Laparoscopic and Robotic Incisional Hernia Repair by Karl A. LeBlanc

Author:Karl A. LeBlanc
Language: eng
Format: epub
ISBN: 9783319907376
Publisher: Springer International Publishing

Fig. 7.4 Bard Echo 2™ device utilizes an accessory introduction device, and assists with unraveling and placement of the mesh over the defect with a nitinol frame. The mesh is pulled up to the abdominal wall through the center of the defect with the attached “hoisting” suture, and is removed after fixed to the abdominal wall by simply pulling the frame through a cannula with a grasper

Mesh Fixation

There are two types of mesh fixation. The first is how the surgeon connects the mesh to the tissue in the operating room, and the second is how the body connects the mesh to the tissue as part of the healing process. To date, there has been no consistent data to suggest one fixation method is better than another. Full thickness anchoring sutures that traverse the mesh, and all layers of the abdominal wall except the skin and most subcutaneous tissue are considered the strongest of all surgical applied fixation methods [20, 21]. There are a variety of mechanical anchoring devices on the market, most of which are helical fasteners that resemble a screw. One fastener has a “U” shape with barbs at the tips to hold it in place, and one resembles a suture, encircling the tissue and mesh, with the ends connected similar to a zip tie. The mechanical devices can deliver both permanent and absorbable fasteners, depending on the version. These types of mechanically delivered fasteners are not as strong as full thickness abdominal wall sutures, because they only go through a portion of the abdominal wall muscle and fascia. There has been no proven benefit of one fixation fastener over another, and new fasteners are continually being introduced to the market in an attempt to continuously improve this aspect of laparoscopic ventral hernia repair [22]. Examples of these fasteners can be seen in Fig. 7.5. Finally, it has become popular among users of robotically assisted surgical devices to use a variety of suture types to connect the mesh to the abdominal wall, with a variety of suturing patterns and suture depths. Because the technique is manual, and operative circumstances not uniform, it is unknown how strong and predictable this fixation method will ultimately be. Furthermore, suture choice and suture pattern are highly variable among surgeons, making a comparison to existing methods of fixation difficult at best. However, whatever the depth and pattern the sutures are placed, they will largely be placed through a partial thickness of the abdominal wall, and thus less strong compared to full thickness sutures [23, 24].

Fig. 7.5Mesh fixation products . (a) Suture-like fixation, permanent (FasTouch™, Via Surgical, Amirim, Israel), (b) “U”-shaped fastener, absorbable (Secure Strap™, Ethicon, Cincinnati, OH), (c) Barbed nail-type fastener, absorbable (Optifix™, Bard, Warwick, RI) (d–f) Helical fasteners, ((d, e) Absorbatack™-absorbable and ProTack™-permanent, Medtronic, Minneapolis, MN; (f) CapSure™, Bard, Warwick, RI-permanent)

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