We investigated the validity of our intraperitoneal onlay mesh (IPOM) Plus technique with barbed sutures.
Laparoscopic intraperitoneal onlay mesh repair has become a proven method for treating abdominal incisional hernias in recent years. There have been a few reports on the utility of IPOM Plus, which is IPOM + celiorrhaphy, although this method has not been widely discussed. We adopted the IPOM Plus technique with barbed sutures at our hospital and investigated the validity of this technique.
We included 7 patients who underwent IPOM Plus repair from 2015 to 2017 at our hospital. We excluded patients with a hernia hilum <2 cm or ≥10 cm, age < 20 years old, PS3 or more, and uncontrolled comorbidity. The hernial orifice was closed laparoscopically using barbed sutures and subsequently secured by tacking on an onlay mesh.
The median hernial orifice size of the 7 patients was 45 mm (25 to 55 mm). Hernia onset occurred after laparotomy in all cases. In one case, an abdominal incisional hernia recurred after IPOM used to treat the condition 15 years earlier. The mean duration of surgery was 80.5 minutes (53 to 126 minutes), and the median pain scale score was 3 points (0 to 3 points), indicating little pain. None of the patients reported persistent postoperative pain. The mean duration of the postoperative hospital stay was a median of 3.5 days (2 to 5 days). Both short- and long-term outcomes indicated that no recurrence or complications, such as bulging or seroma, occurred.
IPOM Plus with intracavitary abdominal suturing using barbed suture for abdominal scar hernia repair may be a valid surgical procedure.
Abdominal incisional hernias are one of the most common complications of laparotomy, occurring after 2% to 11% of surgeries.1 Common symptoms include pain and discomfort. Hernial enlargement impairs the cosmetic appearance and activities of daily living, and surgery is the only form of treatment. Laparoscopic intraperitoneal onlay mesh (IPOM) repair has been established as a useful technique.2,3 Compared to laparotomy, IPOM results in fewer cases with complications and surgical site infection (SSI) or mesh infection, and postoperative pain is also reduced. Shorter mean hospital stays also have been reported with IPOM.2,3
To date, there are few studies on the utility of IPOM Plus, which is IPOM + celiorrhaphy (abdominal wall suturing). Some reports have indicated that IPOM may cause the onset of seroma and mesh bulging; consequently, techniques for suture closure of the defect to prevent the occurrence of such complications have been described.4,5 A meta-analysis by Tandon et al showed that the results after IPOM Plus not only include favorable outcomes in mesh bulging and seroma but also in terms of recurrence.6 However, the problem of postoperative pain caused by suturing of the abdominal wall can be an issue. In addition, it is not known what hernia size is amenable to closure using this technique, and thus further discussion is necessary.
We introduced IPOM Plus at our hospital in 2015. During celiorrhaphy, we perform laparoscopic closure using continuous sutures. Therefore, we retrospectively investigated the methods and outcomes of this technique at our hospital.
Methods
From 2015 to 2017, we targeted patients in whom we diagnosed an abdominal scar hernia by physical examination, computed tomography, and ultrasound imaging. This included patients were those who met the general surgical criteria for abdominal scarring hernia, were ≥20 years old, had a hernia portal of 2 to <10 cm, and had PS2 or less. We excluded patients <20 years old and those with a hernia hilum <2 cm or ≥10 cm, PS3 or more, and uncontrolled comorbidity. The surgeries were performed by multiple trained surgeons.
The patients were placed under general anesthesia while in the supine position. A port was placed in the left hypochondrium using the optical method, and the abdomen was insufflated to 10 mmHg. During intraperitoneal examination, a camera port was placed at a distance from the hernial orifice, and a second additional port was placed to achieve a coaxial setup. If hernia contents were present, they were removed. Then, the hernial orifice was identified and measured to determine its size (Fig. 1c). The hernial orifice was closed with intracorporeal continuous sutures using 1-0 non-absorbable V-Loc (Covidien Japan, Tokyo, Japan) (Fig. 1d and 1e). Because the suturing equipment (V-Loc) was inserted via a 12-mm port, no incision was necessary. The needle was also retrieved through the same port. Next, the mesh was fixed at 2 points. We used either Symbottex (Medtronic, Japan) or Ventrio (BARD, Japan) ST mesh. We selected a mesh size that ensured an overlap of 5 cm and would completely cover the hernial orifice. The mesh was secured using the double crown technique with an absorbable strap fixation device (Secure Strap, Johnson and Johnson, Tokyo, Japan) (Fig. 1f). The fixation was also reinforced as close as possible during tacking; this was performed with particular caution at the mesh margin to prevent the mesh from folding back on itself.
