This research was supported by the Guangdong Science and Technology Plan Project (grant number: 2021A1515410004) and the National Key Clinical Discipline (grant number: [2012]649).

The protocol was carried out in accordance with the tenets of the Declaration of Helsinki and approved by the Ethics Review Committee of the Sixth Affiliated Hospital of Sun Yat-sen University.
The patients and families were informed of the purpose of shooting and making the surgical video, and informed consent was obtained.
1. Patient data and grouping
NOTE: From January 2018 to June 2020, laparoscopic incisional hernia repair using the IPOM method was performed during gastrointestinal, hernia, and abdominal surgery at the Sixth Affiliated Hospital of Sun Yat-sen University. After obtaining informed consent, a total of 84 patients with incisional hernias were included in the study.
<ol>
	<li>Enroll patients based on the inclusion criteria (adult patients diagnosed with incisional hernias) and exclusion criteria (age &#8804;18 years or &#8805;80 years; emergency operation; strangulated incisional hernia; recurrent incisional hernia; the presence of severe organ dysfunction). 
	NOTE: The characteristics of the two groups, including the patient&#39;s age, sex, and body mass index (BMI), the length of time the hernia was present, and the maximum size of the hernia ring defect, are shown in Table 1. There were no significant differences in characteristics between the two groups (all P &#62; 0.05).</li>
	<li>All the operations were performed by the same group of surgeons, who received standardized training and had rich experience in laparoscopic surgery.</li>
</ol>
2. Necessary preparation and examination before the operation
<ol>
	<li>Carry out preoperative examinations, including routine blood tests, blood biochemistry tests, routine urine tests, a routine stool test, a chest X-ray, an electrocardiogram, and an abdominal CT.</li>
	<li>For a giant incisional hernia, use preoperative botulinum toxin A (BTA) and preoperative progressive pneumoperitoneum (PPP) for the surgical preparation11.</li>
	<li>Administer fentanyl at 4 &#181;g/kg using another pump at a rate of 250 &#181;g/min simultaneously with propofol administration. Intravenously inject cisatracurium (0.2 mg/kg) after the patient is anesthetized.
	<ol>
		<li>Subsequently, intubate the patient with the help of an experienced anesthesiologist 4 min after the muscle relaxant injection. Next, mechanically ventilate the patient with sevoflurane 1% inhalation with the following respiratory parameters: tidal volume, 8 mL/kg; respiratory rate, 12 breaths per minute. 
		NOTE: The anesthetic maintenance drugs were sevoflurane 1%-3%, propofol 1-3 mg/kg/h, remifentanil 0.05-0.3 &#181;g/kg/min, cisatracurium 0.15-0.2 mg/kg, and 1/5-1/3 of the additional induction amount every 0.5-1 h12.</li>
	</ol>
	</li>
	<li>Use 0.5% PVP-I disinfectant to disinfect the surgical area. The upper part of the disinfection range should reach the nipple line on both sides, the lower part should reach the pubic symphysis, and both sides should reach the midaxillary line.</li>
	<li>After endotracheal intubation, place the trocars using the method of &#65279;modelized trocar arrangement. Determine the locations of the trocar placement based on the preoperative computed tomography (CT) images and the assessment of the abdominal adhesions13. 
	NOTE: For example, the case in this video is a lower abdominal incision hernia, which requires a total of five puncture tubes. A 12 mm puncture device is placed 10 cm above the belly button, 12 mm and 5 mm puncture tubes are placed at the left and right clavicular midlines, and 5 mm puncture tubes are placed at the left and right axillary midlines.</li>
	<li>Establish carbon dioxide pneumoperitoneum, and maintain the pneumoperitoneum pressure at 13 mmHg.</li>
	<li>Explore the whole abdominal cavity, evaluate the degree of abdominal adhesion around the hernia ring, and separate the adhesion.</li>
	<li>Close the defect of the hernia ring by continuous suture with a 1-0 barbed suture.</li>
</ol>
3. Measurement of the size of the hernia ring defect and anti-adhesion mesh marking
<ol>
	<li>Select an appropriate size anti-adhesion mesh (see Table of Materials) according to the size of the hernia ring defect, and then mark the mesh with a sterile marking pen as described below. 
	NOTE: A commercially available anti-adhesion mesh was used here, which contains a polypropylene mesh on the anterior side with an absorbable hydrogel barrier on the posterior side for laparoscopic hernia repair. The hydrogel barrier on the mesh prevents adhesion, and the mesh on this side should face the viscera.
	<ol>
