Sutureless "Slim-Mesh" Technique for the Repair of Abdominal-Wall Hernias in the Obese Population.

Background and Objectives: In 2009, we designed the sutureless “Slim-Mesh” laparoscopic technique to facilitate and promote repair of ventral hernias in the obese/superobese populations, including cases with large-giant/massive and multiple widely-spaced hernias. We also aimed to reduce surgical time and intra- and postoperative complications.

Cases were divided into Class I (body mass index [BMI] 30.0–34.9 kg/m2), II (35.0–39.9 kg/m2), III (40.0–49.9 kg/m2), and superobese (50.0–59.9 kg/m2). A ventral hernia was small-medium (∅ 2–9.9 cm), or large (∅ 10–14.9 cm)-giant (∅ 15–19.9 cm)/massive (∅ ≥ 20 cm). Between September 2009 and May 2023, 64 obese/superobese ventral-hernia patients were enrolled prospectively (81%)-retrospectively and treated with the Slim-Mesh technique.

We operated on 35 males and 29 females. Mean age and BMI were 60 years old and 33 kg/m2, respectively. Class I cases numbered 48, II 13, III 2, with 1 superobese case. Small-medium, large-giant, and massive ventral hernias were found intraoperatively in 40, 21, and 3 cases, respectively. Mean surgical time for all cases was 104 minutes. Mean length of hospital stay was 2 days and mean follow-up time was 5 years. We had 1 case of chronic abdominal-wall pain and 6 late postoperative-complications: 4 (6%) hernia recurrences, and 2 trocar-site hernias.

The sutureless “Slim-Mesh” technique implements the laparoscopic approach to repair ventral hernias in the obese/superobese populations rather than open surgery or traditional transfixation suture-based laparoscopy, including cases with large-giant/massive and multiple widely-spaced hernias. This study proves that “Slim-Mesh” is safe, straightforward, quick, easy-to-reproduce, and economical.

Hernia recurrence, Obese population, Obesity, Operation time, Slim-Mesh technique, Ventral hernia

