British Journal of Surgery 1995, 82,642

Surgical workshop

Simplifying mesh placement during laparoscopic hernia repair

C. A V E R Y , R . J . E . F O L E Y and A. P R A S A D Depaitment of Surgery, Bedford Hospital, Bedford MK42 9D4 UK Correspondence to: Mr A. Prasad

Transabdominal preperitoneal repair is a popular method of hernia repair in which the peritoneal cavity is entered to reach the hernial sac from ‘behind’. The peritoneum is re-incised to enter the preperitoneal space and the hernial sac is reduced. A mesh is then fixed in the preperitoneal space and the peritoneum closed over it. Two of the criticisms of this technique are the prolonged time it takes to fix the mesh (M. E. Arregui and R. F. Nagan, unpublished data) and the potential for migration of the mesh’.

One way to reduce the potential for migration is to slit the mesh and then hook it around a fixed structure such as the cord or inferior epigastric vessels2. The slit is then closed with staples while the mesh is fixed. The authors’ have used this technique in more than 100 hernia repairs and found it to be an effective, though time-consuming, method. The process of unravelling the mesh intra- abdominally, passing it above the inferior epigastric artery and then positioning it can be frustrating.

A technique that allows easy placement and fixation of the mesh is described. The mesh is introduced like a rolled up blind and fixed superiorly. It is then released and allowed to roll down into the desired position.

Surgical technique The laparoscope is introduced through a 10-mm umbilical cannula after creation of a pneumoperitoneum. A 5-mm trocar is introduced on the side of the hernia and a 12-mm trocar on the opposite side at the transverse umbilical level lateral to the rectus sheath. The preperitoneal space is entered by incising the peritoneum and preperitoneal fascia above the inguinal ligament. The peritoneal flap is brought down and the hernia is reduced. The inferior epigastric vessels are exposed and a gap of about 3 cm in diameter is made between the vessels and the abdominal wall.

A rectangular patch (73 X 15 cm) of polypropylene mesh is then cut with a small triangle and square on the top edge to

Paper accepted 23 August 1994

Fig. 1 Preparing the mesh

Inferior epigastric

Fig. 2a Introducing the mesh roll

Mesh Staples

q=-- -A /’

Fig. 2b Mesh in position

mark the right and left side (Fig. I). After rolling the mesh two- thirds of the way up, it is slit in the middle and then rolled up completely. Two absorbable stitches are used to secure it in the rolled up position. It is introduced through the 12-mm trocar keeping the triangular top end to the right of the patient. This ensures that the mesh later unrolls in a back to front direction. The roll is passed through the gap above the inferior epigastric vessels and the top square and triangle of the mesh are fixed in the desired position (Fig. 2a). The sutures are cut to allow the mesh to roll down covering the dissected area. The slit mesh is crossed and stapled together. The remainder of the mesh is then stapled in position (Fig. 2b). The peritoneal flap is then stapled or sutured back in position.

Acknowledgements All figures were drawn by Gillian Lee Illustrations.

References 1 Crist DW, Gadacz TR. Complications of laparoscopic surgery.

Surg Clin North Am 1993; 73: 265-89. 2 Geis WP, Crafton WB, Novak MJ, Malago M. Laparoscopic

herniorrhaphy: results and technical aspects in 450 consecutive procedures. Surgery 1993; 114: 765-74.

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