|Year : 2013 | Volume
| Issue : 2 | Page : 84-89
Fixation in laparoscopic incisional hernia repair: Suture versus tacks
Adil Bangash1, Nadim Khan2
1 Department of Surgery, Peshawar Institute of Medical Sciences, Peshawar, Pakistan
2 Department of Surgery, Lady Reading Hospital, Peshawar, Pakistan
|Date of Web Publication||23-Jul-2013|
Department of Surgery, Peshawar Institute of Medical Sciences, Peshawar
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To compare the frequency of complications of laparoscopic repair of incisional hernia using fixation of mesh with transabdominal sutures tacks. Materials and Methods: This study was conducted as part of an interventional multicenter trial at the Rehman Medical Institute, Peshawar, Peshawar Institute of Medical Sciences, and Pakistan Institute of Medical Science, Islamabad, from the 1 st of November 2008 till 31 st October 2011. The frequency of complications was calculated as the measure of comparing two methods of fixation in laparoscopic repair of incisional hernia using the IPOM technique. These patients were admitted via the outpatient department and their demographic data were collected on a pro forma basis. Forty-five patients were alternately placed in either group, and group I comprised patients with a ventral hernia that was fixed using spiral tacks whereas the other group was fixed with transabdominal sutures. A polytetraflouroethylene (Dual R ) mesh was applied in all cases. All data were collected onthe individual pro forma of each patient and was loaded on the SPSS R version 13.0. Results: The BMI in both groups was similar (P=0.94) The mean hospital stay was higher in the PTFE mesh group but the values were not significant (P=1.22).No perioperative death was observed in either group. One patient (2.2%) from group I was readmitted with varying complaints and was diagnosed as having subacute intestinal obstruction (P>0.05). A higher but insignificant recurrence rate was observed in the polyester group over a one-year period of follow-up. Three patients (6.6%) were diagnosed with recurrences in group I. Instead the PTFE group had a similar recurrence rate recurrence (P=1.00). Conclusion: The rate of recurrence in this study showed no significant difference by either mode of fixation. But statistically significant pain scores and increased operative time to fixation favors the use of tacks that limits to the few inner millimeters of the peritoneum.
Keywords: Incisional hernia, intraperitoneal onlay mesh, laparoscopic repair, tacks, transabdominal sutures
|How to cite this article:|
Bangash A, Khan N. Fixation in laparoscopic incisional hernia repair: Suture versus tacks. J Sci Soc 2013;40:84-9
| Introduction|| |
The 1980s saw a major turnover in the trends of surgical technique with minimal scars, earlier return to activity, and in maintaining the so-called milieu interior; but with time came changes such as complexity of the anatomy, newer instruments, and image processing that through a steep learning curve has made its way to finding a more firm position in the management of surgical patients.  Yet improving there has been many a case where apart from surgical technique, the materials used in surgery has been debated.  One such example is the use of nonabsorbable clips, tacks that is made usually of titanium or stainless steel. 
The debate to using these materials in laparoscopic surgery has been potentiated by novel concepts of no fixation meshes and use of fibrin glue for the laparoscopic fixation of intraperitoneal onlay meshes.  These novel fixation techniques prove great theoretical boundaries in cases of fixation of large-sized meshes for closure defects from incisional hernias.  The most common in use is the use of nonabsorbable spiral tacks (e.g., Protack R ). The use of this technique fixation is also demonstrated in laparoscopic inguinal hernia repair and for fixation of propylene mesh in rectopexy procedures for rectal prolapse. Other surgeons prefer to use the transabdominal suture with polypropylene that is knotted outside the abdomen and to which the surgeon has postoperative access. 
The choice of the fixation technique at the moment is one of surgeon preference and the availability of either method. This has been documented and compared in trials. Nguyen et al.  compared the frequency of postoperative pain in patients undergoing both fixation techniques. Apart from pain the theoretical risk of intra-abdominal adhesions between viscera and the parieties could be the cause for the postoperative incidence of adhesion obstruction following such repairs. ,,,, Controversy in laparoscopic repair centers on the tensile strength of the mesh fixation method. Recurrence is thought to be the result of inadequate or failed fixation.
