Transfascial suture in laparoscopic ventral hernia repair; friend or foe?

'Suture hernia' is fairly a new and rare type of ventral hernia. It occurs at the site of transfascial suture, following laparoscopic ventral hernia repair (LVHR). Employment of transfascial sutures in LVHR is still debatable in contrast to tackers. Prevention of mesh migration and significant post-operative pain are the pros and cons with the use of transfascial sutures, respectively. We report an unusual case of suture hernia or transfascial hernia, which can further intensify this dispute, but at the same time will provide insight for future consensus.

INTRODUCTION

Laparoscopic ventral hernia repair (LVHR) is a technically simple procedure to perform but potential for complications are overwhelming. As per the literature, the recurrence rate for LVHR ranges from 4.7% to 29%.[12] Theoretically, there will be no recurrence if the basic principles of surgical repair including wide coverage and secure fixation are adhered to. The common causes of recurrence are technical, which include a missed hernia, inadequate mesh overlap and inadequate mesh fixation resulting in failure to cover the defect or migration of part or whole of the mesh.

Some surgeons advocate that sutures are unnecessary for mesh fixation because of excellent incorporation of mesh into the abdominal wall. However, many cases of mesh migration and contraction of various types of mesh have been reported.[3] These events after LVHR can predispose to recurrence.

Very few cases of hernia at the fixation site, either using suture or tacks, have been reported.[456] We hereby report an extremely rare case of ‘suture hernia’, which occurred following laparoscopic umbilical hernia repair with transfascial fixation of mesh. This type of hernia is 4th reported case of its type and second from our institution.

CASE REPORT

The 62-year-old female presented with reducible swelling in right lower quadrant for 5 months. She had a history of laparoscopic mesh repair for umbilical hernia 26 months back. During previous surgery, a single umbilical hernia defect was repaired with mesh (VYPRO, VICRYL PROLENE PARTIALLY ABSORBABLE SYNTHETIC SURGICAL MESH) of size 15 cm × 15 cm. Also, mesh was fixed with multiple metallic tacks and four transfascial sutures.

Patient was posted for laparoscopy surgery. Intra-operatively, patient was found to have a hernial defect of size 3 cm × 3.5 cm at the caudal edge of previous mesh [Figure 1]. After reducing the content of the hernia, a polypropylene suture material was found at the hernial defect margin [Figure 2]. So, it was labelled as suture hernia. Then, 10 cm × 15 cm dual mesh (BARD DULEX) was kept across the defect and fixed with tackers in double-crowing fashion. Post-operative period was uneventful and patient is doing well during follow-up.

Figure 1

Intra-operative image showing hernial defect with previous mesh and tacker

Figure 2

Old Prolene suture material at hernial defect margin

DISCUSSION

Mesh fixation technique is the most contentious discussed issue, even after 20 years of introduction of laparoscopic ventral hernia surgery in 1993 by LeBlanc and Booth.[7] There has been extensive comparative evaluation between tacks and transfascial suture fixation of mesh. Authors like Carbajo et al. claimed low recurrence rates of 1.4 and 4.4%, respectively, with tacks only fixation technique.[8] However, the major drawback of using tacks is risk of mesh shrinkage. In a study by Beldi et al., a significant decrease in mesh size was detected in the horizontal direction in tack fixation group compared with suture fixation group.[3] Schoenmaeckers et al. have reported that following double-crown fixation of expanded polytetrafluoroethylene (ePTFE) meshes, shrinkage rate was 7.5% after 17.9 months of surgery.[9]

LeBlanc in a review article reported that recurrence rate was about 4% with the use of sutures and 1.8% without their use.[10] Furthermore, he suggested that when sutures are not used then a larger overlap of the prosthesis (5 cm) is essential.

Fixation site related hernia recurrence was first reported by LeBlanc in 2003. He described two cases of recurrent hernia, post-laparoscopic mesh repair. In both cases, the hernia defect was adjacent to tacks. Hence, he coined the term ‘tack hernia’ for this new type of hernia.[6]

The first case of ‘suture hernia’ was published by Muysoms et al. in 2007. They reported two cases of recurrent ventral hernia wherein hernia defect was at the site of transfascial suture. Mechanism they described was, hernia occurred gradually through the hole, which was made during the passage of transfascial sutures.[4] In the first case, repair was done using a dual mesh, which was fixed with spiral tackers in double-crown configuration. Second case was repaired with ePTFE mesh and fixation was done with four transfascial orientation sutures applied at cardinal points and double row of spiral tackers.

A similar case was reported by Khandelwal et al. in 2010.[5] They described a case of recurrent incision hernia following LVHR. Laparoscopy revealed multiple hernial defects along caudal border of the mesh, where transfascial sutures were applied. Authors suspected that either too much tension on the sutures or improper tissue healing were responsible for recurrence. Hence, based on their experience they recommended that transfascial sutures should be applied with no tension and mesh must cover suture entry points. Furthermore, hernia defect repair was done using dual mesh and mesh was fixed with spiral tackers in double-crown fashion.

The possible cause of suture hernia in our case could be longstanding ischemia of entrapped tissue in the transfascial suture, resulting in a weak spot in the abdominal wall. This frail spot would have provided nidus for hernia formation. Hence, we suggest that transfascial sutures must not be applied too tight. Also, point of entry for passing suture, should not be too far so that amount of entrapped tissue can be minimised. Mesh shrinkage over a period exerts tension over transfascial suture, thereby leading to shearing effect over site of fixation. As a result, site of transfascial suture fixation may become fragile and can give rise to hernia formation. The mode of suture hernia repair in our case was similar to repair done for previously reported cases that are, use of large mesh and metallic tackers in double-crown pattern. Avoidance of transfascial sutures during second repair is just to prevent repetition of related events which can lead to formation of hernia.

So to conclude, transfascial suture hernia is a very rare form of recurrent hernia following LVHR. The exact patho-physiology is still not clear. In our opinion, technical flaw give rise to suture hernia. Though further debate is required to understand its physiology, following the basics of hernia repair can minimise the occurrence.