		<li>Measure and mark the approximate range of the incisional hernia on the abdominal wall surface with a sterile ruler and marking pen (Figure 1A).The size of the hernia ring defect can also be measured by a preoperative CT examination.</li>
		<li>Place the ruler parallel to the longitudinal axis of the hernia defect, and measure the maximum longitudinal length of the defect (Figure 1B).</li>
		<li>Select an appropriately sized anti-adhesion mesh according to the size of the hernia ring defect. Ensure that the coverage of the mesh exceeds the edge of the defect by at least 5 cm. For example, for an incisional hernia defect of size 7 cm x 5 cm, use a mesh approximately 20 cm x 15 cm in size (Figure 1C).</li>
		<li>Mark the longitudinal length of the defect on the mesh, and mark the nail gun fixation points at intervals of 5 cm on the longitudinal axis. Then, extend the fixation points more than 5 cm along the marked line to the edge of the mesh, which pertains to the &#34;alignment&#34; (Figure 1D).</li>
		<li>Mark the nail gun fixation points evenly every 2-3 cm along the edge of the mesh, which pertains to the &#34;contraposition&#34; (Figure 1E).</li>
		<li>Finally, ensure that the fixing points of the nail gun are uniformly marked 2 cm from the longitudinal axis of the defect on both sides, with an interval of 3 cm (Figure 1F).</li>
	</ol>
	</li>
</ol>
4. Mesh placement method
<ol>
	<li>Roll the mesh such that the anti-adhesion surface will face the abdominal wall. Place the rolled mesh into the abdominal cavity through the 12 mm puncture hole, and then unfold the mesh under laparoscopic guidance (see Table of Materials, (Figure 2B).</li>
	<li>Reduce the pneumoperitoneum pressure to 8-10 mmHg.</li>
	<li>Ensure that the marked line of the unrolled mesh overlaps the longitudinal axis of the hernia ring defect (Figure 2C).</li>
	<li>Fix the marked points on the longitudinal axis of the mesh to the abdominal wall with non-absorbable nails using a nail gun (see Table of Materials; (Figure 2D).</li>
	<li>Fix the edge of the mesh to the abdominal wall along the marked points on the edge of the mesh with non-absorbable nails using a nail gun (Figure 2E).</li>
	<li>Fix the mesh on the abdominal wall along the marked points on both sides of the longitudinal axis of the mesh with absorbable nails using a nail gun (Figure 2F).</li>
	<li>For the control group, flatten the mesh to cover the abdominal wall defect and fix the mesh using the double-loop mesh fixation method9,14.</li>
	<li>For the double-ring fixing method, do not mark the mesh.
	<ol>
		<li>First, place the fixing nails along the edge of the mesh to ensure that the distance between the nails and the edge of the mesh is about 2-4 mm and that the distance between the nails is about 2-3 cm.</li>
		<li>Then, fix the mesh along the outer edge of the hernia ring defect about 2 cm away from it, with a distance between the nails of 3-5 cm 
		&#8203;NOTE: See Figure 3A-D for this method.</li>
	</ol>
	</li>
</ol>
5. Follow-up
<ol>
	<li>Perform postoperative follow-up, including outpatient visits and telephone consultations, for 3 months to 24 months. 
	NOTE: In this study, the median follow-up time was 12 months. A physical examination and abdominal wall color ultrasound were performed in the first month after the operation, and an abdominal CT was performed at 3 months, 12 months, and 24 months after the operation.The follow-up time was 24 months after the operation.After all the follow-ups, the case data were collected and compared.</li>
	<li>Record the occurrence of seromas, hernia recurrence, chronic pain, and mesh infection. 
	Seroma can be diagnosed by an abdominal wall color ultrasound, hernia recurrence and mesh infection by an abdominal CT, and chronic pain by a pain rating scale.In particular, carry out an abdominal CT examination with patients 3 months after surgery, and then compare the results with the preoperative abdominal CT images to evaluate the surgical treatment effects and whether there is a recurrence of the incisional hernia (Figure 4A-F).</li>
</ol>
6. Statistical analysis
<ol>
	<li>Compare the time required for mesh placement, seroma formation, mesh infection, hernia recurrence, chronic pain, the length of hospital stay, and the hospital costs between the two groups. 
	NOTE: In this study, the measurement data (age, BMI, disease time, mesh placement time, length of hospital stay, and hospitalization costs) were expressed as mean &#177; standard deviation, and the count data (gender, maximum defect of the hernia ring, seroma, mesh infection, hernia recurrence, and chronic pain) were expressed as a count and percentage.</li>
	<li>Compare the measurement data between the groups using a t-test, and compare the count data using a chi-square test. A value of P &#60; 0.05 was considered to indicate a statistically significant difference in this study.</li>
</ol>

