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Mesh Fixation Using Intracorporeal Suturing In Laparoscopic Ventral Hernia Repair - A Novel Technique

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                                                Mesh Fixation Using Intracorporeal Suturing In Laparoscopic Ventral Hernia Repair – A Novel Technique

                             M.Swaminathan1,DNB Trainee; S.Talwar2, MBBS, MS(AIIMS);  G.Neelankavil Davis3,DNB, MRCS; A.Kumar4, Chief Biostatistician.

1 Dept. of General Surgery, Manipal Hospitals Bangalore 2 Consultant – Minimal Access & Bariatric Surgeon, Dept. of General Surgery, Manipal Hospitals Bangalore

 3 Specialist Registrar, Dept. of General & Colorectal Surgery, Nevill Hall Hospital(UK), 4 Manipal Hospitals Bangalore

Why intracorporeal suturing?

•Challenge in mesh fixation is to balance recurrence and post operative pain after laparoscopic ventral hernia repair (LVHR)
•Time-tested methods -
Tackers: high rate of recurrence with minimal post operative pain
Transfascial sutures: low rate of recurrence with significant post operative pain
•Intracorporeal suturing can be the solution offering reliable fixation & minimal post-operative pain

Uncommonly used technique – no published study worldwide

Aim

To study the intracorporeal continuous suture mesh fixation technique , in terms of –

•operative time
•post-operative pain
•early recurrence
 

Results

•NRS pain score after 3 months was 0.4
•No post-operative complications were observed
•No recurrence of hernia upto 6 months after surgery
 

Discussion

•Intracorporeal suturing places mesh-anchoring sutures in the posterior fascia-peritoneal plane
•minimal trauma to abdominal wall
•suture knots are intraperitoneal (not intraparietal) in location and tied as ‘air knots’, preventing strangulation of tissue
•Transfascial suture transgresses all layers of abdominal wall causing nerve entrapment & muscle ischemia
•In our study, post-operative VAS scores were 13.2mm, 1.4mm and 1.2mm at 4 hours, 24 hours and 1 week, despite IV Diclofenac as pain medication
•Lower post-operative pain scores at all time intervals compared to studies of mesh repair with transfascial sutures
•Our study had no recurrences until 6 month after surgery – additional follow up period is required to ascertain long term recurrence rates
•Our study showed that intracorporeal suturing is time consuming probably due to –
•Restricted degree of freedom of the laparoscopic instruments
•Requirement of advanced skills to manoeuvre the instruments close to fulcrum of the instrument.
 

Conclusion

•Thus, intracorporeal suturing is a novel method of mesh fixation that can achieve secure fixation with reduced post-operative pain
•Advantages of intracorporeal suturing method of mesh fixation in LVHR
•Pain managed using standard post-operative painkillers
•Nominal surgical cost
•Avoidance of expensive tackers and robotic equipment
•Feasibility of mesh fixation to any part of anterior abdominal wall
•Intracorporeal suturing is an ideal procedure for a robot, but the cost of robotic surgery, at present, would make laparoscopic approach an economically viable option.
 

References

1.Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients. Journal of the Society of Laparoendoscopic Surgeons. 2000;4:141–145
2.Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic approach to incisional hernia. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2003;17:118–22.
3.Wassenaar E, Schoenmaeckers E, Raymakers J, et al. Mesh-fixation method and pain and quality of life after laparoscopic ventral or incisional hernia repair: a randomized trial of three fixation techniques. Surgical Laparoscopy Endoscopy & Percutaneous Techniques.2010;24:1296–1302.
4.Nguyen, S. Q., Divino, C. M., Buch, K. E. Postoperative Pain After Laparoscopic Ventral Hernia Repair: a Prospective Comparison of Sutures Versus Tacks. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2008;12(2), 113–116.
5.Chow S, Shao J, Wang H. 2008. Sample Size Calculations in Clinical Research. 2nd Ed. Chapman & Hall/CRC Biostatistics Series. page 58.






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