By limiting the duration of contact and removal of transabdominal sutures at an earlier (yet to be defined) date, many of the above phenomena may well be avoided. Commercially available absorbable tacks and other such materials (such as clips) are also in common use now in some centers. The aim of this study was to compare the frequency of complications and postoperative pain in patients undergoing laparoscopic intraperitoneal placement of polytetraflouroethylene mesh (PTFE) mesh for incisional hernia, comparing the use of spiral tacks and transabdominal polypropylene sutures.
| Materials and Methods|| |
This study was conducted as part of an interventional multicenter trial from 1 st November 2008 till 31 st October 2011, comparing the outcome of laparoscopic incisional hernia repair using the polytetraflouroethylene mesh. Prior to the induction of the study, a formal application with relevant details of the safety of the procedure, current practices, and cost of the procedure with the plan of management of these patients was put forth by the ethical committee of Peshawar Institute of Medical Sciences. After obtaining a formal permission and the letter of approval the study was carried out at the Peshawar Institute of Medical Sciences, Pakistan Institute of Medical Sciences, and Rehman Medical Institute, Peshawar. Seven surgeons, all informed of the methods of practice, were allocated. Two groups included repair of incisional hernias with spiral tacks (group I) and transabdominal sutures (group II).
In a study conducted by Nguyen et al 50 patients were enrolled into two groups but randomization was not done and none of the studies comparing the methods of suture fixation had a follow-up long enough to document the frequency of recurrence. In reference to a study conducted by Colon MJ et al., where in the frequency of recurrence was 3%. The calculations for the present study were a 95% confidence interval with 5% margin for error revealed a sample size of 45 patients in either group over a follow-up period of one year.
All patients with a history of laparotomy for any cause that presented with a defect (incisional hernia) were admitted through the outpatient department and were explained their inclusion in a double trial of comparison of mesh and fixation technique. Those from group I had their PTFE mesh fixed with spiral tacks at 3-4-cm distance, yet four corners of the mesh were fixed by sutures by intracorporeal knotting technique. Group II had their mesh fixed with transabdominal sutures with SN polypropylene 2/0 at 4-cm interval with the number of sutures ranging from 10 to 20.
Preoperative relevant investigations were performed and females with fertility issues counseled. Those with recurrent hernias were excluded as were patients with comorbid conditions. The size of the defect detected clinically and by sonography was recorded on a proforma basis. Preoperative data were obtained from operative notes and check to the time of fixation noted rather than the total operative time.
Postoperatively, resumption of oral feeds was made according to the discretion of the surgeon attending based on the reappearance of bowel sounds or passage of flatus. Simultaneously the pain score was recorded using the Pain Rating Scale R that observes verbal score from 1 to 10. These recordings were made at 6 hours, 24hours, 1 week, 1 month, and 3 months after surgery. During the same duration any other complaints and follow-up of complications was also done, that included seroma, wound infection, pulmonary complication, bowel obstruction, and perioperative (30 days) mortality. The frequency of recurrence was recorded in a one-year follow-up. This follow-up protocol was performed in the hospital, outpatient department, telephonic conversations, and from hospital records.
All data were collected on the individual pro forma of each patient and was loaded on the SPSS R version 13.0. All demographic data regarding patients were compared between groups and other preoperative data pertaining to the management were documented on tabulated form. Pain scores at varying intervals were compared using paired student-t test.
The rest were tested for significance by the Chi-square test. A value of <0.05 was considered significant and to rule out any confounding variables such as sex and age multivariate analysis was performed.
| Results|| |
Forty-five patients grouped into the suture and tacks group all underwent laparoscopic repair and placement of a PTFE mesh in three centers exercising in the laparoscopic repair of incisional hernias. The patients from the tacks group were older than the suture group with an insignificant difference not confounding results as checked by the multivariate analysis. Males were predominant in both groups and having enquired the original reason for laparotomy, most cases were secondary to trauma (firearm injuries, road traffic accidents, and bomb blast victims). These differences were not significant with a P value >0.05.
