Evaluation of Peritoneal Closure Techniques Following Laparoscopic and Robotic Inguinal Hernia Surgery with Mesh Implantation

Marc R Leduc, MD, Jeffry T Zern, MD. Christiana Care Health System


Since it was first introduced, Laparoscopic inguinal hernia repair using the Trans-abdominal pre-peritoneal approach (TAPP) has been described as a safe modality for repair of inguinal hernias. Perhaps the main difference between TAPP and other types of inguinal hernia repair is that TAPP inherently involves the creation of a peritoneal defect. Over the years many methods for the closure of this defect have been introduced. More recently these techniques have involved the use of barbed, self-anchoring suture devices. There have been several reports of complications associated with the use of barbed sutures. This study compares the use of barbed suture since their introduction at our institution with that of all other peritoneal closures.


We conducted a retrospective review of all of the laparoscopic and robotic TAPP repairs performed at our institution between January 2012 and September 2014. We evaluated the type of peritoneal closure and any associated complications.


In total we evaluated 234 patients who underwent 294 hernia repairs. The age range of the patients was from 21 to 92 years old with an average age of 55 years old. 8.5% of the patients were female (20/234), and 91.5% were Male (214/234).

The types of hernias repaired included indirect, direct, pantaloon, recurrent or unspecified. The surgeries were performed by a total of 15 different surgeons. Types of mesh used in the hernia repairs included 3D Max (52.9%), Ultrapro (41.0%), PhysioMesh (3.4%), Proceed (0.8%) and Polyprophylene (1.9%). 19 of the 234 (8.1%) cases were performed with the use of the DaVinci Robotic System.

Methods to close the peritoneal opening included the EMS Stapler 54.1% (159/294), Endopath Tacker 0.6% (2/294), Ligamax 0.6% (2/294), Protack 1% (3/394), Secure Strap 9.8% (29/294), Surgidac endo-stitch 0.3% (1/294), Stratafix suture 6.1% (18/294) and V-lock suture 22.1% (65/294). In total 83 closures or 28.2% were performed with barbed suture.

There were no cases of small bowel obstruction noted with any method of peritoneal closure. There was 1 case of bleeding from the peritoneal closure with barbed suture requiring return to the operating room. Complication rates at 1.2% and 0% were not statistically significant (p=0.11). There were a total of 4 recurrences.


The use of barbed sutures for closure of the peritoneum is a relatively new method that is becoming more popular at our institution. Its increasing use has been multifactorial. Robotic inguinal hernia repair is being performed more frequently and barbed suture has been the preferred method of peritoneal closure in these cases. In addition the EMS stapler, which had been the most common method of closure, has now become unavailable.

We found no statistical difference between the operative complications following various methods of peritoneal closure. The bleeding complication we observed is a potential risk to all closure methods. We found no complications that can be considered a direct result of the barbed suture. We conclude that barbed suture is a safe and effective method to close the peritoneal defect in trans-abdominal pre-peritoneal inguinal hernia repairs.

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