Ventral hernias, whether naturally occurring or the results of previous surgery, comprise one of the most common problems confronting general surgeons, with overall incidence between 2% and 13% [1] [2] [3]. Laparoscopic ventral hernia repair was described on first by Leblanc in 1993 for all types of hernias [4]. Laparoscopic hernia repair has fewer wound complications, faster functional recovery and improved cosmoses [5] [6]. However, there are still some unresolved issues: a certain number of relapses, problems of fixation of the mesh, mesh bulging and migration, and seroma formation. Primary closure of the hernia defect is desirable to improve the laparoscopic hernia repair results, although technically complex, as shown by previous experience [5] [7]. We report our experience in primary hernia defect closure during laparoscopic hernia repair with percutaneous transabdominal external needle.

This study was done in General and Laparoscopic Surgery Department, Zagazig University Hospital, Egypt, from March 2012 through December 2014. Twenty-seven patients were included in this research (20 patients inguinal hernias, 7 patients lateral ventral hernias; Table 1.) This research was discussed and approved from ethical committee of Zagazig University at January 2012. All information about the technique was discussed with all patients, and gave writing consent for inclusion of their data in this study. The ages of the patients ranged from 23 to 62 years (mean 47 years).

Surgical technique: Under general anesthesia, the patient is positioned supine with the arms alongside the body on an operating table tilting on all levels, to better expose the surgical field. The initial peritoneal access is by Veress needle puncture, 2 cm below the left costal margin in the midclavicular line (Palmer's point) [8] to install the pneumoperitoneum of 14 mmHg has been achieved. A 0-degree, 10 mm laparoscope and two additional trocars of 5 mm in diameters were used. Careful and complete adhesiolysis represents the first time. Then, the peritoneum is incised superiorly, 3–4 cm above the hernia defect. After complete hernia sac dissection, the preperitoneal space exposure for 5–7 cm all around the hernia defect was achieved. Then, the hernia defect was closed through percutaneous transabdominal external needle [9] (using spinal needle No. 18 or tip hole needle [10]. The needle and prolene No. 0 inside it passed through the abdominal wall through the hernia defect wall to appear 1 cm from the edge of hernia defect. The prolene end was holed from the abdominal cavity and withdrawn outside the port. Then, this prolene end is holed by tissue forceps outside the port. Then, the needle and inside prolene were partial withdraw and redirected to pass through 1 cm from other edge of hernia defect. The other prolene end from inside the needle is holed by hook and brings it outside of abdominal cavity through the same port. Now, one suture is complete, which passed through both sides of hernia defect about 1 cm from hernia edge and under the floor of hernia defect, and two suture limbs outside the abdominal cavity through one port. The suture was tied extracorporeal and cut by laparoscopic scissor (Figure 1A-D). Multiple sutures were put by same manner to produce good hernia defect closure. The intraperitoneal pressure is decreased during hernia defect closure. Then, suitable mesh was put at preperitoneal plane to cover the defect and 5 cm all around. The mesh fixation was achieved in it position using Glubran 2 (Gem srl, Viareggio, Italy) (Figure 2A-F). The peritoneum was closed using Vicryl No. 2/0. The pneumoperitoneum was emptied under direct viewing and external pressure was applied to the hernia region and trocars sites were closed. Follow-up period ranged from 3 to 33 months (mean, 26 months).

The mean surgical time was 60 minutes (ranged from 45–90 minutes). The mean time to put one suture was 1.7 minutes (ranged from 1–2 minutes). The number of sutures which needed to produce good closure of hernia defect ranged from 2–7 sutures. Twenty patients (74%) returned to their usual activities in two weeks and 7 patients (26%) required to one week. No seroma, or recurrence, or mesh bulging or chronic pain or infection was recorded in this patients group during the period of follow-up.

The increased acceptance of abdominal hernia repair by a laparoscopic approach has led to many confused reports on technique, results, and complications related to this procedure. Many of these complications are directly related to lack of thorough knowledge of surgical anatomy or improper technique. The complication rate after laparoscopic hernia repair vary from 5–13% but the definition of complication differs widely among studies [11][12]. Sever bleeding usually due to vascular injury of big vessels and generally occurs because the using of staples during mesh fixation [13]. Patients who undergo laparoscopic hernia repair have 1.6 incidence of neuralgias due to nerve entrapment during mesh fixation with staples. Some surgeons advocated placing the mesh without fixation in preperitoneal space to avoid these complication [14], but primary hernia defect closure is vital for this manner. Two factors are predisposed for mesh bulging and hernia recurrence, firstly a loosely stretched the mesh and secondly present of hernia defect [15]. By closure of the hernia defect and restoring abdominal wall integrity will be leading to equalized pressure and tension across the abdominal wall and intra-abdominally placed mesh. Also, closure of hernia defect reduces the dead space preventing the formation of seromas [16] [17]. Previous researches [1] [7] has proposed the use of a straight needle or half circle for hernia defect closure with difficult maneuvers, knotting complicated, and incomplete closure and dead space obliteration. Our technique for closure of hernia defect used external needle (spinal needle No. 18 or tip hole needle) which passed with thread inside it through abdominal wall and abdominal cavity. By our technique it can be closed the hernia defect completely and by any number of sutures, and complete obliteration of dead space preventing seromas formation. The sutures were tied extracorporeally in our study.