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The authors have no conflicts of interest to disclose.

Laparoscopic incisional hernia repair is primarily performed using the IPOM method5, for which the placement and fixation of the mesh are key to achieving good outcomes. If the placement and fixation of the mesh are improper, the mesh will not adhere tightly to the abdominal wall and may be wrinkled or displaced. Improper mesh fixation is associated with seroma formation, abdominal infection, chronic pain, and hernia recurrence. Specifically, the treatment for mesh infections involves puncture and drainage. Postoperative pain associated with mesh infection is often treated conservatively, and poor treatment may necessitate further surgery to remove part or all of the mesh15,16. In order to avoid these complications, it is crucial to master the correct mesh placement and fixation technique. The mesh fixation methods commonly used in laparoscopic incisional hernia repair include hernia nail fixation, suture fixation, and medical adhesive fixation17,18,19. Nail fixation has the advantage of being a simple procedure with a short operation time, and this is the most commonly used method of mesh fixation20. However, the use of hernia nails, especially non-absorbable nails, and the number of nails placed are closely related to the risk of postoperative pain21,22. The use of hernia screws to fix the mesh in certain areas, such as near the external iliac artery and vein in the inguinal region or in the pericardial area of the diaphragm, is associated with an increased risk of massive bleeding23,24. Suture fixation methods include crochet puncture suture fixation, simple suture fixation, and other improved methods25. The main advantages of suture fixation with full abdominal wall suspension are that, with this technique, it is easy to flatten the mesh, and the cost is much lower than that of nail gun fixation. However, using non-absorbable sutures placed through the fascia to fix the mesh is associated with a higher incidence of postoperative pain than hernia nail fixation26. With crochet puncture suture fixation, the crochet needle needs to penetrate the skin into the abdominal cavity, which significantly increases the risk of mesh infection. The use of medical adhesive for mesh fixation is simpler and less expensive, but the fixation with medical adhesive alone is not strong enough, which increases the risk of hernia recurrence27. In addition, the glue block formed during the application of the chemical medical adhesive can affect the process of cell growth and peritoneal mesh formation28. As such, the use of medical adhesive for fixation is only recommended in areas for which the use of nails or sutures may increase the risk of bleeding or pain, such as near blood vessels.
Currently, the most commonly used mesh fixation method is double-loop mesh fixation with hernia nails9,14. However, there are shortcomings to this method. First, it is difficult to accurately locate the spatial axial position of the mesh when placing the mesh, especially for inexperienced surgeons. The mesh center can shift and not completely cover the defect area, which increases the risk of hernia recurrence. Second, the number of hernia nails needed cannot be accurately calculated when placing the mesh, and nail guns typically contain 15 or 30 nails. If the estimated number of hernia nails required is not accurate, some nails may be wasted, thus increasing the medical costs. Third, after the mesh is placed, the blood vessels and nerves cannot be accurately located, which may lead to blood vessel or nerve injury when nailing the mesh.
In view of the shortcomings of the double-loop fixation method, the &#34;contraposition and alignment&#34; mesh fixation method was designed in this study. The results of this study showed that the incidence of seroma and mesh infection, the hernia recurrence rate, the length of postoperative hospital stay, and the hospital costs were similar between the &#34;contraposition and alignment&#34; mesh fixation method and the double-loop fixation method. However, the &#34;contraposition and alignment&#34; mesh fixation method simplifies the surgical procedure by allowing for the mesh to be designed, positioned, and marked in advance, which only takes 1-2 min. After being placed into the abdominal cavity, the mesh is fixed according to the pre-marked positions, which can simplify the placement and reduce the operation time. In addition, marking the areas that overlay vessels and nerves in advance and using absorbable sutures for fixation in these areas can reduce the risk of vascular and nerve injury. It has been reported that in special areas such as the costal margin, the use of a nail gun to fix the mesh or the use of a crochet needle for a full thickness abdominal wall suture can lead to intercostal nerve compression and local muscle ischemia, which may cause chronic pain29. Through a retrospective study, it was found that the &#34;contraposition and alignment&#34; mesh fixation method can significantly shorten the placement time of the mesh. Simultaneously, through the postoperative follow-up, this method was found to reduce the incidence of postoperative chronic pain.
Nevertheless, the &#34;contraposition and alignment&#34; mesh fixation method suffers from a few limitations. This method can only be used with medium or heavyweight anti-adhesion mesh. Lightweight and large anti-adhesion meshes, especially those that are transparent or translucent, are not easy to mark, and it may not be easy to see the marks when placing the mesh. It is also unclear if marking the mesh with a sterile marking pen damages the anti-adhesion coating and, thus, affects mesh adhesion. Additional studies are required to address these issues. Marking in advance when designing and manufacturing the anti-adhesion mesh may help overcome the potential issues arising from using a pen.
There are several key points that should be taken into account when using the &#34;contraposition and alignment&#34; mesh fixation method. When placing the mesh, the length and position of the mesh centerline and the longitudinal axis of the incisional hernia defect should coincide. The longitudinal axis of the defect is the position where the abdominal wall tension is greatest after the hernia ring is closed. The best abdominal wall repair effect can be achieved by fixing the midline based on fixation points that have been designed and marked in advance. Second, the mesh should be fixed according to the nail points marked in advance. When placing the nails, the nail gun, the mesh, and the abdominal wall should be aligned in the same direction to achieve the best fixation effect. Finally, nail gun fixation should not be used in areas containing blood vessels or nerves, and suture fixation can be used to replace nails when necessary to reduce the occurrence of postoperative chronic pain. The ideal effect of the operation is achieved when the mesh is fixed firmly and the use of hernia nails, especially non-absorbable nails, is reduced as much as possible. The mesh edge needs to be fixed with high-strength non-absorbable nails, while absorbable nails can be used on both sides of the longitudinal axis of the mesh to ensure good fixation and reduce postoperative complications.
To achieve the best effect of the mesh placement, the mesh should be completely flattened, the edges should not be curled, and the fixation should be firm such that displacement will not occur. When these conditions are met, the mesh integrates into the peritoneum and abdominal wall tissue rapidly. During the operation, due to the influence of various factors, it is difficult to achieve a rational mesh fixation effect, which requires certain surgical skills. This study shows that the &#34;contraposition and alignment&#34; mesh fixation method offers the advantage of reliable mesh fixation, the technique is easy to learn and master, and the method is associated with a lower risk of chronic pain. Further studies with larger numbers of patients are necessary to confirm the results of this study.