(a) Computed tomography (CT) findings (coronal slice). (b) CT findings (sagittal slice). c Hernial orifice. (d) Abdominal wall closure using barbed sutures after hernial orifice closure and (f) after mesh fixation.
(a) Computed tomography (CT) findings (coronal slice). (b) CT findings (sagittal slice). c Hernial orifice. (d) Abdominal wall closure using barbed sutures after hernial orifice closure and (f) after mesh fixation.
Oral fluid intake was permitted from the morning of postoperative day 1. Pain was evaluated using a 0–10 numeric rating scale (NRS), and 10 mg/kg of acetaminophen was administered to the patients with an NRS of ≥ 5 or to those who requested it. The patients were examined at the surgical outpatient department upon discharge and at 1 week and 3 months later. Thereafter, patients were re-examined if necessary. The short- and long-term outcomes at 3 years were confirmed using medical records and phone calls to the patients.
Results
Patient characteristics are shown in Table 1. There were 7 patients (5 men, 2 women) with a median age of 81.5 years (66 to 88 years). The median ASA-PS (American Society of Anesthesiologists-Physical Status) was 2 (2 to 3), and the median body mass index was 27.7 kg/m2 (21.6 to 37.9 kg/m2). Of the 7 patients, 1 was diabetic (14.3%), 2 were taking oral antiplatelet agents (28.6%), and none were taking steroids. Onset of the hernia occurred after laparotomy in all cases, with 1 case of abdominal incisional hernia recurring after IPOM used to treat the same condition occurring 15 years earlier. The median hernial orifice size was 45 mm (25 to 55 mm). The hernias were located along the midline in all cases, with 5 umbilical hernias and 1 epigastric and 1 hypogastric hernia.
The perioperative results are shown in Table 2. The mean duration of surgery was 80.5 minutes (53 to 126 minutes), the median pain scale score was 3 points (0 to 3 points), and the median duration of analgesic use was 0 times (0 to 4 times). Four of the 7 patients did not require any analgesia, and none of them reported persistent postoperative pain. The mean duration of the postoperative hospital stay was a median of 3.5 days (2 to 5 days). Short- and long-term outcomes indicated that no recurrence or complications, such as bulging or seroma, occurred.
Discussion
Abdominal incisional hernias are one of the complications observed after laparotomy. The frequency is 2% to 11%, and from 8% to 29% are asymptomatic.1 Reports have also indicated an incidence of 3% to 20% after laparoscopic surgery.7 We believe that the actual overall frequency is higher. In addition, an abdominal incisional hernia is the result of dehiscence of the abdominal wall sutures, and it can be diagnosed by palpation and imaging investigations, irrespective of the presence of protuberance.8
Surgery is the only form of treatment. The condition can be managed by means of emergency or elective surgery, or follow-up observation. Emergency surgery is required if there are findings suggesting incarceration or strangulation; if such findings are absent, irrespective of whether the patient is symptomatic, elective surgery can be performed at the patient's request. In some cases, follow-up observation may be selected in consideration of an underlying disorder, although reports indicate that 2.6% of cases require emergency surgery at 1 year during follow-up observation.9 Emergency surgery is associated with frequent perioperative complications and a high fatality rate, so preventive elective surgery is fundamentally desirable. IPOM repair has become established as a useful technique in this regard.
The utility of IPOM Plus has been reported in recent years. In terms of pain, the application of tension to the abdominal wall was originally believed to intensify the postoperative pain; however, Clapp et al did not observe specific, significant differences in postoperative pain between IPOM with and without celiorrhaphy.10 On the basis of the aforementioned findings, we believe that IPOM Plus is an effective technique.
The research up to present has made it clear that abdominal wall closure is desirable, but to date, no reports have compared the methods of closure. Thus, we investigated the suture closure of abdominal incisional hernias. The most commonly used technique for this purpose is extracorporeal interrupted closure. A 2-mm incision is made, and a needle grasper (Endo Close, Covidien) is used to perform extracorporeal closure of the abdominal wall. To date, there have been 7 reports on the utility of extracorporeal interrupted closure using IPOM Plus, and the results have been favorable. Meanwhile, in 2007, Palanivelu et al reported on an intraperitoneal abdominal wall closure method that uses continuous sutures.11 Since then, a few similar reports have appeared. However, no reports have directly compared extracorporeal interrupted closure with intracorporeal running suture, although reports that have considered them individually indicate low recurrence rates for both techniques and no significant differences between the two. There were also few complications and favorable outcomes.
