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The "Inside-out" Technique for Hernia Repair with Mesh Underlay.

Berhanu AE, Talbot SG - Plast Reconstr Surg Glob Open (2015)

Bottom Line: An improved method for mesh repair of ventral/incisional hernias after component separation is presented.The "inside-out" technique was performed on 23 patients at a single tertiary academic medical center from November 2011 to February 2014.The "inside-out" technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable.

View Article: PubMed Central - PubMed

Affiliation: Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.

ABSTRACT

Background: An improved method for mesh repair of ventral/incisional hernias after component separation is presented. The use of a Carter-Thomason suture passer (Cooper Surgical, http://www.coopersurgical.com) allows for safe passage of preplaced sutures on the mesh from within the abdominal cavity through the anterior rectus sheath. This "inside-out" method makes the underlay of mesh fast and easy by improving visualization and control of sharp instruments as they are passed through the abdominal cavity. Preplacement of sutures circumferentially on the mesh also improves the distribution of tension around the repair, which may ultimately reduce the risk of hernia recurrence.

Methods: The "inside-out" technique was performed on 23 patients at a single tertiary academic medical center from November 2011 to February 2014. We have followed these patients for a median of 24.5 months to assess for postoperative complications and hernia recurrence.

Results: We report an acceptable hernia recurrence rate (2 of 23 = 8.7%). One recurrence was observed in a patient who underwent repair of a recurrent ventral hernia and the other had significant loss of domain requiring an inlay mesh.

Conclusions: The "inside-out" technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable. We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique.

No MeSH data available.


Related in: MedlinePlus

A Carter-Thomason suture passer is used to grasp each suture and pass it through the rectus abdominis under direct vision and without the need for a suture needle within the abdominal cavity. The mesh protects the viscera from inadvertent injury by the sharp end of the Carter-Thomason suture passer. Sutures are tied external to the rectus sheath, alternating from one side of the defect to the other to evenly distribute tension. (Original artwork commissioned and paid for by Dr. Simon G. Talbot, all rights to publish are retained by the owner, Dr. Simon G. Talbot.)
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Figure 1: A Carter-Thomason suture passer is used to grasp each suture and pass it through the rectus abdominis under direct vision and without the need for a suture needle within the abdominal cavity. The mesh protects the viscera from inadvertent injury by the sharp end of the Carter-Thomason suture passer. Sutures are tied external to the rectus sheath, alternating from one side of the defect to the other to evenly distribute tension. (Original artwork commissioned and paid for by Dr. Simon G. Talbot, all rights to publish are retained by the owner, Dr. Simon G. Talbot.)

Mentions: The abdomen is opened using a prior vertical midline incision, and a generous lysis of adhesions is performed. The fascia is found and freed on either side of the midline, and any hernia sac is removed. The peritoneum, where it will contact mesh, is also scored or removed to promote adhesion at this interface. The skin and subcutaneous tissue is elevated from the fascia taking care to protect any significant perforators supplying the overlying skin. A component separation is performed by incising with monopolar cautery lateral to the lateral border of the rectus muscle to free the external oblique aponeurosis, allowing the rectus to move medially for possible direct closure of the midline fascia. A generous piece of mesh is prepared and placed into the abdomen and then cut to allow overlap with the fascia of at least 5 cm from the reapproximated midline defect.6 The mesh is then brought to a back table where the location of polypropylene or polyester interrupted sutures is marked every 2 cm circumferentially and 2 cm from the edge. Sutures are placed and the needles removed. The mesh is placed back into the abdomen with the sutures on hemostats. The location where sutures should exit the rectus sheath is marked on the outside of the fascia to facilitate even distribution and tensioning. A Carter-Thomason is used to retrieve the sutures and pass them through the fascia from within the abdomen (Figs. 1 and 2). The sutures are then tied external to the rectus sheath, alternating from side-to-side around the defect to help distribute tension and firmly secure the mesh to the underside of the rectus sheath. A #15 suction drain is placed in the potential space between the mesh and the posterior rectus. A #19 suction drain is placed over each component separation. Over the top of the mesh, the fascia is closed with #1 or #0 looped polydioxanone suture. Scarpa’s fascia and the deep dermis are approximated with interrupted 3-0 absorbable suture. The skin is then closed with a technique commensurate to the degree of wound contamination. The authors understand and abide by the rules set forth in The Declaration of Helsinki.


