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Triple-step laparoscopic incisional hernia repair: midline suture closure supported by dorsal component separation and intraperitoneal onlay mesh reinforcement.

Strey CW - World J Surg (2014)

Bottom Line: Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function.It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling.This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Visceral and Vascular Surgery, Diakoniekrankenhaus Friederikenstift, 5 Humboldtstrasse, 30169, Hannover, Germany, strey@gmx.de.

ABSTRACT
Incisional hernias remain a surgical challenge when balancing surgical morbidity, functional restoration, and risk of recurrence. Laparoscopic intraperitoneal onlay mesh (IPOM) placement reduces postoperative wound infections and allows fast patient recovery. Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function. We propose a novel triple-step hernia repair technique that includes tension-free midline reconstruction. It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling. Combining dorsal abdominal wall component separation, a midline closure with adequate suture strength, and IPOM reinforcement merges the benefits of open and laparoscopic hernia repair. This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.

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External view of the progress of the laparoscopically performed suture line. The PDS sling is subsequently pulled into the abdomen as additional length is required
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Fig2: External view of the progress of the laparoscopically performed suture line. The PDS sling is subsequently pulled into the abdomen as additional length is required

Mentions: The second step of the operation is now initiated. The needle of the PDS sling is inserted cephalad from the hernia gap via a 5-mm skin incision. The needle is then reversed under laparoscopic control and extracted via the same skin incision (Fig. 1). The sling is engaged, and the needle is again inserted into the abdomen while the major part of the sling suture remains external (video 2). This facilitates laparoscopic handling of the sling, and the whole length of the sling can be preserved. The sling can now be stitched laparoscopically, carefully controlling the stitch width (Fig. 2). The comparatively large size of the needle allows adequate stitch length. The monofilament suture material must not be damaged so as to avoid the risk of disconnecting the needle. As the suture line proceeds, the required suture length can be provided from the external part of the sling. With this technique, the amount of suture in the abdomen can be kept to a minimum to facilitate laparoscopic handling while suturing. After completion of the suture line, the needle is extracted through an additional incision at the foot end of the hernia gap. The suture can now be pulled through manually with laparoscopic assistance in a manner comparable to tying shoelaces (video 2; Fig. 3). Before applying the final tension of the suture, abdominal pressure must be reduced to 6 mmHg to facilitate approximation of the fascial edges. After that is accomplished, the needle is once again inserted into the abdomen, reversed, and extracted, thereby generating an external loop. Final tying is done with an Aberdeen knot [3] (Fig. 4). The Aberdeen knot allows the needle to remain connected to the suture, which helps bury its end in the subcutaneous tissue after securing the knot.Fig. 1


Triple-step laparoscopic incisional hernia repair: midline suture closure supported by dorsal component separation and intraperitoneal onlay mesh reinforcement.

Strey CW - World J Surg (2014)

External view of the progress of the laparoscopically performed suture line. The PDS sling is subsequently pulled into the abdomen as additional length is required
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4232746&req=5

Fig2: External view of the progress of the laparoscopically performed suture line. The PDS sling is subsequently pulled into the abdomen as additional length is required
Mentions: The second step of the operation is now initiated. The needle of the PDS sling is inserted cephalad from the hernia gap via a 5-mm skin incision. The needle is then reversed under laparoscopic control and extracted via the same skin incision (Fig. 1). The sling is engaged, and the needle is again inserted into the abdomen while the major part of the sling suture remains external (video 2). This facilitates laparoscopic handling of the sling, and the whole length of the sling can be preserved. The sling can now be stitched laparoscopically, carefully controlling the stitch width (Fig. 2). The comparatively large size of the needle allows adequate stitch length. The monofilament suture material must not be damaged so as to avoid the risk of disconnecting the needle. As the suture line proceeds, the required suture length can be provided from the external part of the sling. With this technique, the amount of suture in the abdomen can be kept to a minimum to facilitate laparoscopic handling while suturing. After completion of the suture line, the needle is extracted through an additional incision at the foot end of the hernia gap. The suture can now be pulled through manually with laparoscopic assistance in a manner comparable to tying shoelaces (video 2; Fig. 3). Before applying the final tension of the suture, abdominal pressure must be reduced to 6 mmHg to facilitate approximation of the fascial edges. After that is accomplished, the needle is once again inserted into the abdomen, reversed, and extracted, thereby generating an external loop. Final tying is done with an Aberdeen knot [3] (Fig. 4). The Aberdeen knot allows the needle to remain connected to the suture, which helps bury its end in the subcutaneous tissue after securing the knot.Fig. 1

Bottom Line: Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function.It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling.This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Visceral and Vascular Surgery, Diakoniekrankenhaus Friederikenstift, 5 Humboldtstrasse, 30169, Hannover, Germany, strey@gmx.de.

ABSTRACT
Incisional hernias remain a surgical challenge when balancing surgical morbidity, functional restoration, and risk of recurrence. Laparoscopic intraperitoneal onlay mesh (IPOM) placement reduces postoperative wound infections and allows fast patient recovery. Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function. We propose a novel triple-step hernia repair technique that includes tension-free midline reconstruction. It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling. Combining dorsal abdominal wall component separation, a midline closure with adequate suture strength, and IPOM reinforcement merges the benefits of open and laparoscopic hernia repair. This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.

Show MeSH
Related in: MedlinePlus