The incidence of wound infection and seroma onset may differ between these two techniques. Extracorporeal interrupted closure requires multiple skin incisions, which may increase the risk of infection,12 and a 2013 report by Clapp et al indicated a wound infection incidence of 8.3%, making it somewhat common.10 We also performed abdominal closure using an intracorporeal running suture and did not observe wound infection, indicating that this suture technique may be desirable from the perspective of wound infection risk.
The incidence of seroma after intracorporeal running sutures was somewhat high. According to Palanivelu et al, incidence of seroma after the use of intracorporeal running suture was 7.56%,11 and their subsequent study documented a seroma incidence of 17%.13 We wonder whether this is due to issues with the surgical technique. It is comparatively easy to perform closure using intracorporeal running suture, but the angles of needle handling are limited, causing some difficulty. In the case of IPOM Plus, the separated abdominal muscles are returned to a physiologic position by means of adequate application of traction. During the procedure, the needle must be handled perpendicular to the abdominal wall, and it is important to suture the abdominal wall muscles firmly. By pushing on the body and matching the desired direction of the needle, we believe that the success of this technique can be guaranteed. No seroma occurred in our 7 patients. In addition, in 2015, Gonzalez et al performed abdominal wall closure by means of robot-assisted intracorporeal running sutures.14 Duration of surgery was 107 minutes, which was somewhat longer than that in other reports, although incidence of recurrence, complications, and seroma were all favorable. During robot-assisted surgery, it is possible to achieve even more accurate abdominal wall closure than during laparoscopy. If the abdominal wall closure that is performed using intracorporeal running sutures is adequate, we believe that favorable outcomes can be achieved in seroma onset. Based on the aforementioned, intracorporeal IPOM Plus closure results in the same outcomes as extracorporeal IPOM Plus closure in recurrence, postoperative pain, and seroma onset and may even reduce risk of infection.
The European Hernia Society (EHS) issued guidelines for abdominal wall closure to prevent herniation.15 The EHS guidelines also recommend careful suturing of the fascia when creating running sutures. Interrupted sutures tend to apply tension to the suture thread and may cause ischemia of the wound margin. By contrast, tension applied during the use of running sutures is distributed evenly along the entire length of the suture thread, so it is unlikely to cause wound ischemia or dehiscence.16 We thus believe that performance of the intracorporeal running sutures technique is advisable.
Next, we investigated the suture materials used. Previous reports have documented use of running non-barbed sutures, such as polyamide and polypropylene sutures, although we believe that this technique is somewhat challenging in practice as the suture thread tends to loosen easily. For this reason, we believe it would be easier to close the abdominal wall using a barbed suture created using a knotless tissue control device (V-Loc). When barbed suture is used in practice, the skill level of the surgeon does not have a major impact, and it is possible to close the abdominal wall accurately without the suture thread loosening during the process. Compared to that of previous reports, duration of surgery in our study was shorter, and this may have been associated with shorter abdominal wall suture time due to the use of barbed sutures. In 2017, Wiessner et al reported on the outcomes of abdominal wall closure using intracorporeal running sutures, making use of the same barbed suture technique as the 42 patients included in that report, and outcomes were favorable. Though we believe that the aforementioned techniques are still valid, we also believe that the use of barbed sutures is effective.
We were unable to address the limits of hernia size that can be managed using the IPOM Plus technique. Based on our experience, IPOM Plus can be used for a hernial size of up to 55 mm. There have also been reports of using IPOM Plus to manage hernias of up to 11 × 18 cm in size with no subsequent recurrence,18 but at present, the consensus is that the technique should be used to manage lesions of 2 to 10 cm in size. In the future, we plan to accumulate additional cases.
In conclusion, although it is difficult to confirm our findings from only 7 cases, we believe that IPOM Plus with intracavitary abdominal suturing using barbed suture for abdominal scar hernia appears to be a valid surgical technique.
Acknowledgments
The authors thank Prof. Tina Tajima of St. Marianna University School of Medicine for her helpful comments on the manuscript. This study was approved by the ethics committee of Teikyo University Hospital (TUIC-COI 19-0583). Patients signed an informed consent before the procedure. The authors have nothing to declare.