Incisional hernia is a common complication after abdominal surgery and can be properly treated only with surgery1. Compared with traditional open incision herniorrhaphy, laparoscopic herniorrhaphy has the advantages of less surgical trauma, a lower infection rate, and faster postoperative recovery2,3. Currently, laparoscopic herniorrhaphy is the method of choice for the treatment of incisional hernia if there are no contraindications4.
However, laparoscopic herniorrhaphy is technically complex. Intraperitoneal onlay mesh (IPOM) is commonly used in laparoscopic incisional hernia repair, and this involves placing a mesh into the abdominal cavity laparoscopically to cover the hernia defect5. The mesh is a new type of medium-weight monofilament polypropylene mesh covered with a hydrogel barrier on the visceral side6. For laparoscopic incisional hernia repair using the IPOM method, it is necessary to master the placement of the trocars, the techniques to separate intra-abdominal adhesions, the techniques for suturing the incisional hernia, and the methods for placing and fixing the mesh in the abdominal cavity. In particular, if the mesh is not properly placed and fixed, this can result in the recurrence of the hernia, as well as potentially serious complications such as intestinal obstruction and mesh infection7,8. Therefore, mastering the correct mesh fixation technique is an important criterion for achieving a good surgical outcome. 
The traditional method of mesh fixation for incisional hernia is to fix the mesh with a double-ring hernia nail. After the mesh is placed into the abdominal cavity, the edge of the mesh is fixed with a nail gun first, and then the edge of the hernia ring is fixed9. However, this method has poor spatial positioning, and the mesh is prone to displacement, leading to hernia recurrence. By reviewing and analyzing the various mesh fixation methods, a new "contraposition and alignment" method for mesh fixation is proposed and presented in this protocol10. In this method, the size and scope of the incisional hernia are measured in advance, after which the mesh fixation points can be marked in advance. When the mesh is placed into the abdominal cavity during the operation, nail gun fixation and suture fixation can be performed according to the previously marked locations. This method can reduce the difficulty of the operation, the operation time, the medical cost, and the occurrence of complications. In this study, this new method is compared with the conventionally used double-loop hernia nail fixation method for mesh fixation during laparoscopic incisional hernia repair surgery.

<table><tbody><tr><td>1-0 Stratafix Symmetric PDS Plus Violet 45cm PS-1&amp;nbsp;</td><td>ETHICON</td><td>sxpp1a401</td><td>STRATAFIX Symmetric PDS Plus</td></tr><tr><td>3-0 VICRYL suture</td><td>ETHICON</td><td>VCP316</td><td>absorbable suture</td></tr><tr><td>AbsorbaTack Fixation</td><td>Covidien llc</td><td>ABSTACK15</td><td>absorbable nail gun</td></tr><tr><td>Laparoscopic needle holder</td><td>KARL-STORZ</td><td>26173KL</td><td>needle holder</td></tr><tr><td>Laparoscopic separating forceps</td><td>KARL-STORZ</td><td>38651ON</td><td>separating forceps</td></tr><tr><td>Laparoscopic system (OTV-S400)</td><td>Olympus</td><td>CLV-S400_WA4KL530</td><td>4K HD image large screen surgical laparoscope</td></tr><tr><td>ProTack Fixation</td><td>Covidien llc</td><td>174005</td><td>Non absorbable nail gun</td></tr><tr><td>VENTRALIGHT ST</td><td>BARD</td><td>5954810</td><td>Biological anti-adhesion mesh</td></tr></tbody></table>

