Fixation of the mesh in laparoscopic hernia is an important step .I presented about different meshes used in hernia surgery along with the fixation devices.

1. MESHES IN
LAPAROSCOPIC
HERNIA SURGERY &
FIXATION METHODS
DR.T.VARUN RAJU
H.O.D GENERAL SURGERY ST-HOSPITAL
COURSE DIRECTOR –IAMA-AMS
ADVANCED LAPAROSCOPIC SURGEON
TVR LAPAROSCOPY CANTER
HYDERABAD

2. HERNIOPLASTY
Tension Repair
– Bassini
– Shouldice
Tension-free Repair
– Open
Lichtenstein
Devices
Laparoscopic
TAPP
TEP

3. MYOPECTINEAL ORIFICE (MPO)
DIMENSIONS OF THE MYOPECTINEAL ORIFICE: A HUMAN CADAVER STUDY -
T. WOLLOSCHECK,
M. A. KONERDING
HERNIA .DECEMBER 2009, VOLUME 13, ISSUE 6, PP 639–642
• The MPO averaged 7.8 cm (±3.0) in width and 6.5 cm (±1.9) in height. The
weak inguinal area cranially to the inguinal ligament was 4.5 cm (±1.7) high.
We found significant gender differences: MPOs in males showed the same
width and height (7.6 × 7.6 cm), whereas in females, the MPO width was
greater than its height (8.1 × 5.3 cm). Noticeable correlations of the MPO
parameters to constitutional parameters were found for body size versus the
height of the MPO (r = 0.5005) and interspinous distance versus the height
of the MPO (r = 0.7653).
• A mesh measuring 10 × 8 cm is suitable for both genders: in females, it will
cover the whole MPO, including the infraligamental part, whereas in males,
the weak inguinal area is preferentially covered

4. Wuerz burg classification of ventral and incisional hernias
Department of General, Visceral, Vascular and Pediatric Surgery,
University Hospital of Wuerzburg, Wuerzburg, Germany
HERNIA -February 2014, Volume 18, Issue 1, pp 19–30
INCISIONAL HERNIA CLASSIFICATION

5. Classification
of incisional
hernias
according to
the European
Hernia Society
2017

6. • In 1890 - Theodor Billroth suggested “the ideal way to repair hernias is
to use a prosthetic material to close the hernia defect”
Billroth T. In: The Medical Sciences in the
German Universities: A Study in the History of
Civilization. Welch W.H., editor. Macmillan;
New York, NY, USA: 1924.

7. WE ACCEPT THAT THERE WILL BE OCCASIONS WHEN THE INCISED
LATERAL EDGES ARE NOT ABLE TO BE BROUGHT TOGETHER WITHOUT
EXCESSIVE TENSION; IN SUCH SITUATIONS EXPANDED
POLYTETRAFLUOROETHYLENE COULD BE USED
Anatomical repair of large incisional
hernias.
A. Loh, J. S. Rajkumar, and L. M. South
1992 Mar; 74(2): 100–105.

8. CURRENT OPTIONS IN INGUINAL HERNIA REPAIR
IN ADULT PATIENTS
H KULACOGLU
HIPPOKRATIA. 2011 JUL-SEP; 15(3): 223–231.

9. MESH CATEGORIES
• DENSE :- A mesh with density >100 g/m2
• LIGHT WEIGHT :-35-50 g/m2 density
• Several recent controlled clinical studies have suggested that lightweight
meshes may improve patient comfort .Some objective findings in favour of
lightweight meshes have also been obtained from laboratory experiments,
however some others reported that a lower weight mesh does not correlate
with a decreased biological response.
Klosterhalfen B, Junge K, Klinge U. The lightweight and large
porous mesh concept for hernia repair. Expert Rev Med
Devices. 2005;2:103–117

