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Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 95-98

Double rolling and center hitch technique for laparoscopic ventral hernia repair

Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission19-Jun-2012
Date of Acceptance03-Oct-2012
Date of Web Publication22-Apr-2013

Correspondence Address:
Asfar Ali
Clinical Associate and Fellowship Co-ordinator, Institute of Minimal Access, Metabolic and Bariatric Surgery, Room No. 400, SW Block, Sir Gangaram Hospital, Rajender Nagar, New Delhi - 110 060
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.110973

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 ¤ Abstract 

Background: Intraperitoneal onlay mesh repair is an established modality to treat large ventral hernias. Various techniques of laying the mesh are utilized. We present the Double Rolling and Center Hitch technique to lay a large intraperitoneal onlay mesh. Objective: The aim of the study is to devise and adopt a method to reduce the difficulty in manoeuvring a large mesh inside the peritoneal cavity. It should also help in correct placement of mesh and decrease the operative time. Materials and Methods: The DRACH technique was used in eighteen patients with large ventral hernias between May 2010 and September 2011. The Mesh size used was 15x20cm and more (considered to be large mesh). Results: All the procedures were completed successfully. Mesh handling was significantly easier with the DRACH technique. The average mesh deployment time (MDT) was 15mins. In all cases the mesh was adequately centred with a margin of 3-5cm from the defect. Conclusion: The DRACH technique can be employed to lay large intraperitoneal meshes in order to reduce the handling difficulties associated with large meshes, and to aid in better placement of meshes so as to centered over the defect.

Keywords: Intraperitoneal onlay mesh, laparoscopy, large mesh, ventral hernia

How to cite this article:
Ali A, Bhatia P, Kalhan S, Khetan M, John S, Bindal V. Double rolling and center hitch technique for laparoscopic ventral hernia repair. J Min Access Surg 2013;9:95-8

How to cite this URL:
Ali A, Bhatia P, Kalhan S, Khetan M, John S, Bindal V. Double rolling and center hitch technique for laparoscopic ventral hernia repair. J Min Access Surg [serial online] 2013 [cited 2022 Jul 1];9:95-8. Available from:

 ¤ Introduction Top

With the advent of laparoscopy, repair of ventral hernias has undergone a revolution. With continuous improvement in technology and instrumentation, laparoscopic repairs are on the increase. Various studies have shown beneficial patient outcomes for this modality. On the other hand, laparoscopic repair of large ventral hernias can be technically challenging. Various factors influence the complexity of the procedure, an important one of which is the handling of mesh intraperitoneally. Various techniques of laying the mesh have been used. We present the double rolling and center hitch (DRACH) technique to lay a large intraperitoneal onlay mesh.

 ¤ Materials and Methods Top

The DRACH technique was used in 18 patients with large ventral hernias between May 2010 and September 2011 [Table 1]. These included large primary paraumbilical, epigastric, and incisional hernias. All patients underwent laparoscopic intraperitoneal onlay mesh repair.
Table 1: Types of hernia

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Operative technique

Three ports are made: One 12-mm camera port and two 5-mm working ports. All are made on one side of abdomen, just within the anterior axillary line. Additional 5-mm ports may be needed for mesh deployment/fixation. Diagnostic laparoscopy is performed. Adhesiolysis is done and the hernia contents are reduced. In eight cases, we encountered Swiss cheese defects and in one there was gross divarication of recti. The defects are measured in centimeters and the size of mesh to be placed is determined. A minimum of 5 cm margin of the mesh is kept on all sides of the defect. In 10 patients, we used 15 × 20 cm mesh and in five patients, 20 × 25 cm mesh is used. In one patient, we had to use an additional 10 × 15 cm mesh to cover all defects with the required margin, and a very large mesh (42 × 28 cm) had to be used in one patient [Table 2]. We prefer Proceed TM mesh (Ethicon, Sonnerville, NJ, USA), which was used in all the cases.
Table 2: Size and time relationship

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The center of the defect is marked on the skin and so is the outline of the mesh, keeping the pneumoperitoneum to 10 mm of Hg. The mesh is prepared after changing gloves.