application of a new mesh fixation method in laparoscopic incisional hernia repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Either "contraposition and alignment" mesh fixation (experimental group) or traditional double-loop hernia nail fixation (control group) was performed for the patients in the study, with 42 patients in each group.
During the hernia repair surgery performed in this study, the anti-adhesion mesh was placed after the hernia ring was sutured. In the experimental group, the "contraposition and alignment" method was used to place the mesh, while the traditional double-loop fixation method was used to place the mesh in the control group.
Section 3 of the protocol details the specific mesh placement methods (Figure 1, Figure 2, and Figure 3). The mesh placement time, the frequency of seroma formation, mesh infection, hernia recurrence, chronic pain, the length of hospital stay, and the hospitalization costs were compared between the experimental and control groups. Figure 4 shows the comparison images before and after the operation. The mean mesh placement time of the experimental group was 32.5 min ± 11.6 min and of the control group was 44.7 min ± 12.5 min (P &lt; 0.05), indicating a reduction in the time required for mesh placement with the "contraposition and alignment" method used in this study. There were only two cases of chronic pain in the experimental group, which was a significantly lower number than the eight cases observed in the control group (P &lt; 0.05). In addition, there were no significant differences between the two groups in terms of seroma formation, mesh infection, recurrence of incisional hernia, the length of the postoperative hospital stay, and hospitalization expenses (Table 2).
<img alt="Hernia surgical procedure; includes defect diagram, laparoscopic view, implant measurements." class="xfigimg" src="/files/ftp_upload/64916/64916fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Measurement of the hernia ring defect size and marking the anti-adhesion mesh. (A) The size of the incisional hernia defect on the abdominal wall is measured. (B) The longitudinal axis length of the hernia ring defect is measured under laparoscopy. (C) The appropriate mesh size is selected. (D) The range of the vertical axis is marked on the mesh. (E) The fixation positions of the nails are marked on the edge of the mesh. (F) The fixation positions of the nails are marked in the middle of the mesh. This figure is reprinted with permission from Ning et al.10. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64916/64916fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Abdominal surgical procedure diagrams showing incision, mesh placement, and closure technique." class="xfigimg" src="/files/ftp_upload/64916/64916fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Steps of mesh placement under laparoscopy. (A) The layout of the puncture holes for an incisional hernia. (B) The mesh is placed into the abdominal cavity through the puncture hole. (C) The longitudinal axis of the mesh overlaps the longitudinal axis of the hernia ring defect (red dotted line). (D) The marked positions on the mesh longitudinal axis are fixed on the abdominal wall with non-absorbable nails (indicated by a red arrow). (E) The mesh is fixed to the abdominal wall along the marked points on the edge of the mesh (red arrow) with non-absorbable nails. (F) The mesh is fixed on the abdominal wall along the marked points in the middle of the mesh (red arrow) with absorbable nails. This figure is reprinted with permission from Ning et al.10. