection.
 PRINCIPAL RATIONALE

4. Defects in midline or paramedian - detachment of origin

or insertion of muscles of abdominal wall.

Sutured closure of the defect muscles are re-

attached to their point of insertion or origin this
aids in proper functioning.
 TENSION-FREE REPAIR

• Tension-free repair is meant for ing. hernia:

– In inguinal hernia, conventional repair entails forcibly
suturing musculo-tendinous structure in an unnatural
positon.
– In sutured closure of ventral hernia, the muscles are
re-attached to their natural points of origin or
insertion.

• Not suturing the defect is unphysiological

 ANALOGY

FOR A RUPTURED TENDON OF BICEPS MUSCLE

YOU WOULD RE-ATTACH THE TENDON TO ITS INSERTION
WHY NOT APPLY THE SAME PRINCIPLE
FOR A RUPTURED INSERTION (OR ORIGIN)
OF ABD. WALL MUSCLE?
 OTHER TECHNICALITIES

• Surgeon stands at the head end of the pt. for

infra-umb defects
– Advantages:
• Triangulation.
• Most of the defects are vertically oriented – both sides of
the adhesions visible with angled scope – inadvertent
bowel injury avoided.
• Standardized port positions
• Defect closure with polyamide 1 ( Ethilon ® )

• Mesh used is Parietex® (Sofradim, France) – 90%

or Goretex ® (WL Gore and Associates, USA) – 10%
 MESH CONFIGURATION
MESH SIZE – 10 X 15 Cms.

Intracorporeal sutures – polyester (Ethibond®)/ polydiaxanone (PDS®)/

polygalactin (Vicryl®)
Tacking sutures – polyamide (Ethilon®)
 OTHER TECHNICALITIES

• We do not use tackers for mesh fixation:

– Not cost-effective
– Experimental evidence: Tensile strength with sutures
is 2.5 times that with tackers.1

1.van’t Riet M, et al. Surg Endosc 2002

 OTHER TECHNICALITIES

• Difficult bowel adhesions:

– Small mini-lap incision extra-corporeal
adhesiolysis bowel replaced fascia closed
pneumoper. induced & lap. repair.
– Advantages:
• No skin flaps.
• 3-4 cms. skin incision – minimum pain.
• Hospital stay not prolonged
– N = 20 (2.8%).
 OTHER TECHNICALITIES

• Pendulous abdomen
– After laparoscopic suturing of defect and mesh
placement, abdominoplasty done.
– Advantages:
• No skin flaps no drain/flap necrosis.
• By suturing the defect, the mesh is segregated from the area
of abdominoplasty reduced risk of mesh infection.
• Absence of drain + reduced incidence of wound infection
short hospital stay.
– N = 28 (3.9%)
 OTHER TECHNICALITIES

• Suprapubic midline hernias:

– Peritoneal flap raised (as in TAPP) to create
preperitoneal space upto the pubic symphysis.
– Defect closed with continous sutures.
– Double mesh placed outer polypropelene
mesh
covered by inner Parietex/Goretex mesh
 RESULTS

Average operating time in min. (range) 95 (60-115)

Return of bowel function (days) 1.5

Average hospital stay in days (range) 2 (1-6)

Resumption of normal routine work (days) 6

 RESULTS

Seroma 55 (7.6%)

Lower respiratory tract infection 7 (1%)

Trocar site hematoma 6 (0.8%)

Bowel injury – full thickness 2 (0.3%)

Bowel injury - seromuscular 2 (0.3%)

Recurrences 4 (0.6%)

Total 78 (10.8%)
 RESULTS - Seroma

• Seroma formation: Most common complication – 7.6%

• Aspirated if it seroma persisted beyond 8 weeks, which
happened in 22 patients (3%)
• In 9 (1.2%) patients, more than 1 (2-5) aspiration was
required
• Of these, 4 patients required placement of a drainage
tube under local anasthesia, which could be removed
after the effluent decreased (range: 6-18 days).
• One pt. required excision of an seroma with sac after 12
weeks
 RESULTS - Seroma