The mean duration from first surgery varied tremendously between patients, of course the discretion on behalf of the surgeon to decide a timing was not recorded. The BMI of the patients from both groups fell to a favorable range and no significant differences were observed (P=0.94).
The study included all ranges of defects; and any conversions to open repair, were excluded from the study as were those patients that were lost to follow-up. This could be afforded due to the alternate placement of patients in groups without a proper sample frame of patients being initially enrolled in the study. The defect size was slightly greater in the tacks group, with a mean of 9.6 cm in length (P=1.05). The area of the defect was not documented for purpose of ease, also considering all were midline laparotomy incisions (the first surgery).
The operative details were collected from operative notes that were greater in the suture group (P=0.72). The possibility of individual cases confounding the time to completion was rectified by collection of the time to fixation after completion of adhesions and to no surprise the fixation time in the tacks group was much less than the suture group. This difference was a mean of approximately 30 min (P=0.01). Still more the hospital stay was also greater but that finding was not significant [Table 1].
One postoperative death was observed on the day following to death and attributed to pulmonary embolism. Eight patients in total from both groups were diagnosed with a pulmonary complication (8.8%). Two patients both in the older age group had a postoperative myocardial infarction documented, one of which had no antecedent history. The frequency of seroma after repair was a staggering 13.3% in the suture group that did not differ from the tacks group statistically(P=0.97) [Table 2].
Wound infection was not a detrimental factor in majority of patients, with neither case requiring removal of mesh following re-exploration and all settled with antibiotics irrespective of both groups (P=0.89). Adhesion obstruction was one patient from each group (2.2%) and both cases settled with relevant conservative management.
The backbone of this study was to test the tensile strength of the mesh following fixation that was a major factor in prevention of recurrence, even though observing a 5-cm overlap with an adequately sized mesh the frequency was 6.6% in both groups (P=>0.05).
The postoperative period had another observation that was worth mentioning: the high doses of analgesia in the form of diclofenac sodium and tramdol during the first week in both groups. The average first 24-hour requirements from both groups were similar: 128.2mg of diclofenac sodium I/M and 57.6mg of I/V Tramadol. This figure was not alarming but the later weeks pain chart readings observed a significantly higher mean score in the suture group. At one week postoperation the mean score of the suture group remained at a mean of 5.9(+1.7). This in comparison to the tacks group was 3.2(+0.89) which was high but on application of statistical test was insignificant. The findings beyond 1 month were statistically significant with majority presenting for workup of a suspected intra-abdominal pathology (P<0.05). Without doubt the pain scores were statistically significant till the third month but at one year only 6(6.6%) patients comprising from both groups had complaints of pain at the suture site [Figure 1].
| Discussion|| |
The introduction of the laparoscopic repair of ventral hernias and incisional hernia advanced great distances in the field of biomaterials since 1993.  The need for the right type of incorporated mesh has been most debated. What had been neglected was the tensile strength of the construct following the diminishing of the pneumoperitoneum at the end of the procedure. For this reason it is recommended to use a 5-cm overlap in all directions from the defect.  In this study we used a standard mesh made of PTFE that was fixed by both techniques in equal numbers. , Sutures pass through all layers of the fascia and muscle of the anterior abdominal wall, while tacks secure the mesh to the innermost millimeters of the peritoneal cavity.
The fact that earlier studies like ours focused on the effect of postoperative pain and majority limited to the 3-month interval from which no record of any early recurrence has been documented. In a study conducted by Casey et al.  and another by Bansal et al.  there were no records to suggest a rate of early recurrence due to the short duration of the study.
That patients included in this study belonged to the same region with the male predominance being explained by the indication for the first surgery being trauma in most cases and this was statistically significant. In comparison to the study conducted by Carbajo et al.  this male predominance was not observed.
Majority of the patients in this study had a normal to high normal BMI with a mean of 23.9 in the suture group, in contradiction to many Western studies where the BMI lies well over 30.  The figures of recurrence rates by the laparoscopic repair have been well documented by the studies to be much lower in most Western studies (3% vs 30-50%). ,,,,,,,,, This is also observed in our study but the frequency of recurrence at one year for both modes of fixation of the standard PTFE mesh is similar (6.6%).
