A new method to insert the DualMesh prosthesis for laparoscopic ventral herniorrhaphy.

The introduction of the prosthetic biomaterial during the laparoscopic repair of incisional and ventral hernias can present a challenge. Presented herein is a simplified method to fold and unfold the DualMesh (W. L. Gore and Associates, Flagstaff, AZ) prosthesis during this operation.

INTRODUCTION

The repair of incisional and ventral hernias with the laparoscopic approach is rapidly becoming a popular choice for this problem. Comparative studies have documented the superiority of this repair over the open prosthetic repair.[1, 2, 3] Other reports have shown the cost-effectiveness of the laparoscopic repair over the open method.[4, 5] These studies and other long-term follow-up studies have supported the expansion of the use of this technique.[6, 7]

The adoption of this procedure requires the surgeon to learn the use of new instruments and techniques if not already familiar with them. One such concept is the introduction of the prosthetic biomaterial into the abdominal cavity. Many variations exist that I have either seen or personally used in the past. At least 1 report[8] has been published about the use of a suture to ease the unrolling of the patch with the abdomen. The DualMesh® Plus (W. L. Gore and Associates, Inc., Flagstaff, AZ) biomaterial is my prosthesis of choice. It is currently used in more than 75% of the cases reported in the literature of this procedure either as the Standard (nonantimicrobial) or Plus (antimicrobial) product. The method that I have developed for the introduction of the patch simplifies both the introduction of the prosthesis and the unfolding of it into the flattened material for fixation to the abdominal wall. This has proven to be especially helpful since I only use 5-mm trocars for this procedure.

TECHNIQUE

Once the adhesions have been dissected from the abdominal wall and the appropriately sized DualMesh® Plus has been chosen, the product is marked at the midpoints of both the long and short axes (. This has been previously described.[8] The preplaced sutures are placed onto the corduroy surface of the DualMesh® Plus (. This process is best completed on the surface of a flat metal pan or tray.

The parietal surface of the DualMesh® with the single marks at the midpoints of the short axis and the double marks at the midpoints of the long axis.

The central position of the preplaced expanded polytetrafluoroethylene on the prosthesis prior to folding.

The prosthesis is then sequentially folded into a small tubular shape along the long axis of the prosthesis. The first fold results in the patch being one half the size of the original. It is important at this first fold that the edges of the patch do not align perfectly. This exposes the previously placed marks, which will assist in the unfolding maneuvers once the patch is within the abdomen (. One or 2 more folds are then made along this axis (. The ultimate number and size of the final fold(s) will depend on which size of the prosthesis has been selected.

The first fold of the patch with uneven edges of the long axis.

Second fold of the patch.

Third fold of the patch.

The smaller prostheses, such as the 8 cm x 12 cm and occasionally the 10 cm x 15 cm, can be introduced without any further effort. This is not the case with the patches that are bigger than these sizes. These larger biomaterials will need to be twisted tightly. This is easily accomplished because the DualMesh® products are 50% air by volume. One can tighten this twist much like one would wring out a dishtowel. This will give the final appearance seen in . Even the largest patch (26 cm x 34 cm) can be introduced in this manner.

Twisted appearance of the patch prior to insertion into the abdomen.

The site of introduction will be the location of a trocar, ideally one that is laterally placed. I exclusively use 5-mm trocars for this operation. Because of this, the limitation for the introduction of the patch will be the size of the skin incision. This site must be 7 to 8 mm in length rather than 5 mm to allow the entry of the trocar. A strong grasping instrument is passed through the trocar placed at the site of the larger skin incision. The trocar is then removed.

The prosthesis is placed into the jaws of the instrument. The DualMesh® Plus is then pulled into the abdomen as the shaft of the grasper is rotated in a direction to maintain the twist of the patch as it enters the abdomen. Concomitantly, the assistant surgeon will also rotate the patch in the opposite direction so that the tightness is maintained on that portion of the biomaterial that is external to the abdomen.

The patch is not fully introduced at this point. Because of the tight twist that will result from the above maneuvers, the unrolling of that twist within the abdomen will be extremely difficult, frustrating, and time-consuming. To avoid this problem, a small portion of the patch is not introduced prior to unrolling the twist (. This is accomplished by 1 operator maintaining a firm hold on the external patch while the grasper is now rotated in the direction opposite the initially placed twist. In this way, the very tight roll of the patch is undone and the original folds are once again seen (. At that point, the entire patch is brought within the abdomen. There will, of course, frequently be a small portion of the twist that remains on that last part but this is easily undone when the prosthesis is unfolded.

Laparoscopic appearance of the twisted DualMesh® Plus prosthesis as it is introduced into the abdomen.

Laparoscopic appearance of the patch after the twist is undone just prior to the final introduction of the bio-material.

The folded patch is allowed to rest upon the bowel with the long axis parallel to the long axis of the abdomen. Now each surgeon grasps the double marks at the midpoints of the long axis with an instrument. These are then pulled in opposite directions so that the patch is unfolded (. This results in a patch nearly as flat as it was prior to folding. The larger prostheses will frequently not unfold at the very distal ends of the product. The 2 surgeons will need to work in concert to pull these edges apart so that the entire patch is as flat as possible. I find it much easier to fixate the prosthesis to the abdominal wall if the entire patch is flattened prior to attempting to bring the material upward to the undersurface of the abdominal wall. Once the patch is in this position, the surgeons can then continue the procedure in their usual manner.

Unfolding maneuver with graspers in opposing directions by the 2 operating surgeons.

CONCLUSION

The introduction of the DualMesh® products into the abdomen for proper placement in the laparoscopic repair of incisional and ventral hernias can be very difficult. A simplified method, which allows an easier introduction and flattening of the product (through trocars as small as the 5 mm), is presented.