Getting a Grip on Hernia Mesh Fixation

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


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.

— STAY FLEXIBLE How you perform a hernia repair — open surgery, laparoscopy or with robotic assistance — should influence your decisions on fixation.

3 Glues and sealants. Easy-to-use fibrin glues and other sealants may help to reduce operative time, and they also tend to offer a low incidence of chronic post-operative pain. At the same time, glues tend to be more expensive when compared with tacks or sutures. Some studies have examined the long-term results of glue-based fixation, wondering if weakening adhesive strength over time may increase the potential for migration. That being said, we continue to see new market entrants promising strong, rapid and long-term adhesion without causing any negative reactions to surrounding tissue.

4 Self-gripping mesh. Suture-less self-gripping meshes allow for a quick fixation by way of Velcro-like micro-fasteners that grip the tissue, which is especially useful in areas where tacking or suturing may be contraindicated due to vessels and other structures. The drawbacks? Self-gripping meshes are costly, and they're also tough to use because they have a propensity to stick to just about everything. Also, over-manipulating the mesh could diminish its ability to adhere to tissue and, therefore, increase the risk of migration or dislocation.

ROBOTIC ARMS RACE
Can Robotics Yield Better Outcomes in Hernia Repair?

robotics console AT EASE A surgeon might find that sitting at the robotics console, away from the patient's bedside, removes some stress from hernia repair surgery.

Over the past 5 years, I've repaired about 35 inguinal hernias using a robotic surgical system, which is a paltry number compared with the nearly 2,000 I've performed laparoscopically throughout my career. But I'm confident those numbers will likely come closer together in the years ahead. Here's why.

Benefits to the patient. A robotic surgical system's 3D optics and precise motion are far superior to that of its laparoscopic counterpart, meaning there's much less of a chance of injuring surrounding structures. Also, the 360-degree rotation of the robotic wrist is vastly superior to the 180-degree rotation of the human wrist, so the arm articulation makes it easier to suture for seamless fixation.

Benefits to the surgeon. If you've mastered laparoscopic hernia repair, there tends to be a relatively short learning curve with robotics. In addition, when you're using a robotics system, you're sitting at a console away from the patient's bedside — theoretically, you could be doing the surgery on a patient who's across the country — and I find that little bit of distance makes the surgery less stressful.

Benefits to the surgical facility. A surgeon has only 2 hands, so in a laparoscopic case you need other people to hold the instruments for you. With a robotic case, I can essentially control 4 different arms holding the camera and the instruments, which may free up another highly skilled surgeon. Also, most patients look at robotics as a sign that a facility invests in its surgical program. This, in turn, might attract patients — even if they're not candidates for robotics-assisted surgery — and elite surgeons eager to use the system. Of course, robotics is no cure-all. Bear in mind that the initial cost of the robot is significant — upwards of $1 million — and, in general, the cost of a robotic hernia repair will exceed that of either a traditional or laparoscopic hernia repair.

— Mark A. Reiner, MD

5 No fixation. Forgoing fixation is the least expensive option, and it also has the potential to significantly reduce operative time and post-op pain. But because there's essentially nothing to hold the mesh in its intended position, non-fixation may present the greatest risk of migration and reoperation. Even so, some clinical studies have found that, when comparing fixation with non-fixation, there's virtually no difference in terms of complications and early recurrence rates.

Mull your options
To me, the right mesh-fixation option will balance 3 primary factors: how easy it is to use; how effectively it integrates the mesh with surrounding tissue; and how much it costs. I find using 1 or 2 tacks to be quite feasible from a cost perspective, and it's also often the quickest and easiest option for getting the mesh fixated early, so patients can get back to their routine within a few days of surgery.

A word of caution for less experienced surgeons: Don't assume that something provides superior fixation just because it costs more. No surgeon wants to encounter a problem, so there may be a temptation to hedge your bets by opting for the "best" (read: most expensive) option. But chances are that once you've gotten a good result with a certain device or technique, you'll never want to change. That's why you may want to develop proficiency in multiple modes of fixation, including those that can help you keep costs down without compromising patient safety. A high-end biologic mesh could easily double your case costs, compared with a synthetic polypropylene mesh, so you have to save wherever you can in order to preserve your profit margin. OSM

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