Ventral hernias (VH) are commonly found in the abdominal-wall (AW) of the obese/superobese (O/So; Figure 1) populations during physical examinations, ultrasound (US) and/or CT-scans of the abdomen. Literature discusses various types of VH: epigastric, primary umbilical, paraumbilical, lumbar, traumatic and incisional, plus other less common defects of the AW (interparietal, Richter and Spigelian hernias1). VH repair is performed on over 1 million patients annually in the United States, including on the O/So populations, about 5% more than cholecystectomy, and it is currently the operation most routinely performed by general surgeons.1 Although most VHs are asymptomatic, they may develop acute complications that require emergency surgery in 30% of cases. In fact, VH-related complications are one of the most common reasons for emergency surgery on patients over 50 years old in the United States.1 The laparoscopic intraperitoneal onlay mesh technique (IPOM) was first introduced by Le Blanc in 1993 and is gradually replacing open VH-repair, also in the O/So populations, in many centers throughout the world.2–4 In fact, IPOM is gaining increasing acceptance, with novel aspects of the technique, plus novel instruments and prosthesis types being introduced. One aspect is IPOM plus, which involves the plication of the fascia, or linea alba, before the prosthesis is fixed onto the AW. Early IPOM studies indicate shorter surgical times and hospitalization, fewer wound-related and overall complications, and a lower rate of hernia recurrence than in open procedure.2–4 One disadvantage, however, is that the IPOM technique leads to chronic AW pain (1.6–28%5), one of the most common postoperative complications when permanent transfixation sutures are involved. Since the introduction of laparoscopic IPOM, there has been an ongoing dispute over the optimal method of prosthesis fixation onto the AW. In fact, postoperative chronic AW pain due to permanent transfixation sutures has led to a search for less penetrating fixation methods that also stabilize prosthesis anchorage in a bid to lower recurrence rate due to prosthesis shrinkage and migration.6 Another reason is that permanent transfixation sutures may break down, increasing the risk of VH recurrence to 5%.5,7 The “Slim-Mesh” (SM) technique is a novel laparoscopic sutureless procedure that was designed at Padua University Hospital in 2009. Since then, we have used it here for VH treatment, also in the O/So populations (Figure 1), without full-thickness stitches and other expensive alternatives for mesh intrabdominal introduction and/or fixation in order to eliminate the operative and postoperative complications related to full-thickness stitches and reduce surgical time8–21 (see SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw). Another aim of this study was to evaluate the findings of the first 64 consecutive SM VH repairs in the O/So populations, including giant-type VH (G ≥ Ø 15–19.9 cm) according to EHS classification22,23 (Figure 1); massive-type (M ≥ Ø 20 cm without loss of domain,16 see SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw); and multiple widely-spaced hernias (MWSH) described by the author S.A.C.18 (Figures 2 and 3). METHODOLOGY The SM procedure was performed on 64 VH O/So cases from September 2009 to May 2023 in our Department of Surgery (see SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw). It was a nonrandomized descriptive study involving a single center and approved by the Institutional Ethics Committee for the Province of Padua (contract no. 3902/AO/16). After being given detailed information about the SM technique, its advantages and risks, all O/So cases signed the SM consent form before they underwent SM surgery and agreed to the publication of their clinical and video records. Data on all SM cases were collected prospectively in a (Microsoft Excel) database, which was used to enroll and follow up the cases. The demographics included the cases’ gender, age, body mass index (BMI), WHO class of obesity (Class I BMI 30.0–34.9 kg/m2, Class II 35.0–39.9 kg/m2, Class III 40.0–49.9 kg/m2),13 and superobesity (So, using a common definition of So as massive obesity with a BMI ≥ 50.0–59.9 kg/m2),13 American Society of Anesthesiologists (ASA) class, preoperative or external size of fascial defect at physical examination, AW US and/or CT-scan, VH laparoscopic or internal neck-size diameter for circular-shaped VH, or major axis for oval-shaped ones (small-medium, S-Me: Ø 2–9.9 cm; large, L: Ø 10–14.9 cm; giant, G: Ø 15–19.9 cm; and massive, M ≥ Ø 20 cm, without loss of domain), multiple widely-spaced VH (MWSH). VH were defined MWSH when they were widely-spaced and/or often located at the opposite ends/sides of the AW and needing to be repaired in a single operation with multiple (2 or more) SMs. Furthermore, it was technically impossible to repair the MWSH with a single mesh, even when there were only 218 (Figures 2 and 3). Additional data collected comprised additional VH, mesh-type (composite or noncomposite) used, mean surgical time, estimated blood loss at suction, operative complications (e.g., organ iatrogenic lesions, bleeding, hematoma, cardiac event), conversion to open surgery, early (within 30 days after surgery) postoperative complications (e.g., chronic postoperative AW pain, hernia recurrence, adherence syndromes), readmission to hospital, reoperation, postoperative day when the case returns to oral intake, length of hospital stay, and the final outcome at follow-up (F.U.). The last F.U. for midterm results was carried out in Nov 2023, a minimum of 6 months after surgery. The F.U. surveillance program included an interview during an outpatients visit, which included a physical examination at 1 and 4 weeks and 3 months postoperatively. Patients underwent an identical interview, including a review of AW US results 6 months after surgery, and yearly thereafter. Surgical Technique Briefly, the SM technique involves 4 surgical phases: Laparoscopic exploration of the entire abdominal cavity with adhesiolysis when necessary,8,9 identification of possible additional VH, measurement of SM overlap (≥7 cm) for various sizes of VH, marking of 4 peritoneal axial points (PAPs), and measurement of peritoneal (internal) SM application area (SMAA).8–21 See SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw. Marking the 4 skin axial points (SAPs) corresponding to the 4 PAPs, and external measurement of skin (external) SMAA (Figures 1–3). Preparation of the SM on the operative bench by tailoring it to the corresponding skin (external) SMAA, markings its 4 axial points (APs), which correspond to the 4 SAPs and 4 PAPs. The SM is then handled and introduced through a 12-mm Ø-port into the abdomen as per the SM technique.8–21 SM 12-mm Ø-port introduction, orienting and fixation for VH repair.8,9 Basically, the peritoneal (internal) SMAA, skin (external) SMAA, and the mesh size and shape (Phase 3) must all be exactly the same. This means that the SM technique has been performed correctly as published.8–21 Fixation was achieved by anchoring the 4 APs of the SM correctly onto the 4 premarked PAPs with absorbable straps 6.7 mm long and at 1–2 cm intervals by anchoring the SM deeply in the AW. As SM fixation device we used Ethicon Absorbable SecureStraps which are made of a blend polydioxanone and L–lactide/glycolide copolymer. They are significantly absorbed after their critical AW integration period has occurred, and the polymer is considered essentially absorbed at approximately 12–18 months. They have a compact ergonomic profile with less implantable mass, less exposed surface, and a double anchoring point with maximum 6.7 mm AW penetration. Their tensile strength is reduced by 50% to 4 postoperative months, and their absorption is completed in 6 to 12 months. Moreover, the SM is fixed onto the AW with double crown-straps,24 according to the SM technique.8–21 The following technical details are important: in phase 1 (first laparoscopic step), methylene blue is used to mark the first PAP in the north (epigastric) or in the south (pelvic) in the event of having to repair epigastric or hypogastric VH, respectively. Moreover, in phase 4 (last laparoscopic step), extra straps are applied between the VH in the event of newly discovered hernias separated by bridges of fibrous parietal tissue.