Anecdotally, pain is generally worse after repair with sutures than with tacks. Sutures penetrate through the full thickness of abdominal wall musculature and fascia. This has been theorized to cause local muscle ischemia resulting in severe pain postoperatively. In addition, numerous sutures are typically needed around the perimeter of the hernia defect. Because mesh overlap on normal muscular fascia is usually aimed for around 5 cm, the circumference around which sutures must be secured becomes quite large. Convincingly, in our study the pain chart scores in the first 24 hours showed no statistical difference but the 1-month mean scores as well as the 3-month mean scores showed a statistically significant difference. Nguyen et al.  , who conducted a pilot study for such a case, found no statistically significant difference between pain scores in the following week and their study limited to the 3-month period also failed to determine the rate of recurrence in either group as well as the use of a standard mesh such as in our study.
The theories behind the cause for this chronic agonizing pain remains many such as as suggested by Cobb et al.  , who claim that the pain is persistent neuropathic pain as a result of intercostals nerve entrapment. Some recommend repeated intercostal and local nerve blocks that were not instituted in our series like in their study and majority settled on oral analgesics. To add to more confusion, the study of LeBlanc et al. noted that patients in the earlier half of their series had more pain. These patients had fewer sutures used, suggesting the use of these sutures was unrelated to postoperative pain.
Regardless of the cause for pain in the suture group, the dilemma about the operative fixation time calculated no longer exists. Our study showed beyond doubt that procedure when using tacks which was quicker and proved to be statistically significant. , This was also observed in other studies with slightly varying designs. The only perception on behalf of the surgeon was because earlier studies failed to demonstrate a difference between the total time of surgery in comparison to time only to fixation of the mesh.
Seroma remained an issue regardless of the method of fixation following laparoscopic incisional hernia repair. It was 13.3% in the suture group but statistically not significant and like other studies conducted by Parker et al.  seroma formation directly above the mesh was the most frequent complication but not requiring removal of mesh, although repeated aspirations were done and only a small number of patients required repeated aspirations after 8 weeks.
Tendency of such intra-abdominal biomaterials can also be a cause for adhesion obstruction and fistulation but these were not observed in most series although two of our patients (4.4%) had readmissions for the management of subacute intestinal obstruction. There was one perioperative mortality case in our study attributed to pulmonary embolism. Selective policy to prophylactic administration of low molecular weight Heparin was administered by attending surgeon.
| Conclusion|| |
With an adequately enrolled number of patients and a modest duration of follow-up the rate of recurrence in this study showed no significant difference by either mode of fixation. But statistically significant pain scores and increased operative time to fixation favors the use of tacks that limit to the few inner millimeters of the peritoneum.
| References|| |
|1.||Franklin ME, Gonzalez JJ Jr, Glass JL, Manjarrez A. Laparoscopic ventral and incisional hernia repair: An 11-year experience. Hernia 2004;8:23-7. |
|2.||LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: Preliminary findings. Surg Laparosc Endosc 1993;3:39-41. |
|3.||Soler M, Verhaeghe P, Essomba A, Sevestre H, Stoppa R. [Treatment of postoperative incisional hernias by a composite prosthesis (polyester-polyglactin 910). Clinical and experimental study]. Ann Chir 1993;47:598-608. |
|4.||van't Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, Steyerberg EW, Bonjer HJ. Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair. Surg Endosc 2002;16:1713-6. |
|5.||Parker HH, 3rd, Nottingham JM, Byone RP, Yost MJ. Laparoscopic repair of large incisional hernias. Am Surg 2002;68:530-3. |
