Surg Today (2001) 31:945–947

The Use of Needlescopic Instruments in Laparoscopic VentralHernia Repair

Nobumi Tagaya, Hiroshi Aoki, Hidetoshi Mikami, Hiroaki Kogure, and Keiichi Kubota

Second Department of Surgery, Dokkyo University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan

Surgical Technique

Following the induction of general anesthesia, the pa-tient is placed in the supine position. The first 12-mmport is introduced into the peritoneal cavity using anopen technique, away from the hernia defect and anyprevious abdominal incision. The number and positionof working ports are individualized depending on thesize, location, and number of hernia defects present. Inmost cases, three or four ports are required for thisprocedure. After inducing pneumoperitoneum, anangled 10-mm laparoscope is introduced into the perito-neal cavity. Initially, we divide and free any incarcer-ated viscera, and confirm the border of the hernia defectto be traced on the outside of the abdomen circum-ferentially. Subsequently, we mark the border line ofthe hernia defect and another line 3 cm away from thefirst border in all directions on the abdominal surface.The outer line corresponds to the size of the Gore-Texsoft tissue patch (expanded polytetrafluoroethylene (e-PTFE) patch: Gore & Associates, Flagstaff, AZ, USA)(Fig. 1). The e-PTFE patch is trimmed according to theouter line on the abdominal surface. Before the patch isinserted intraperitoneally, several sutures are placedand tied at four or more points around the entire patch.The patch is rolled longitudinally and inserted into theabdominal cavity through the first hole. Once the patchis unrolled, a tiny skin incision is made with a #11 bladescalpel at four or more points and the locations, whichare predetermined, are drawn on the abdominal sur-face. A 2-mm miniport (U.S. Surgical, Norwalk, CT,USA) is then inserted through the abdominal wall viathe incision site, and a 2-mm needlescopic instrument(grasper: U.S. Surgical), introduced through theminiport, is used to grasp one of the suture strand ends.The suture is pulled up through the abdominal wall andout through the puncture site (Fig. 2). This process isrepeated for the other strand and after both strand endshave been retrieved, the sutures are tied down with the

Abstract A successful laparoscopic hernia repair re-quires complete covering of the hernia defect, adequatetension of the prosthesis, and secure stapling with astapler. We describe herein our technique of perform-ing laparoscopic hernia repair using a needlescopicinstrument which results in minimal damage to the ab-dominal wall and has significant cosmetic benefits. Ourtechnique is easy to perform and useful for achievinginitial anchoring of the prosthesis before fixation to theabdominal wall with a laparoscopic stapler.

Key words Laparoscopic hernia repair · Ventral her-nia · Needlescopic instrument

Introduction

Several laparoscopic techniques for performing initialanchoring in ventral hernia repair have been re-ported.1–5 In fact, a number of researchers have intro-duced their own methods of using T-bars, the Carter-Thomason needle-point suture passer, the Keith needle,and the endoscopic suture passer. We also deviseda four-corner tacking technique using a Funada-type double-straight needle device (Create Medic,Yokohama, Japan); however, this technique is associ-ated with a risk of problems such as hernia recurrence.Furthermore, the early removal of the stay suture fol-lowing this laparoscopic technique causes an immaturemicroporous structure that allows collagen ingrowthand supports a continuous layer of mesothelial-like cellson the peritoneal surface. To resolve this problem, wedesigned a new technique involving the use of aneedlescopic instrument for the initial anchoring duringlaparoscopic ventral hernia repair.

Reprint requests to: N. TagayaReceived: October 18, 2000 / Accepted: May 15, 2001

946 N. Tagaya et al.: Laparoscopic Ventral Hernia Repair

knots lying in the subcutaneous tissue (Fig. 3). Thisprocedure is repeated for each respective suture placedin the patch. After fixation between the patch and ab-dominal wall is complete, the patch is further securedusing a laparoscopic stapler (Tacker: U.S. Surgical) totack it into the peritoneum and fascia between thesutures (Fig. 4).

Discussion

The goal of laparoscopic hernia surgery is to achievecomplete covering of the hernia defects and to performsecure stapling. The important aspects during laparos-copic ventral hernia repair are the method of initialanchoring and whether or not the stay sutures areremoved.

Several surgeons have described their own tech-niques of initial anchoring.1–5 The differences lie in thenumber of tacks and the tacking instruments used. Parket al.2 and Toy et al.5 adopted the four or more cornertacking of the patch. We also devised a four-cornertacking technique using a simple straight needle with anylon strand and a Funada-type double-straight needledevice. The four-corner tacking technique achieves asafe and secure stapling during the laparoscopic proce-dure.6 These devices have proven helpful for perform-ing the initial anchoring in laparoscopic ventral herniarepair, by shortening the operation time.

