New Technique for Fascial Defect Approximation During Laparoscopic Ventral Hernia Repair with Mesh

Irving Jorge, MD, Victor Maciel, MD, Henry J Lujan, MD. Mount Sinai Hospital, Jackson South Community Hospital, Miami, FL

Objective:  Recently, some authors have advocated closure of the hernia defect prior to mesh placement so as to recreate the abdominal wall.  Advantages cited include increased mesh overlap, more physiologic repair, improved functional results, better cosmesis, less seroma, and decreased recurrence.  We describe a simple way to close the hernia defect utilizing the Endostitch 10mm Suturing Device (Covidien, Norwalk, CT) during laparoscopic ventral hernia repair with mesh

Description and Methods:  On select ventral hernias, we performed a primary approximation of the fascial edges of the hernia defect with the Endostitch device using 0 ethibond sutures.  Several interrupted figure of eight sutures are placed with the Endostitch, and then, tied with a knot pusher to provide the appropriate tension.  After closing the defect primarily, a mesh is placed and secured by using both trans-fascial suture and tack fixation.  When suture closing the hernia defect, the pneumoperitoneum can be decreased as needed to assist in placing the sutures.

Preliminary Results:  We have performed 4 laparoscopic ventral hernias with primary fascial approximation using the Endostitch device. We had previously been approximating the fascia using an extracorporeal technique with a suture passer.  Defects closed with our new technique ranged from 2-4 cm in diameter.  We found using the Endostitch device to be easier and faster.  Short-term clinical results have been favorable.

Conclusions/Future directions:  Many authors believe that approximating the hernia defect during laparoscopic ventral hernia repair, prior to mesh fixation, provides a more physiologic and anatomic repair.  Defect closure also provides more defect overlap with mesh placement and, possibly decreases recurrence rates.  We believe that our technique provides a simple and reproducible way to close the hernia defect during laparoscopic ventral hernia repair.  More study is needed to determine the maximum size defect that can be safely closed using this technique.  Furthermore, combining this technique with laparoscopic component separation, will make this approach more widely applicable.  More study is needed to validate both short-term and long-term advantages.