|6.||Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg 2007;142:562-7. |
|7.||Nguyen SQ, Divino CM, Buch KE, Schnur J, Weber KJ, Katz LB, et al. Postoperative pain after laparoscopic ventral hernia repair: A prospective comparison of sutures versus tacks. JSLS 2008;12:113-6. |
|8.||Kossovsky N, Freiman CJ, Howarth D. Biomatrial pathology. In: Bendavid R, editor. Abdominal wall hernias. New York: Springer-Verlag; 2001. P. 221-34. |
|9.||Temudom T, Siadati M, Sarr MG. Repair of complex giant or recurrent ventral hernias by using tension-free intraparietal prosthetic mesh (Stoppa technique): Lessons learned from our initial experience (fifty patients). Surgery 1996;120:738-43. |
|10.||Rives J, Pire JC, Flament JB, Palot JP, Body C. Treatment of large eventrations. New therapeutic indications apropos of 322 cases. Chirurgie 1985;111:215-25. |
|11.||Wantz GE. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet 1991;172:129-37. |
|12.||Debord J, Whitty L. Biomaterials in hernia repair. Mastery of Surgery. Vol. 2. In: Fischer J, editor. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 1965-7. |
|13.||Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic ventral hernia repair: A community hospital experience. Am Surg 1996;62:336-8. |
|14.||Costanza MJ, Heniford BT, Arca MJ, Mayes JT, Gagner M. Laparoscopic repair of recurrent ventral hernias. Am Surg 1998;64:1121-5. |
|15.||Matthews BD, Pratt BL, Pollinger HS, Backus CL, Kercher KW, Sing RF, et al. Assessment of adhesion formation to intra-abdominal polypropylene mesh and polytetrafluoroethylene mesh. J Surg Res 2003;114:126-32. |
|16.||Colon MJ, TelemDA, Chin E, Weber K, Dovino CM, Nguyen SQ. Polyester Composite versus PTFE in Laparoscopic Ventral Hernia Repair. J Soc Lap End Surg 2011;15:305-8. |
|17.||Casey JB. Postoperative Pain After Laparoscopic Ventral Hernia Repair: A Prospective Comparison of Sutures Versus Tacks. JSLS 2009;13:120-1. |
|18.||Bansal VK, Misra MC, Kumar S, Rao YK, Singhal P, Goswami A, et al. A prospective randomized study comparing suture mesh fixation versus tacker mesh fixation for laparoscopic repair of incisional and ventral hernias. Surg Endosc 2010;25:1431-8. |
|19.||Carbajo MA, Martp del Olmo JC, Blanco JI, Toledano M, de la Cuesta C, Ferreras C, et al. Laparoscopic approach to incisional hernia. Lessons learned from 270 patients over 8 years. Surg Endosc 2003;17:118-122. |
|20.||Raftopoulos I, Courcoulas AP. Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/ m 2 .Surg Endosc. 2007;21:2293-7. |
|21.||Malik AM, Jawaid A, Talpur AH, Laghari AA, Khan A. Mesh versus non-mesh repair of ventral abdominal hernias. J Ayub Med Coll Abbottabad 2008;20:54-6. |
|22.||Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989;124:485-8. |
|23.||Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176:228-34. |
|24.||Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578-83. |
|25.||Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: A meta-analysis. Ann Surg 2000;231:436-42. |
|26.||Awad ZT, Puri V, LeBlanc K, Stoppa R, Fitzgibbons RJ Jr, Iqbal A, et al. Mechanisms of ventral hernia recurrence after mesh repair and a new proposed classification. J Am Coll Surg 2005;201:132-40. |
|27.||George CD, Ellis H. The results of incisional hernia repair: A twelve year review. Ann R Coll Surg Engl 1986;68:185-7. |
|28.||Blount AL, Craft RO, Harold KL. Safety of laparoscopic ventral hernia repair in octogenarians. JSLS 2009;13:323-6. |
|29.||Clarke JM. Incisional hernia repair by fascial component separation: Results in 128 cases and evolution of technique. Am J Surg 2009;200:2. |
|30.||Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133:378-82. |
|31.||Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin N Am 2005;85:91-103. |
|32.||LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic incisional and ventral hernioplasty: Lessons learned from 200 patients. Hernia 2003;7:118-24. |
|33.||McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SRG, Laycock WS, Birkmeyer JD. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surg Endosc 2003;17:1778-80. |
|34.||Heniford B, Park A, Ramshaw BJ, Voller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190:645-50. |
|35.||Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996;6:123-8. |
[Table 1], [Table 2]