Percutaneous transabdominal external needle technique for closure of hernia defect is easy, suitable for all types of laparoscopic abdominal hernia repair, and associated with good results.

1. Banerjee A, Beck C, Narula VK, Laparoscopic ventral hernia repair: Does primary repair in addition to placement of mesh decrease recurrence? Surg Endosc 2012 May;26(5):1264–8.   [CrossRef]   [Pubmed]    
2. Lomanto D, Iyer SG, Shabbir A, Cheah WK. Laparoscopic versus open ventral hernia mesh repair: A prospective study. Surg Endosc 2006 Jul;20(7):1030–5.   [CrossRef]   [Pubmed]    
3. Höer J, Lawong G, Klinge U, Schumpelick V. Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. [Article in German]. Chirurg 2002 May;73(5):474–80.   [CrossRef]   [Pubmed]    
4. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993 Feb;3(1):39–41.   [Pubmed]    
5. Orenstein SB, Dumeer JL, Monteagudo J, Poi MJ, Novitsky YW. Outcomes of laparoscopic ventral hernia repair with routine defect closure using "shoelacing" technique. Surg Endosc 2011 May;25(5):1452–7.   [CrossRef]   [Pubmed]    
6. Melvin WS, Renton D. Laparoscopic ventral hernia repair. World J Surg 2011 Jul;35(7):1496–9.   [CrossRef]   [Pubmed]    
7. Elazary R, Abu-Gazala M, Schlager A, Trans-fascial laparoscopic mesh fixation: a procedural comparison using the standard suture passer versus iMESH stitcher™ device. Hernia 2011 Jun;15(3):321–4.   [CrossRef]   [Pubmed]    
8. Sharma A, Mehrotra M, Khullar R, Soni V, Baijal M, Chowbey PK. Laparoscopic ventral/incisional hernia repair: a single centre experience of 1,242 patients over a period of 13 years. Hernia 2011 Apr;15(2):131–9.   [CrossRef]   [Pubmed]    
9. Lasheen AE, Safwat K, Morsy M, Allam Z, Awad W. Modified transabdominal external needle for mesh size estimation in laparoscopic hernia repair. Int J Surg 2014 Oct;12(10):1074–6.   [CrossRef]   [Pubmed]    
10. Lasheen AE, Elzeftawy A, Ahmed AH, Lotfy WE. Anatomical closure of trocar site by using tip hole needle and redirecting suture hook. Surg Endosc 2010 Oct;24(10):2637–9.   [CrossRef]   [Pubmed]    
11. Fitzgibbons RJ Jr, Camps J, Cornet DA, Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 1995 Jan;221(1):3–13.   [CrossRef]   [Pubmed]    
12. Fitzgibbons RJ Jr, Camps J, Cornet DA, Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 1995 Jan;221(1):3–13.   [Pubmed]    
13. Miguel PR, Reusch M, daRosa AL, Carlos JR. Laparoscopic hernia repair–complications. JSLS 1998 Jan-Mar;2(1):35–40.   [Pubmed]    
14. Hakeem A, Shanmugam V. Effectiveness of multiple neurectomies to prevent chronic groin pain after tension-free hernia repair. Int Surg 2011 Apr-Jun;96(2):162–3.   [CrossRef]   [Pubmed]    
15. Schoenmaeckers EJ, Wassenaar EB, Raymakers JT, Rakic S. Bulging of the mesh after laparoscopic repair of ventral and incisional hernias. JSLS 2010 Oct-Dec;14(4):541–6.   [CrossRef]   [Pubmed]    
16. Sodergren MH, Swift I. Seroma formation and method of mesh fixation in laparoscopic ventral hernia repair–highlights of a case series. Scand J Surg 2010;99(1):24–7.   [Pubmed]    
17. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Nikas K, Karfis E, Sioziou H. Seroma and recurrence in laparoscopic ventral hernioplasty. JSLS 2008 Jan-Mar;12(1):51–7.   [Pubmed]