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64916/64916fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Hernia repair process using mesh implant; surgical procedure, medical application, implantation technique." class="xfigimg" src="/files/ftp_upload/64916/64916fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Steps of the double-loop mesh fixation method. (A)After closing the hernia ring, the extent of the hernia ring defect is measured with a ruler under laparoscopy. (B) The appropriate mesh is selected according to the size of the hernia ring defect. (C) Fixation of the outer ring: the fixing nails are placed along the edge of the mesh to ensure that the distance between the hernia nail and the edge of the mesh is about 2-4 mm and the distance between the nails is about 2-3 cm. (D) Fixation of inner ring: the mesh is fixed about 2 cm along the outer edge of the hernia ring defect, and the distance between the nails is 3-5 cm. This figure is reprinted with permission from reference Ning et al.10. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64916/64916fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Abdominal hernia diagnosis; ultrasound, CT scan images; pre and post surgical intervention." class="xfigimg" src="/files/ftp_upload/64916/64916fig04.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Comparison of the condition before and after the operation. (A)Photos of the incisional hernia of the abdominal wall before the operation. (B) A color ultrasound image of the abdominal wall before the operation. (C) A CT image of the abdominal wall before the operation. (D) Photos of the abdominal wall 3 months after the operation. (E) A color ultrasound image of the abdominal wall 1 month after the operation. (F) A CT image of the abdominal wall 3 months after the operation. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64916/64916fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>experimental group 
			n=42</td>
			<td>control group 
			n=42</td>
			<td>P-value</td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>52.5±3.4</td>
			<td>53.2±4.2</td>
			<td>0.4</td>
		</tr>
		<tr>
			<td>Gender (n) 
			Men 
			Women</td>
			<td> 
			26 
			16</td>
			<td> 
			27 
			15</td>
			<td>0.82</td>
		</tr>
		<tr>
			<td>BMI (kg/m2)</td>
			<td>24.0±3.3</td>
			<td>23.5±2.7</td>
			<td>0.45</td>
		</tr>
		<tr>
			<td>Disease time(yr)</td>
			<td>2.73±0.51</td>
			<td>2.56±0.64</td>
			<td>0.18</td>
		</tr>
		<tr>
			<td>Maximum defect 
			of hernia ring(cm)</td>
			<td></td>
			<td></td>
			<td>0.35</td>
		</tr>
		<tr>
			<td>≥10cm</td>
			<td>11</td>
			<td>15</td>
			<td></td>
		</tr>
		<tr>
			<td>&lt;10cm</td>
			<td>31</td>
			<td>27</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of the baseline data of the experimental and control groups. The baseline characteristics compared included the patients' age, sex, body mass index (BMI), the length of time of the hernia defect, and the maximum defect size of the hernia ring.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>experimental group 
			n=42</td>
			<td>control group 
			n=42  </td>
			<td>P-value</td>
		</tr>
		<tr>
			<td>Mesh placement time (min) </td>
			<td>32.5±11.6</td>
			<td> 44.7±12.5</td>
			<td>&lt;0.05</td>
		</tr>
		<tr>
			<td>Seroma</td>
			<td>3</td>
			<td>4</td>
			<td>1.00</td>
		</tr>
		<tr>
			<td>Mesh infection 
			Recurrence of hernia </td>
			<td>1 
			1</td>
			<td>2 
			3</td>
			<td>1.00 
			1.00</td>
		</tr>
		<tr>
			<td>Chronic pain</td>
			<td>2</td>
			<td>8</td>
			<td>  &lt;0.05</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (days)</td>
			<td>5.8±1.3</td>
			<td>  5.5±1.1</td>
			<td>0.26</td>
		</tr>
		<tr>
			<td>Hospitalization cost (ten thousand )</td>
			<td>4.9±0.6</td>
			<td> 4.7±0.5</td>
			<td>0.1</td>
		</tr>
	</tbody>
</table>
Table 2: Comparison of the intraoperative and postoperative data between the experimental and control groups. The indices compared between the two groups included placement time, seroma formation, mesh infection, hernia recurrence, chronic pain, the length of thepostoperative hospital stay, and the hospitalization costs.