Preparing the mesh

The mesh is laid on its envelope. Four corner stitches are taken with 2-0 polypropylene and both ends are cut long. The mesh is tightly rolled from either side along its long axis to meet in the mid-line keeping two corner sutures inside the roll [Figure 1]. The anti-adhesion coating is kept on the inside, which after deployment would be adjacent to the abdominal viscera.
Figure 1: Rolling of mesh

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One polypropylene stitch is taken through both rolls to prevent unrolling. Having done this, a center hitch is taken with 2-0 polypropylene on the outer (parietal) side [Figure 2].
Figure 2: The center hitch

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Deployment of mesh

In three cases, the needle was inserted along with the mesh roll and retrieved out through the center of the defect. In the rest, the suture was retrieved with a suture passer needle through the center. The mesh is drenched in saline and both rolled halves squeezed together to negotiate it through the 12-mm port [Figure 3].
Figure 3: Mesh insertion

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After the center hitch, the long axis of mesh is aligned craniocaudally. First, the right half of mesh is unrolled by a "pushing maneuver," keeping the center hitch in place [Figure 4]. Four transfascial corner sutures (TFS) were placed in 14 patients, while in two patients, both with infraumbilical hernias and 20 × 25 cm mesh, the inferior corners were tacked to the Cooper's Ligament after raising a peritoneal flap. The free edge between the TFS is fixed using ProTacks TM (Ethicon, USA) in two concentric rings or "crowns." The outer crown is placed 1 cm from the margin of mesh, at an interval of approximately 2 cm. The inner crown is placed at least 2-3 cm inside the outer crown. The interval between the tacks of inner crown is variable and depends on the number of remaining tacks in tacking device.
Figure 4: Mesh unrolling

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After securing the right half of the mesh, the left half is unrolled with a "pulling maneuver." For this, we prefer curved bladed dissectors with their jaws open [Figure 4]. The fixation is done in the same manner as described. The inner crown of tacks is placed after the outer crown is completed. All along the center hitch is held tight ensuring proper centering of mesh over the defect. The TFS were delivered out with a suture passer needle.

The total operative time was noted starting from creation of carboperitoneum till closure of last port incision. Mesh deployment time (MDT) was also noted. This was marked from the beginning of insertion of mesh and till firing of last tack. It includes the time taken for mesh insertion, unfolding the mesh, centering it over the defect, securing it with corner transfascial sutures, and fixing it with tacks. The relationship of mesh size and the MDT (size-to-time ratio) was calculated. A final check laparoscopy was done before exiting the abdomen.

 ¤ Results Top

All the procedures were completed successfully. Two out of the 18 procedures were performed by 2 nd -year trainee fellow.

Mesh deployment time: The average MDT of the 18 procedures was 28.6 min with the DRACH technique which was less than for the usual technique.

  1. Size-to-time ratio: the mean size-to-time ratio was 12.2 which was less than for the usual technique
  2. In all cases, the mesh was adequately centered with a minimum margin of 5 cm from the defect.
With tight double rolling of mesh, it was easier to negotiate it through a 12-mm port. In cases where mesh larger than 20 × 25 cm was used, a 15-mm port was utilized for mesh passage. Once inside, the alignment of mesh in craniocaudal axis and centering over the defect was greatly simplified and much quicker by suspending the mesh with the center stitch retrieved percutaneously. As the mesh was tightly suspended throughout the fixation, the handling of mesh was considerably reduced. This center hitch also helped in avoiding the mesh to get folded on itself.