VH were repaired with the SM technique in a total of 64 O/So cases. Mean age was 59.9 ± 1.8 years (mean ± SEM; range 31–82 years), mean BMI was 33.1 ± 0.4 (mean ± SEM; range 30–51). Table 1 lists the demographics, VH type and operative features for the 64 VH O/So cases undergoing SM surgery. The results were expressed as mean ± SEM (SD) and as numbers (%) (Table 1). Table 1. | Obesity Class | |||| |---|---|---|---|---| | O/So Cases and VH Clinical Features | I | II | III | So | | No. O/So cases M/F (total: 64 cases) | 28/20 (48) | 5/8 (13) | 2/0 (2) | 0/1 (1) | | Mean Age (60 years old) | 61 | 57 | 43 | 67 | | No. ASA 1/2/3 | 0/34/14 | 0/11/2 | 0/2/0 | 0/0/1 | | Mean BMI (33 kg/m² for all 64 cases) | 32 | 36 | 42 | 51 | | No. US/CT-scans/US+CT-scans | 14/28/6 | 6/5/2 | 1/0/1 | 0/1/0 | | S-Me VH (total: 40 [62%] cases) | 28 | 10 | 2 | 0 | | L-G (total: 21 [33%] cases)/M (total: 3 [5%] cases) VH at LAP | 17/3 | 3/0 | 0/0 | 1/0 | | MVSH (total: 3 [5%] cases) | 2 | 1 | 0 | 0 | | % total cases (28%) with difference between US and/or CT-scan and LAP VH neck-size cm Ø | 20.3%/Tot. | 4.7%/Tot. | 1.5%Tot. | 1.5%/Tot. | | AUVHs (total: 12 [19%] cases) | 7 | 3 | 1 | 1 | | Prostheses: CM (92%)/non-CM (8%) | 69%/7% | 19%/1% | 3%/0% | 0%/1% | | Fixation device: TT (5%)/AS (95%) | 3%/72% | 1%/19% | 0%/4% | 0%/1% | | Mean ST (overall = 104 minutes) | 104 min. | 108 min. | 97 min. | 110 min. | | Mean BL (overall = 8 ml) | 9 ml | 8 ml | 6 ml | 3 ml | | Intraoperative complications (B, OL, P, C) | 0/0//0//0 | 0/0//0//0 | 0/0//0//0 | 0/0//0//0 | M, male; F, female; ASA, American Society of Anesthesiologists; BMI, body mass index (kg/m2); O, obesity, Class I = BMI 30.0–34.9 kg/m2, Class II = BMI 35.0–39.9 kg/m2, Class III = BMI 40.0–49.9 kg/m2, So, superobesity using a common definition as “massive obesity with BMI = 50.0–59.9 kg/m2”; US, AW ultrasound; CT, computerized tomography; VH, ventral hernia; S-Me, small-medium (2–9.9 cm Ø circular hernias or major axis for oval ones); L, large (10–14.9 cm Ø); G, giant (15–19.9 cm Ø); M, massive (≥20 cm Ø) VH without loss of domain; LAP, laparoscopy; MVSH, multiple widely-spaced VH; AUVHs, additional VH undetected by US and/or CT-scan and found at LAP; CM, synthetic composite mesh; non-CM, synthetic noncomposite mesh; TT, titanium tacks (used from September 1, 2009 to September 30, 2013); AS, absorbable straps (used from October 1, 2013 to May 31, 2023); ST, surgical time; BL, blood loss; B, bleeding; OL, organ iatrogenic lesions; P, bowel perforation; C, conversion to open surgery. Overall, mean surgical time for the 64 cases was 104.6 ± 4.7 minutes (range: 52–295 minutes, mean ± SEM). Surgical time for 48 VH O/So Class I cases was 104.9 ± 5.2 minutes (range: 52–295 minutes, mean ± SEM); for 13 Class II cases, it was 108.4 ± 2.7 minutes (range: 60–150 minutes, mean ± SEM); for 2 Class III cases, it was 97.5 ± 1.3 minutes (range: 90–105 minutes, mean ± SEM); and for 1 superobese case, it was 110 minutes. The percentage of cases with large-giant/massive VH and multiple widely-spaced VH is reported in Table 1. Table 1 also reports the number of cases of conversion to laparotomy (0), as well as mean operative blood loss and complications. Time to return to oral intake was first p.o. day in 98% of cases and mean length of hospital stay was 2.2 ± 0.1 days (mean ± SEM). The mean duration of F.U. was 5 years + ½ year ± 4.2 months (range: 6–168 months, mean ± SEM). Cases were followed-up with an interview which included a physical examination and a review of AW US results 6 months after surgery, and then annually in accordance with the SM F.U. program. A 14-year F.U. showed 5 cases of early (<30 days after surgery) postoperative complications: 4 with seromas and 1 with AW pain. The latter case was an obese female who was reoperated with laparoscopy (LAP), which confirmed that the SM operation had been performed properly. The pain persisted at the third-month outpatient visit, but it had stopped spontaneously by the sixth-month visit as the straps were gradually absorbed. Six cases of late postoperative complications occurred: 4 with recurrences of a symptomatic hernia, 2 of them undergoing reoperation; and 2 with a trocar-site hernia which did not need surgery.