Watch this Scientific Journal Video about Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair at JoVE.com

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

application-new-mesh-fixation-method-laparoscopic-incisional-hernia

Nanyang Technological University

Research

JoVE Journal

Medicine

6.1K Views.  Sun Yat-sen University. Dit protocol biedt een nieuwe methode om het probleem van mesh-fixatie bij laparoscopische incisieherniaherstel effectief op te lossen. De voordelen van deze methode zijn nauwkeurige mesh-positionering, stevige fixatie en eenvoudig leren, vooral voor beginners. Na het beheersen van deze methode kan de tijd van mesh-fixatie tijdens bedrijf aanzienlijk worden verkort.Tekst- en beelddemonstratie kan niet effectief het hele proces van deze mesh-bevestigingsmethode weergeven, vandaar dat vi...

Video: Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Use of a Rat Model to Study Ventral Abdominal Hernia Repair

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal hernia typically requires implantation of a material to serve as a mechanical bridge across the defect in the abdominal wall. Biomaterials, such as porcine small intestinal submucosa (SIS), also serve as a lattice for cell growth into the implant and can naturally incorporate into the host tissue. Development of such repair materials benefits from use of animal models in which experimental abdominal wall defects are easily created and are amenable to repair in a reproducible fashion. The method offered here describes surgical creation and repair of ventral abdominal hernia in a rat model. When SIS is used to repair an experimental ventral abdominal hernia in this model, it is rapidly incorporated into host tissue within 28 days of implantation. Histologically, incorporation of their implanted material into host tissue is characterized by a robust fibrovascular response. Future refinements and applications of the rat abdominal hernia model may likely involve diabetic and/or obese animals as a means to more closely mimic common co-morbidities of man.

This manuscript describes methods associated with creation and repair of a ventral abdominal wall defect (hernia). This model can be used to study repair strategies such as those that use implanted materials. In this manuscript, repair of the experimental hernia with porcine small intestinal submucosa is presented as an example.

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal ...

Bioengineering

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

Closure of catastrophic open abdominal wounds presents a challenge to the surgeon. We present a surgical technique utilizing a combination of mechanical and biologic xenograft closure systems in closing complex open abdominal wounds. This technique offers another option to the surgeon for definitive fascial closure and accelerated wound healing.