 ¤ Discussion Top

Intraperitoneal onlay mesh repair is presently an established modality to treat ventral hernias. It was introduced by Le Blanc and Booth in 1993. [1] Hesselink and associates concluded that hernias over 4 cm diameter should be repaired using a prosthesis. [2] Luijendijk et al. showed that use of mesh significantly reduces the number of recurrences after incisional hernia repair. [3] Over the years, various types of meshes have been used inside the abdomen. The current trend is to use mesh with adhesion barrier. [4],[5]

Placing a large mesh inside the abdomen demands technical expertise. Jenkins et al. demonstrated an increase in operating time with every square centimeter increase in size of mesh, and with less number of years of post-graduate training. [6]

Introduction of a large mesh mandates proper rolling to insert it through a 12- or 15-mm laparoscopic port. Himpens et al. suggested that the mesh should be inserted in a sterile bag after removal of the 10-mm port. [7] We use the 12-mm Excel port (Ethicon, USA) for insertion after tight doublerolling [Figure 4]. Negotiating a mesh larger than 15 × 20 cm through a 12-mm port carries a higher risk of mesh damage, even after tight rolling. In this situation, we change 12 mm to a 15 mm one. Special care is taken with meshes having adhesion barriers to prevent its damage during insertion. In the DRACH technique, the adhesive coat is kept on the inside and the mesh is drenched in saline for easier passage.

Centering of the mesh is crucial. All the defects are covered properly with adequate margin of at least 3 cm to reduce recurrence. [8] Measuring the span of the defects from inside more accurately determines the size of mesh to be placed and avoids over- or under-sizing. [9] An overlap of minimum 5 cm on all sides is needed for larger hernias. Our preference is an overlap of 3-5 cm. In our technique, the center hitch is taken through a point on the skin which is marked under laparoscopic guidance. It suspends the mesh to the anterior abdominal wall centering over the defect/cluster of defects.

Alignment of the mesh becomes progressively difficult with increasing size. Rotating a large mesh in a confined space becomes difficult. This is simplified by rolling it in the desired axis. We roll the mesh along its shorter axis. This allows for the unfolding along a craniocaudal axis.

Injuries at the time of mesh placement are well known. Handling a large mesh in a compromised domain predisposes to bowel and vascular injuries. The DRACH applies the mesh to the abdominal wall. This reduces multiple grasping of the mesh. One roll is unfolded at a time and fixed with tacks and transfascial sutures. This maneuver drastically reduces the complexity and the MDT [Table 2].

All the above factors determine the surgeon's comfort level. Technical challenge of handling a large mesh after an already exhaustive adhesiolysis (especially in incisional hernias) adds to the fatigue and frustration of the surgeon. This makes the learning curve steeper.

 ¤ Conclusion Top

The DRACH technique can be useful in laying a large intraperitoneal mesh. It may reduce the handling difficulties associated with large meshes. It is helpful in better centering of mesh over the defect. The reduction in the technical difficulty may be of advantage to the surgeons especially in the early phase of their learning curve.

 ¤ References Top

1.LeBlanc KA, Booth WV. Laparoscopic repair of incisional hernia. Br J Surg 2002;89:534-45.  Back to cited text no. 1
2.Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176:228-34.  Back to cited text no. 2
3.Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392-8.  Back to cited text no. 3
4.Alponat A, Lakshminarasappa SR, Teh M, Rajnakova A, Moochhala S, Goh PM, et al. Effects of physical barriers in prevention of adhesions: An incisional hernia model in rats. J Surg Res 1997;68:126-32.  Back to cited text no. 4
5.Ozmen MM, Aslar AK, Terzi MC, Albayrak L, Berberoðlu M. Prevention of adhesions by bioresorbable tissue barrier following laparoscopic intraabdominal mesh insertion. Surg Laparosc Endosc Percutan Tech 2002;12:342-6.  Back to cited text no. 5
6.Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler RB, Frisella MM, et al. Clinical predictors of operative complexity in laparoscopic ventral hernia repair: A prospective study. Surg Endosc 2010;24:1872-7.  Back to cited text no. 6
7.Himpens JM, Leman GM, Deloose KR. Technique for introducing large composite mesh while performing laparoscopic incisional hernioplasty. Surg Endosc 2002;16:1244-6.  Back to cited text no. 7
8.Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin North Am 2005;85:91-103.  Back to cited text no. 8
9.Carbonell AM, Cobb WS. Tricks for laparoscopic ventral hernia repair. Contemporary Surgery 2007;63:8.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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