Over the last 2 decades, literature has reported lengthy surgical times when VHs were repaired in the O/So populations with the laparoscopic IPOM2–4,24 and permanent transfixation sutures. IPOM may also be responsible for a high rate of suture-related acute and chronic postoperative AW pain (1.6–28%),5 leading to research into mesh-fixation alternatives.6 Indeed, many laparoscopic VH-repair methods not using transabdominal full-thickness stitches have recently been described by literature: mesh fixation by double crown straps24; absorbable fixation devices; mesh anchorage with glue to reduce the number of straps or eliminate them6; self-gripping prostheses; and the AccuMesh™ (Covidien)25 or the Echo PS systems™ (Bard Davol)25; laparoscopic closure or plications of the hernia-neck before mesh fixation. Surgeons use this vast range of alternatives individually or in combinations in an unstandardized manner and will thus never have a clear view of their benefits and drawbacks.6 This study details the short/midterm results from a 14-year F.U. study of a novel sutureless straps-only fixation technique for VH treatment in the O/So populations called SM previously described by the authors8–21 (Figures 1–3). It is well-known that a mean F.U. time of 5 years is not adequate to determine long-term outcomes, especially when considering VH recurrence. Consequently, our data need to be confirmed by studies with a longer F.U. In our prospective study, 64 VH O/So cases, including some with L/G and M VH and MWSH, were operated with the SM technique between September 2009 and May 2023 (Table 1). In 28% of cases, the internal (laparoscopic) hernia-neck size was larger than its external (US and/or CT-scan) size. Additional undetected (AU) VHs were found during operation in 19% of cases (Table 1). AUVHs may not be visible in open surgery during VH repair because it does not reveal the entire AW surface as LAP does. Consequently, we recommend LAP with complete AW adhesiolysis, when necessary, in all VH O/So cases for correct clinical diagnosis and management of VHs and AUVHs.9 See SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw. During operation, we found that the adhesion force (AF) between the mesh and parietal peritoneum was the greatest when we used a “Type III biomaterial” rather than a “Type II,” as classified by Amid.26 We used mainly 2 Type III prostheses. ProceedTM (87%) and B|Braum Omyra® (8%). During the intraoperative phase 4, AF acts simultaneously with the elastic and tension forces of SM, resulting in a combined triple action. The elastic force is due to the shape memory of a mesh. This force is particularly strong when a Type III braided polypropylene composite prosthesis with high shape memory is used as an SM.8–21 In our experience, the combined triple action of these forces, unique to the SM sutureless technique, enables the surgeon to perform all SM fixation maneuvers safely, easily, and quickly with optimal SM distension and tension without wrinkling. We have already described8–21 the benefits of not using permanent transabdominal fixation sutures in terms of saving surgical time and reducing related operative and postoperative complications. Our early SM technique studies13 indicate a reduction in mean surgical time (104 minutes) in the O/So populations when compared with IPOM using the transfascial, nonabsorbable sutures described in the literature.27,28 This is lower than the mean surgical times in the series of O/So cases operated on by the authors Novitsky and Tsereteli, which were 178 and 154 minutes, respectively (Figure 4). When caring for VH O/So populations, we achieved our aim to reduce surgical time and consequently the duration of pneumoperitoneum for LAP, general anesthesia and mechanical ventilation which may lead to postoperative pulmonary (e.g., pneumonia and dyspnea29,30), cardiac (e.g., arrhythmias31), and circulatory diseases (e.g., pulmonary and venous thromboembolism32). Mechanical ventilation may induce pulmonary atelectasis, which may appear after induction of general anesthesia and recur postoperatively, potentially aggravating postoperative morbidity, especially in O/So cases.30 During general anesthesia, O/So populations encounter a greater risk of lung atelectasis and disease, as well as cardiac and circulatory diseases, than normal-weight cases, leading to extra healthcare costs.13,30 In addition, obesity and intra-abdominal insufflation for LAP are 2 well-known contributing factors to an increase in intrabdominal pressure.16,28 Abdominal insufflation pushes the diaphragm into the thorax, raising intrathoracic pressure and squeezing the lungs.16,33 This aggravates the risk of intra- and postoperative lung atelectasis and diseases due to general anesthesia and mechanical ventilation, especially in the O/So populations. We found and operated on L-G/M VHs16 (Figure 1) (see SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw) and MWSH18 (Figures 2 and 3) in 38% and 5% of O/So cases, respectively (Table 1), thus proving that the SM technique has optimal feasibility and reliability. When compared with open surgery, LAP also benefits gynecological patients especially when treating benign diseases34 or endometriosis,35 as stated in many studies. Moreover, in our opinion, the SM procedure has been beneficial for our group of VH O/So cases, with regard to duration of surgery and postoperative outcome.36 In our experience, the SM technique has helped us to extend the laparoscopic approach to an increasing number of VH O/So cases, including those with L-G and M VH (Figure 1) and MWSH (Table 1, Figures 2 and 3), which generally require open surgery. In our series of cases, we considered ≥ 7 cm beyond the perimeter of the hernia defect to be an adequate SM overlap for VH repair, as per Leblanc’s advice for larger meshes.24 Consequently, the entire perimeter of the hernia defect will be overlapped safely and correctly, thus ensuring good operation outcome in terms of a reduction in hernia recurrence (6%), especially in VH O/So cases, which have a higher rate of recurrence than normal-weight cases. See SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw. Moreover, AW tissue layers do not need to be dissected for SM placement as in the standard IPOM operation, with no dissection-related postoperative complications, such as hematomas, seromas and mesh infections. Despite this, IPOM procedure can engender postoperative adherence syndrome with high risk of intestinal occlusion and/or perforation, especially when spiral titanium tackers are used as devices for prosthesis fixation. These postoperative complications occurred more frequently when spiral tackers protrude from the fixed prosthesis,37 and this is why we used the Ethicon SecureStraps Fixation Device for most our SM operations, with their aforementioned benefits (Table 1). The following 5 basic principles of the SM technique may have been the game-changer for our reduced postoperative complications, including chronic AW pain and recurrence rate: no dissection of AW tissue layers; no AW drains; no transabdominal fixation sutures for mesh fixation; large or giant SMs, thus guaranteeing a safe overlap (≥7 cm); double crown absorbable straps24 for SM fixation. See SM YouTube video: https://www.youtube.com/watch?v=FCVgepXgLRw. Other prospective studies are needed to support and extend our findings on the safety and efficacy of the SM technique for VH repair in the O/So populations.

