Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана

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Clinically, Fumagalli etal. evaluated 96 patients in TAPP inguinal hernia repair and found no differences between the tack group and the self-gripping mesh group. Follow-up was 13.8months, and there was one recurrence in the tack group. They also concluded there trended to be less chronic pain in the self-grip­ping mesh group [12].

Historically, intraperitoneal mesh placement for ventral hernia repair stems from the Rives retrorectus repair, which was developed in the 1970s. The idea was that plac­ing the mesh behind the defect was better than on top of the defect. Prior to the popularity of the Rives repair, in the United States, it was standard to bridge a hernia defect with a prosthetic by suturing it to the fascial edges of the defect. Recurrence rates were signicant since the tissue the mesh was xated to was not strong enough to resist high intra-abdominal pressures. With the introduction of the laparoscopic repair of ventral/incisional hernias, the technique required, at that time, that the mesh be placed intraperitoneally. Initially point xation with staples was used, and this was then soon replaced by the “tack,” which gave better xation than the classic staple. We used our early experience with the Rives open repair, where suture

Basic science data comparing suture xation and tack xation for intraperitoneal mesh xation has shown that transfascial suture xation is biomechanically stron­ger. Van’t Riet etal. conducted a porcine model evaluating the differences in xa­tion strength between suture and tack in 1–5 different locations on a 7cm piece of mesh. For one point of xation, suture was signicantly stronger (67N vs 28N). For two points of xation, suture was again statistically stronger (115N vs 42N). For ve points of xation, there were no statistical differences though suture trended to be stronger (150N vs 82N) [15].

The standard of transfascial xation combined with tack xation of mesh has produced excellent clinical results. Heniford etal. reviewed 850 laparoscopic repairs with this technique and found a recurrence rate of 4.7% with mean of 20.2months follow-up [16]. For those surgeons not wanting to add suture xation to their repair, Morales-Conde described the “double-crown” method of intraperitoneal mesh xa­tion wherein an inner and outer ring of tacks are used for mesh xation. They reviewed 140 patients with 40months follow-up and found a recurrence rate of 2.1% [17]. Baccari etal. reviewed 200 patients with a double-crown tack technique with mean defects of 107cm2 and found a recurrence rate of 3.5% at 22months [18]. Wassenaar randomized three groups: tacks and permanent suture, double-crown tacks, and tacks and absorbable sutures. A total of 199 patients were studied, and there were only 2 recurrences (1 double-crown and 1 absorbable suture with tacks) [19]. Brill etal. conducted a meta-analysis reviewing 6015 patients with tacks and sutures and 2045 with tacks only and found no signicant differences in recurrence or chronic pain [20]. Alternatively, Leblanc etal. reviewed his rst 100 patients in 2001 and found that the recurrence rate was 9.3%. All patients with recurrence had been identied to have tack or staple xation without transfascial suture xation [21]. He followed up that study in 2007 with a meta-analysis reviewing whether transfacial sutures were necessary, but no rm conclusions could be made as the variations in suture placement could not be accounted for. By the numbers recurrence rates with suture xation were 4% and without were 1.8%. He did conclude that if no sutures were used, a larger overlap of the defect [3–5] was needed [22].

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into question the potential utility of brin glue xation. As newer preperitoneal and retrorectus techniques like laparoscopic and robotic preperitoneal ventral hernia repairs mature clinically, there will be a greater need for understanding the behav­ior of brin glue in this space.

At the same time that Rives was describing his retrorectus repair, Chevrel, also in France, described his onlay method for incisional hernia repair. Chevrel’s goals of repair were to recreate the linea alba with the anterior rectus sheath. This concept was based on cadaver studies he conducted that revealed the anterior rectus sheath was the next strongest part of the abdominal wall secondary to the linea alba. In his repair, he reconstructed the abdominal wall in three layers, which included a dou­ble-layer midline closure using the anterior rectus sheath and then placement of an onlay prosthetic. Chevrel’s approach to xation was revolutionary for the time. He sutured his onlay mesh but also described how to make and place brin glue on the midline closure. His outcomes were excellent with up to 20-year follow-up and a recurrence rate of 4.9% [25].

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