Regarding stay sutures, Toy et al.5 reported that theinitial method of using only staples provided inadequatefixation. They began to suture the mesh to the anteriorfascial layer with a suture passer instrument, and in-serted tacks or staples in the areas between the suturesites. We initially performed stapling only, with theearly removal of stay sutures during this procedure but

Fig. 1. The inner line (arrow) on the abdominal surface showsthe hernia defect and the outer line (arrowhead) shows thesize of the Gore-Tex soft tissue patch

Fig. 2. The suture was pulled up through the abdominal walland out through the puncture site by a needlescopic grasper. e-PTFE, expanded polytetrafluoroethylene

Fig. 3. The suture was tied down with the knot lying in thesubcutaneous tissue

Fig. 4. The patch was tacked into the peritoneum using alaparoscopic stapler

947N. Tagaya et al.: Laparoscopic Ventral Hernia Repair

after encountering a hernia recurrence, we considered amethod for retaining stay sutures. Toy et al.5 also statedthat the security of fixation was primarily due to thesutures. Heniford et al.7 reported a large series oflaparoscopic ventral and incisional hernia repair, with arecurrence rate of 3.4% (14/407). They emphasized thatlarge and nonabsorbable sutures appear to provide astrong and reliable fixation of the prosthesis, whereashernia tacks or staples should not be used for primarysources of attachment, but for filling gaps betweensutures. Therefore, we developed our method usingneedlescopic instruments with the permanent sutureslying subcutaneously to achieve secure fixation betweenthe patch and the abdominal wall.

There has been an increasing demand for needle-scopic instruments, including the needlescope, inlaparoscopic surgery.8,9 We have used needlescopic in-struments to perform cholecystectomy, intragastric sur-gery, unroofing of hepatic and splenic cysts and herniarepair, and have obtained good results with these proce-dures. Needlescopic instruments allow for minimaldamage to the abdominal wall, eliminate the risk ofincisional hernia, and achieve better cosmetic resultscompared with conventional laparoscopic instruments.We have had no problems manipulating or grasping thenylon strand and patch using needlescopic instrumentsduring this procedure.

We successfully performed this technique in threepatients, none of whom had any recurrences or majorcomplications during the follow-up period. Our tech-nique is a safe and quick way to achieve initial anchor-ing between the prosthesis and the abdominal wall,

reducing damage to the abdominal wall and providingcosmetic benefits. Furthermore, the stay sutures pro-vided us with more secure fixation of the prosthesis tothe abdominal wall. Thus, we believe that laparoscopicsurgery using needlescopic instruments will progressand become standard procedure in the 21st century.

References

1. LeBlanc KA, Booth WV (1993) Laparoscopic repair of incisionalabdominal hernias using expanded polytetrafluoroethylene:preliminary findings. Surg Laparosc Endosc 3:39–41

2. Park A, Gagner M, Pomp A (1996) Laparoscopic repair of largeincisional hernias. Surg Laparosc Endosc 6:123–128

3. Saiz AA, Paul D, Willis IH, Sivina M (1996) The use of T-bars inlaparoscopic ventral hernia repair. J Laparoendosc Surg 6:109–112

4. Franklin ME, Dorman JP, Glass JL, Balli JE, Gonzales JJ (1998)Laparoscopic ventral and incisional hernia repair. Surg LaparoscEndosc 8:294–299

5. Toy FK, Bailey RW, Carey S, Chappuis CW, Gagner M, JosephsLG, Mangiante EC, Park AE, Pomp A, Smoot RT Jr, Uddo JF Jr,Voeller GR (1998) Prospective, multicenter study of laparoscopicventral hernioplasty. Surg Endosc 12:955–959

6. Tagaya N, Mikami H, Kogure H, Ohyama O (1995) Laparoscopicrepair of an abdominal wall hernia using an expandedpolytetrafluoroethylene patch secured by a four-corner tackingtechnique. Surg Today 25:930–931

7. Heniford BT, Park A, Ramshaw BJ, Voeller G (2000) Laparos-copic ventral and incisional hernia repair in 407 patients. J Am CollSurg 190:645–650

8. Gagner M, Garcia-Ruiz A (1998) Technical aspects of minimallyinvasive abdominal surgery performed with needlescopic instru-ments. Surg Laparosc Endosc 8:171–179

9. Schauer PR, Ikramuddin S, Luketich JD (1999) Minilaparoscopy.Semin Laparosc Surg 6:21–31