We believe that SM, a novel laparoscopic sutureless technique for VH repair in the O/So populations, simplifies the mesh’s introduction into a 12-mm Ø-port, as well as its orienting, handling, and fixation, because the SM is small, compact and easily manipulated. Furthermore, it requires no transabdominal fixation sutures or expensive alternatives for mesh introduction and/or fixation. The SM technique is safe, as it reduces morbidity and mortality; it also economical, simple, fast, easy-to-learn and -reproduce, even when treating VH O/So cases, including those with L-G and M VH and MWSH. Footnotes Conflict of interests: none. Funding sources: none. Disclosure: none. Ethical approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any experimental studies with human participants and/or animals performed by the authors. This study was approved by the Institutional Ethics Committee of the Province of Padua, contract no. 3902/AO/16, Jul 28, 2016. Authors’ contribution: S.A.C. invented the “Slim-Mesh” technique in 2009. He was the responsible for clinical management, wrote the manuscript, and supervised the editing. He presented the above abstract as a scientific paper at SLS MIS Week Congress in Orlando, FL, on September 26, 2024. It was awarded an Honorable Mention – Medicator Educator Consortium Award for Best Scientific Paper (see SM YouTube video: https://www.youtube.com/watch?v=hh_Ryl6GP5U). M.V. coassisted with postoperative management. Both authors read and approved the final manuscript. Informed consent: Dr. Silvio Alen Canton declares that written informed consent was obtained from the patient/s for publication of this study/report and any accompanying images. The authors thank Andrew Bailey for his supervision of the English version and Carla Brighenti for editing the photographs.

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