Untitled Document

Creation of Pneumoperitoneum:

All procedures were done under general anesthesia with right arm tucked by the side and patient lying supine. Pneumoperitoneum is created using veress needle or by open technique depending on the individual case well away from the scar and hernial defect (figure 1).

Figure 1

Position and the number of the port:

The position and the number of ports are variable. In majority of cases we have managed with three ports. Two ports are inserted in right anterior axillary line: 10 mm port close to costal margin for 0 degree laparoscope and later on for the insertion of mesh and another 5 mm port close to anterior superior iliac spine. Depending on the site of hernia a third 5 mm port is inserted in the midline in epigastrium well above the umbilicus (figure 3). The surgeon and the assistant stands on the right side of the patient side by side.

Figure 3

Reducing the Hernial contents:

Usually the contents (Figures 2, 4) are reduced by itself with the help of general anesthesia, and by pneumoperitoneum. The adhesions can be taken down with the help of scissors, ultracision hook, spatula or shears (Figure 4), external compression, and sometime by limited laparotomy. The hernial sac is not excised and hernial defect is not closed.


Figure 2		Figure 4

Reduction and viability

Defect sizing

Measuring the hernial defect:

After reducing the contents, the hernial defect is measured by probing its margins at several places with a 22 gauge spinal needle (figure 5). Each pass is marked on the skin. These marks are joined together in a circle using the compass from the center point of the defect. This inner circle outlines the size of the defect.

Figure 5

Further markings on the skin:

Holding a circular protractor with its centre point on the centre point of the defect, an outer circle is drawn 3-4 cm perimeter away from the inner circle which represents the size of mesh. The full circular protractors are our standard tool for this procedure and they are commercially available in different sizes of 10, 15, 18, and 20 cm etc. in diameter. A third circle is drawn from the centre point of the hernial defect with the help of the compass, 1 cm inside the outer circle. Outer sutures are tied on this third circle thus allowing a 1 cm free edge of the mesh circumferentially. Utilizing the radial markings on the circular protractors, the radial lines are drawn at equidistance from the outermost circle to the centre point of the defect resembling the spokes of a wheel (figure 6). These lines represent the suture intervals and the number of sutures required. The number of radial lines and hence the number of sutures vary according to the size of the mesh used, larger the mesh more the number of sutures.

Figure 6

Markings on the mesh:

Similar 3 circles and the radial lines are drawn on the both sides (the white rough sticky side and brown smooth nonstick side) of the Gore-Tex Dual Mesh plus biomaterial corresponding precisely to the markings on the skin. The dual mesh is cut in a round patch along the outer circle. This patch when fixed is geometrically symmetrical around the hernial defect. Gore-Tex Dual Mesh plus biomaterial is ideal for the markings on both the sides of it as the markings are durable, do not rub off & spill even when the mesh is wet in the abdomen (Figures 7, 8).


Figure 7		Figure 8

Mesh insertion

With the help of circular protractors we have standardized the placement intervals, positions and the number of sutures required for a particular size of mesh. For a 10x10 cm size circular patch of mesh we tie 16 sutures on the outer circle on all the radial lines and 8 sutures on the inner circle at the alternate radial lines. This number of sutures is doubled for 20x20 cm size mesh. Similarly for a 15x15 cm size mesh the number of sutures required is 24 on outer and 12 on inner circles and for a 18x18 cm size mesh 28 on outer and 14 on inner circle, and so on (figures 6, 7, 8).

Four quadrant prolene sutures and Inserting the mesh:

The next step is to tie four corner suture(6) of 'O' prolene at 0, 90, 180 & 3600 on the rough white side of the dual mesh 5 mm from the edge, leaving two free 18 cm long ends (figure 7). Holding on a grasper the mesh is inserted in a roll with the long ends of the sutures inside the roll (figure 9). Throughout the procedure the mesh does not come in contact with the patient's skin.

Figure 9

Mesh fixation 1

Mesh fixation 2

Unfurling the mesh & retrieving the four corner sutures:

The mesh is unfurled intra-abdominally by the graspers, the white sticky side with four corner sutures facing up towards the anterior abdominal wall (figure 10). The long ends of the four corners suture are retrieved through the small stab wounds on the skin by the 'endoclose hook' (Tyco health care, USA) (figure 11). Abdomen is deflated and these sutures are tied subcutaneously (figure 12).


Figure 10		Figure 11		Figure 12

Fixation of mesh in two circles:

Multiple 1 mm stab wounds are made on the skin by size 11 surgical blades, on the radial lines on the outer circle to fix the mesh further by sutures circumferentially. Holding a free 36 cms long 'O' prolene suture on its hook with one end short and other end long, the endoclose hook is inserted through the stab wound and through the mesh. The long end of the suture is held on the artery clip outside while the short end is released from the endoclose hook and held on a grasper intraabdominal (figure 13).

Figure 13

The endoclose hook is taken out and passed again through the same stab wound and through the mesh at a different angle making sure a bridge of mesh and tissue. This short end is re-fed on the hook and retrieved outside, thus making a horizontal mattress suture in place. The hook is passed on the either side of the radial line on the mesh to ensure a good bite of mesh in the suture. Both ends are held together on artery forceps. This is repeated through all the stab wounds. By feeding the suture on the endoclose hook before reinserting it and with right and left hand combination the operating time is reduced considerably. Geometrically the distance between the radial lines on the inner circle is reduced as compared to the outer circles. The sutures are inserted on the alternate radial lines on the skin on the inner circle, the hook is passed through one radial line on the mesh and coming out through the adjoining radial line on the mesh.

Positioning of the sutures is accurate as the radial lines on the skin falls on the radial lines drawn on the mesh like mirror image. The commonest sizes of mesh used in our patients were 10 and 15 cms in diameter. We leave minimum 3 cm overlap of mesh over the defect but mostly it is more as Dual mesh plus biomaterial is supplied in sizes of 10, 15, 18, 20 etc. in oval shapes but we cut a round patch leaving the transverse width intact. The Abdomen is deflated and all the sutures tied subcutaneously. This completes the suture fixation of the mesh (figures 14). The greater omentum is spread between the mesh and bowel as abdomen is deflated (figure 15).


Figure 14		Figure 15

Mesh final view

Second look