12. MESH COMPOSITION AND VARIETIES

13. NEWER LIGHTER MESHES
• To overcome those problems --- Foreign body sensation and chronic
postoperative pain newer lighter meshes have been produced (1)
• More expensive
• Pure polypropylene light mesh is the most economic option.
• There are also coated polypropylene meshes in the market
• The purpose of the coating is to attenuate the host response to the
prosthetic, yet still provide adequate strength for repair(2)
• Fish oil, beta glucan and titanium have been used for coating (3)
1.Shah BC, Goede MR, Bayer R, Buettner SL, Putney SJ, McBride CL, et al. Does type of
mesh used have an impact on outcomes in laparoscopic inguinal hernia? Am J Surg.
2009;198:759–764
2. Klinge U, Klosterhalfen B, Muller M, Anurov M, Öttinger A, Schumpelick V. Influence
of polyglactin-coating on functional and morphologic parameters of polypropylene-
mesh modifications for abdominal wall repair. Biomaterials. 1999;20:613–623.
3. Earle DB, Mark LA. Prosthetic material in inguinal hernia repair: how do I choose?
Surg Clin North Am. 2008:179–201

14. PARTIALLY ABSORBABLE MESHES
• Two components.
• Polypropylene non absorbable part (Permanent)
• The other half is absorbed within 12 weeks. (1)
• Eventually less foreign material
• Remaining mesh can still provide a sufficient mechanical barrier against
recurrence.
• A recent meta analysis also found no differences however use of partially
absorbable light meshes could be associated with reduced feeling of a
foreign body (2)
1.Rosch R, Junge K, Quester R, Klinge U, Klosterhalfen B, Schumpelick V. Vypro
II mesh in hernia repair: impact of polyglactin on long-term incorporation in
rats. Eur Surg Res. 2003;35:445–450
2. Gao M, Han J, Tian J, Yang K. Vypro II mesh for inguinal hernia repair: a
metaanalysis of randomized controlled trials. Ann Surg. 2010;251:838–842

15. POLYGLACTINE/POLYPROPYLENE MESH VS.
PROPYLENE MESH: IS THERE A NEED FOR
NEWER PROSTHESIS IN INGUINAL HERNIA?
SAUDI J GASTROENTEROL. 2010 JAN-MAR; 16(1): 8–13.
IM KHAN, ADIL BANGASH, MUZAFFARUDDIN SADIQ, AIN UL HADI, AND HARIS HAMID
Conclusion
Modern day light weight meshes do not promise the
prospects of a comparatively reduced incidence of chronic
pain in patients undergoing Lichtenstein technique of
tension free mesh repair for inguinal hernia. Neither do
they exhibit a higher incidence recurrence nor infection
following repair of inguinal hernia when compared to
polypropylene meshes.

16. RANDOMIZED CLINICAL TRIAL COMPARING A POLYPROPYLENE WITH A
POLIGLECAPRONE AND POLYPROPYLENE COMPOSITE MESH FOR
INGUINAL HERNIOPLASTY.
Br J Surg. 2008 Dec;95(12):1462-8. doi: 10.1002/bjs.6383.
Polish Hernia Study Group1, śmietański M.
CONCLUSION
Use of partially absorbable mesh reduced
postoperative pain in the short term. No difference
in pain or recurrence rates were observed at 12
months.

18. SELECTION OF A MESH – INGUINAL HERNIA

19. SELECTION OF A MESH – VENTRAL HERNIA

20. BIOLOGIC MESHES
May gain importance in the future
Extremely expensive
Advantage of using contaminated areas (1)
The first prospective randomized study for a biologic mesh derived from
porcine intestinal sub mucosa revealed promising results after Lichtenstein
repair, while the number of subjects is quite small (2)
Puccio et al. compared this biologic mesh with standard polypropylene and
partially absorbable meshes in Lichtenstein repair and found similar outcomes
for a short follow-up (3)
Laparoscopic use of this mesh is also feasible, but series are not large yet to
make a conclusion (4)
1. Franklin ME, Jr, Gonzalez JJ, Jr, Glass JL. Use of porcine small
intestinal submucosa as a prosthetic device for laparoscopic
repair of hernias in contaminated fields: 2-year follow-up.
Hernia. 2004;8:186–189
2. Ansaloni L, Catena F, Coccolini F, Gazzotti F, D'Alessandro L,
Pinna AD. Inguinal hernia repair with porcine small intestine
submucosa: 3-year follow-up results of a randomized controlled
trial of Lichtenstein's repair with polypropylene mesh versus
Surgisis Inguinal Hernia Matrix. Am J Surg. 2009;198:303–312.
3.Puccio F, Solazzo M, Marciano P. Comparison of three
different mesh materials in tension-free inguinal hernia
repair: prolene versus Vypro versus surgisis. Int Surg.
2005;90(3 Suppl):S21–23
4. Agresta F, Bedin N. Transabdominal laparoscopic
inguinal hernia repair: is there a place for biological
mesh? Hernia. 2008;12:609–612.

