A. E. Berhanu1,2, S. G. Talbot1,2 1Brigham And Women’s Hospital,Division Of Plastic Surgery,Boston, MA, USA 2Harvard School Of Medicine,Boston, MA, USA
Introduction: Techniques for mesh installation in hernia repair are varied and can be improved by preventing recurrent herniation, reducing intraoperative visceral injury, and increasing procedural efficiency. We present a method of securing mesh (either prosthetic or biologic) as an underlay concurrent with component separation, with pre-placed sutures on the material, to the overlying fascia through an ‘inside-out’ technique using a Carter-Thomason suture passer. The Carter-Thomason is a sharp, narrow trocar (3mm diameter) with the ability to grasp a suture at the distal end. It was originally designed to aid with closure of laparoscopic ports by facilitating the placement of sutures through fascia around port sites.
Methods: The ‘inside-out’ technique was performed on 23 patients at a single tertiary academic medical center from November, 2011 to February, 2014. We have followed these patients for a median of 12.5 months to assess for post-operative complications and hernia recurrence. The innovative steps in this technique include (1) the preplacement of sutures on the mesh and removal of needles, (2) placement of mesh into the abdomen, and (3) retrieval of each end of the sutures with the Carter-Thomason for safe passage through the fascia from within the abdomen under direct visualization (Figure).
Results: There have been two recurrences (2/23=8.7%), one in a patient at 383 days post-operatively and the other at 311 days post-operatively. The former recurrence occurred in a patient who underwent repair for a recurrent ventral hernia and the latter patient had significant loss of domain requiring an inlay mesh. There were no hernia recurrences in patients who underwent repair of a primary ventral hernia with an underlay technique.
Conclusion: The ‘inside-out’ technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable. We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique. By pre-placing the sutures in the mesh, these can be evenly spread, giving the surgeon better control over the distribution of tension across the repair. The technique described here seemingly reduces the risk of bowel injury by allowing direct visualization of the entire path of the sharp instrument, the tip of the Carter-Thomason, as it passes through the rectus. Additionally, pre-placed sutures lie between the mesh and posterior rectus fascia, allowing the mesh to shield the viscera from the path of the Carter-Thomason.