The "Inside-out" Technique for Hernia Repair with Mesh Underlay.

Berhanu AE, Talbot SG - Plast Reconstr Surg Glob Open (2015)

A Carter-Thomason suture passer is used to grasp each suture and pass it through the rectus abdominis under direct vision and without the need for a suture needle within the abdominal cavity. The mesh protects the viscera from inadvertent injury by the sharp end of the Carter-Thomason suture passer. Sutures are tied external to the rectus sheath, alternating from one side of the defect to the other to evenly distribute tension. (Original artwork commissioned and paid for by Dr. Simon G. Talbot, all rights to publish are retained by the owner, Dr. Simon G. Talbot.)
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4494492&req=5

Figure 1: A Carter-Thomason suture passer is used to grasp each suture and pass it through the rectus abdominis under direct vision and without the need for a suture needle within the abdominal cavity. The mesh protects the viscera from inadvertent injury by the sharp end of the Carter-Thomason suture passer. Sutures are tied external to the rectus sheath, alternating from one side of the defect to the other to evenly distribute tension. (Original artwork commissioned and paid for by Dr. Simon G. Talbot, all rights to publish are retained by the owner, Dr. Simon G. Talbot.)
Mentions: The abdomen is opened using a prior vertical midline incision, and a generous lysis of adhesions is performed. The fascia is found and freed on either side of the midline, and any hernia sac is removed. The peritoneum, where it will contact mesh, is also scored or removed to promote adhesion at this interface. The skin and subcutaneous tissue is elevated from the fascia taking care to protect any significant perforators supplying the overlying skin. A component separation is performed by incising with monopolar cautery lateral to the lateral border of the rectus muscle to free the external oblique aponeurosis, allowing the rectus to move medially for possible direct closure of the midline fascia. A generous piece of mesh is prepared and placed into the abdomen and then cut to allow overlap with the fascia of at least 5 cm from the reapproximated midline defect.6 The mesh is then brought to a back table where the location of polypropylene or polyester interrupted sutures is marked every 2 cm circumferentially and 2 cm from the edge. Sutures are placed and the needles removed. The mesh is placed back into the abdomen with the sutures on hemostats. The location where sutures should exit the rectus sheath is marked on the outside of the fascia to facilitate even distribution and tensioning. A Carter-Thomason is used to retrieve the sutures and pass them through the fascia from within the abdomen (Figs. 1 and 2). The sutures are then tied external to the rectus sheath, alternating from side-to-side around the defect to help distribute tension and firmly secure the mesh to the underside of the rectus sheath. A #15 suction drain is placed in the potential space between the mesh and the posterior rectus. A #19 suction drain is placed over each component separation. Over the top of the mesh, the fascia is closed with #1 or #0 looped polydioxanone suture. Scarpa’s fascia and the deep dermis are approximated with interrupted 3-0 absorbable suture. The skin is then closed with a technique commensurate to the degree of wound contamination. The authors understand and abide by the rules set forth in The Declaration of Helsinki.

Bottom Line: An improved method for mesh repair of ventral/incisional hernias after component separation is presented.The "inside-out" technique was performed on 23 patients at a single tertiary academic medical center from November 2011 to February 2014.The "inside-out" technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable.

View Article: PubMed Central - PubMed

Affiliation: Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.

ABSTRACT

Background: An improved method for mesh repair of ventral/incisional hernias after component separation is presented. The use of a Carter-Thomason suture passer (Cooper Surgical, http://www.coopersurgical.com) allows for safe passage of preplaced sutures on the mesh from within the abdominal cavity through the anterior rectus sheath. This "inside-out" method makes the underlay of mesh fast and easy by improving visualization and control of sharp instruments as they are passed through the abdominal cavity. Preplacement of sutures circumferentially on the mesh also improves the distribution of tension around the repair, which may ultimately reduce the risk of hernia recurrence.

Methods: The "inside-out" technique was performed on 23 patients at a single tertiary academic medical center from November 2011 to February 2014. We have followed these patients for a median of 24.5 months to assess for postoperative complications and hernia recurrence.

Results: We report an acceptable hernia recurrence rate (2 of 23 = 8.7%). One recurrence was observed in a patient who underwent repair of a recurrent ventral hernia and the other had significant loss of domain requiring an inlay mesh.

Conclusions: The "inside-out" technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable. We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique.

No MeSH data available.


Related in: MedlinePlus