21. BIOLOGICAL MESH

22. SIZE OF THE MESH – INGUINAL HERNIA
VENTRAL HERNIA (SAGES)
• The optimal amount of prosthetic overlap over the defect has been poorly
studied and is not known. This is recognized by the Italian Laparoscopic
Ventral Incisional Hernia Guidelines, but they do recommend a minimum of
3cm overlap but note a trend to extend to at least 5cm overlap, especially in
larger defects.
• In laparoscopic repair, most surgeons use one of these sizes: 15 x 10cm, 15 x
12cm or 15 x 7.5cm. The recommendation is to adequately cover the
myopectineal orifice of Fruchaud.15/15 c.m is Ideal.

23. INSERTION OF THE MESH

25. MESH FIXATION WITH GLUE VERSUS SUTURE FOR CHRONIC
PAIN AND RECURRENCE IN LICHTENSTEIN INGUINAL
HERNIOPLASTY.
Cochrane Database Syst Rev. 2017 Feb 7;2:CD010814. doi:
10.1002/14651858.CD010814.pub2.
• Sun P1, Cheng X1, Deng S2, Hu Q1, Sun Y3, Zheng Q1.
• Based on the short-term results, glue may reduce postoperative chronic pain
and not simultaneously increase the recurrence rate, compared with sutures
for mesh fixation in Lichtenstein hernia repair. Glue may therefore be a
sensible alternative to suture for mesh fixation in Lichtenstein repair. Larger
trials with longer follow-up and high quality are warranted. The difference
between synthetic glue and biological glue should also be assessed in the
future

26. COMPARATIVE EVALUATION OF TAPP HERNIOPLASTY WITH
USE OF VARIOUS METHODS OF FIXING THE RETICULAR
ENDOPROSTHESIS AND TEP IN THE TREATMENT OF
INGUINAL HERNIAS.
• Georgian Med News. 2018 May;(278):15-20.
• Krikunov D1, Akimov V1, Toidze V1, Churgulia M1, Dvаladze L1.
• Laparoscopic transabdominal preperitoneal inguinal hernia repair in
combination with use of glue composition for fixation of mesh implant
improves the quality of life of a patient during post-operative period,
contributes to early discharge from the hospital and quicker recovery for
resuming job activities

27. HERNIA MESH
Material
Strength
Elasticity
Density
Pore size
Standard polypropylene mesh is most frequently
used one.
It is
cheap,
Easily available
non-absorbable, and strong enough to avoid
recurrence.
Foreign body sensation and chronic postoperative
pain have created a conflict about standard
polypropylene mesh.
Polyester mesh might be an alternative, but it
could not gain popularity.
Polyester meshes can degrade by time especially
in infected areas.

28. METHODS OF MESH FIXATION
• Staples
• Tacks
• Glue
• Anchor
• Sutures

30. DOUBLE CROWN TECHNIQUE
• The first crown was applied on the mesh periphery
with 1 cm between each 2 successive tackers .
• The second crown was applied around the edge of the
defect

33. VIDEOS

34. FINALLY….
• Today, standard polypropylene mesh still seems to be the choice for inguinal
hernia repairs. Its use provides low recurrence and complication rates.
• Newer and more expensive lightweight meshes may be considered in certain
situations as ……

35. POSSIBLE INDICATIONS FOR PARTIALLY ABSORBABLE
LIGHTWEIGHT MESHES IN INGUINAL HERNIA REPAIR
Current options in inguinal hernia repair in adult patients
H Kulacoglu
Hippokratia. 2011 Jul-Sep; 15(3): 223–231.

36. IN CONCLUSION
Mesh repairs are superior to "nonmesh" tissue-suture repairs in repair of inguinal
hernias
The advantages of the meshes well exceed their potential risk of complications
Selection of the mesh and it’s size depends on the size if the hernial orifice and
individual choice
15/15 c.m in inguinal hernia and minimum 5 c.m overlap in vetnral hernias are
essential to prevent the recurrence
Light weight or heavy weight meshes, long term results are not different
Precautions are must to prevent mesh infection
Fixation methods are individual preferences
Mesh complications must be recognised early with proper management

38. THANK YOU
Website- www.drvarunraju.com
Phone - 9866159160