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is placed, the peritoneum must be resutured to avoid contact with the tissues and organs in the abdominal cavity. If the peritoneal suture time is too long, the operation and anesthesia time will be prolonged, increasing the burden on the patient. Moreover, improper suture methods cause serious consequences, such as intestinal obstruction and mesh infection.
The straight-needle suture method transforms the three-dimensional spatial configuration of the needle holder and the arc needle tip into a two-dimensional planar structure, which greatly reduces the difficulty of suturing. The three-tailed knot can be anchored at the beginning of the suture by its friction and button effect, which has an exact fixation effect. Thus, the suture does not easily slip, and the time to complete the suturing is shortened. Compared with the traditional suture method, the operator can suture the peritoneum more quickly, beginners can pass through the difficult learning curve faster, and skilled operators can also shorten the total operation time of TAPP to a certain extent. Thus, this suture method is extremely amenable to clinical application.

Here, we present a protocol to introduce a new peritoneal suture method. This method is called straight-needle, three-tailed, knot-free suture, and we will outline the manufacturing method and clinical application of this suture in detail.

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full decompression has been shown to decrease the recurrence rate of lumbar disc herniation during endoscopic surgery. Traditional suture operations under endoscopy involve only simple suturing of the ruptured AF. Due to the weak and poor quality of the AF tissue around the tear portal, using this area as needle insertion points during suturing may lead to insufficient tension and a low success rate of AF closure. Currently, there is no detailed technical illustration based on video for AF tear suturing under lumbar full-endoscopy. We innovatively propose a method of covering and suturing the AF tear by pulling up the posterior longitudinal ligament (PLL) under lumbar endoscopy and using three stitches (PLL-AF suture technique). The patient who received the novel suture technique achieved satisfactory results. Six months after the operation, lumbar MRI showed no evidence of recurrence in the outpatient clinic.

Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full ...

Surgical Closure of Equine Abdomen, Prevention, and Management of Incisional Complications

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may jeopardize return to athletic function. Therefore, many techniques have been developed to reduce their occurrence and expedite their resolution when they occur. Our technique of celiotomy incision closure includes the use of tension sutures (vertical U mattress) of polyglactin 910 on the linea alba, which is then apposed by polyglactin 910 interrupted sutures or a simple continuous pattern suture with a stop midway before routine closure of the superficial layers. The celiotomy incision is protected by an elastic bandage during the immediate postoperative period. This technique has been associated with favorable results: 5.3% confirmed incisional infections after a single celiotomy and 26.7% after repeat celiotomy. The overall incisional complication (serous/sanguineous discharge, hematoma, infection, hernia formation, and complete wound breakdown) occurrence was 9.5% and 33.3% after single and repeat laparotomy, respectively. In cases considered more susceptible to infection (early relaparotomy or laparotomy incisions longer than 30 cm), negative pressure therapy was found easy to apply on closed incisions. No detrimental effects were observed. However, the potential prophylactic benefit of this therapy needs to be confirmed in a larger group. In infected laparotomy wounds requiring drainage, the use of negative pressure therapy seemed to have a positive effect on the formation of granulation tissue. However, there was no control group to allow statistical confirmation. Finally, one case of complete breakdown of the laparotomy incision was managed by stainless steel retention sutures, the application of negative pressure therapy, and a hernia belt. At re-evaluation 15 months post-surgery, several small hernias were detected, but the horse had returned to his previous level of sports performance and had not shown any episode of colic.

This paper describes a method of abdominal wall closure using tension and apposition sutures in horses undergoing ventral midline laparotomies. It also describes methods for prevention and management of postoperative incisional complications, such as bandaging, negative pressure therapy, and in case of wound breakdown, the application of retention sutures.

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may ...

Uterine-Preserving Laparoscopic Cerclage Pectopexy 

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. 
The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (&plusmn; 10.18 min) and an average bleeding volume of 53.57 mL (&plusmn; 48.77 mL). The mean follow-up duration was 19.71 &plusmn; 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

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