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Archive November 2017 XVIII, No. 11

Getting a Grip on Hernia Mesh Fixation

Reliable options abound for keeping mesh in its proper place after hernia repair.

Mark Reiner

Mark Reiner, MD


hernia mesh DON'T GET ATTACHED Developing proficiency in multiple modes of fixating hernia mesh may help to control costs.

Surgical mesh is a tried-and-true solution for repairing the defects associated with inguinal, umbilical and ventral hernias, but only if the mesh remains firmly in place. Thankfully, whether a surgeon chooses to repair the defect through open surgery, laparoscopy or with robotic assistance, he has a near-infinite list of options for fixating the mesh — and new tools and devices are continually joining the fold.

The surplus of options begs the natural, yet controversial, question: "Which one is the safest and most reliable?" That's akin to asking a mother of 3 to choose her favorite child. The truth is that there's no such thing as "one size fits all." Many factors will influence which fixation method you choose, from the size and type of the hernia, to the surgical approach, to surgeon preference.

Let's take a look at the 5 most common means of fixation and see how they stack up in terms of their ability to reduce post-operative complications, prevent recurrence and control costs, which is especially vital in an era of declining reimbursements.

1 Sutures. Suture is one of the least expensive ways to fixate mesh, but keep in mind that suturing will likely extend the amount of time you spend in the OR (see "Can Robotics Yield Better Outcomes in Hernia Repair?"). Also, suturing raises the risk of compressing or entrapping a nerve, which will likely result in post-operative pain or numbness and, quite possibly, the need for reoperation. Besides traditional suture, we're starting to see some "hybrid" fixation options that fall loosely into this category. One example is a newly introduced system that offers suture-like fixation, in which each lockable suture is deployed with the speed and ease of use associated with a handheld tacking device.

2 Tacks. Tacks come in an assortment of shapes and styles, so for the sake of convenience, we'll distill them into 2 different types. Permanent titanium tacks are durable and cost effective, though the non-coated titanium tacks have been known to cause adhesions and bowel lesions. Then there are absorbable tacks, which are pricier alternatives that can be fully absorbed by the body within 12 to 18 months, depending on the manufacturer. Like suture, a misplaced tack may result in an injury to the anatomy — a nerve or vessel, say — that could necessitate reoperation. The good news is that tacking options continue to improve and evolve. One example: A tacking device that delivers a "liquid anchor" capable of setting in less than 10 seconds, though it's currently available only in overseas markets.

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