Author Year Total no. of pts. Seroma (%)

LeBlanc1 2003 200 15 (7.5)

Carbajo2 2003 270 32 (11.8)

Sanchez3 2004 85 8 (9.4)

Palanivelu 2006 721 55 (7.6)

1. LeBlanc KA, et al. Hernia 2003

2. Carbajo MA, et al. Surg Endosc 2003
3. Sanchez LJ, et al. Hernia 2004
 RESULTS - Recurrence
• 4 recurrences
• In 3 cases, recurrences were by side of mesh - through new defects
- false recurrences
• In the last case,
– the pt had 2 previous abdominal surgeries: through low pfannensteil
incision & vertical midline subumbilical incision.
– Lap sutured IPOM repair of incisional hernia in the vertical midline scar.
– Subsequently, the patient developed hernia in lateral part of the
pfannensteil incision
• Case for using a large mesh covering all potential sites of defects in
selected patients:
– Weak surrounding fascia
– Scarred abdomen
 RESULTS - Recurrence

Author Year Total no. of pts. Seroma (%)

LeBlanc1 2003 200 13 (6.5)

Carbajo2 2003 270 12 (4.4)
Sanchez3 2004 85 3 (3.5)
Palanivelu 2006 721 4 (0.6)

1. LeBlanc KA, et al. Hernia 2003

2. Carbajo MA, et al. Surg Endosc 2003
3. Sanchez LJ, et al. Hernia 2004
 RESULTS - Pain

• All patients receive oral diclofenac (50 mg. bid) for 5 days.
• Analgesic requirement beyond 5 days in 68 patients (9.4%).
• Sharply localized lateral pain.
• ? Due to neural entrapment by the tacking sutures or fixation
transfascial sutures

CHANGE IN TECHNIQUE – CENTRAL TACKING SUTURES

ONLY
• We have found pain to be less in intensity and duration in the central
tacking sutures group of pts.
 RESULTS - Costs

• To improve cost-effectiveness:
– Largest Parietex ® mesh – 30 X 20 cms. – cut into 2-4
pieces – each piece sterilized with Sterrad ®
(peroxide-based) sterilization system
– Intracorporeal sutures instead of tackers
– Use of reusable autoclavable instruments
 EXCEPTIONS

• Only closure of defect, no mesh:

1. Small (< 3 cm. defect) with strong surrounding fascia.
However, if surrounding fascia is weak, place a mesh.
2. Women who have not completed child-bearing.

• Only mesh, no closure of defect:

1. Multiple ‘swiss cheese’ defects.
2. Thinned out surrounding fascia, not strong enough to bear
sutures.
3. Scarred fascia with fibrosis due to multiple prior laparotomies.
 REPRODUCIBILITY

• 4 Consultants & 12 Registrars trained over the last 5

years.
– After a median of 5 supervised surgeries, all could perform
independently.
– The operative time was related to the amount of laparoscopic
experience.
– Senior’s help was sought for difficult cases as defined by:
• Very large hernia.
• Dense bowel adhesions.
– Initially, intracorporeal knotting is difficult. So, intracorporeal
suturing with extracorporeal knotting can be done.
 CONCLUSION
• With the tech. of laparoscopic sutured closure of defect
with intraperitoneal onlay mesh repair, it is possible:
– To reduce the recurrence rate to very low level
– To minimise morbidity
• Seroma formation
• Persistent post-operative pain
– To regain abdominal wall domain, to improve the function.
– To improve the cosmesis
• Avoid skin incision
• Revision scar
• Abdominoplasty
– To resume routine work early
 CONCLUSION

• Laparoscopic sutured closure of ventral hernia defects

followed by IPOM placement is a physiologically,
logically and functionally sound repair
• It gives good results as far as seroma formation, mesh
infection and recurrences are concerned
• Requires ability to carry out intracorporeal suturing in
upside-down position – “practice makes perfect”
THANK YOU