1. Consultant Laparoscopic Surgeon
Laparoscopic Ventral Hernia Repair (LVHR) Endoscopic defect closure with IPOM, without any 10mm Port (P10) & Atraumatic suture fixation of mesh
Dr. Brij B. Agarwal
Consultant Laparoscopic Surgeon
Sir Ganga Ram Hospital
India

2. LVHR “Standard of Care”
Prerequisites for success
Generous overlap >3 cms
Transfascial suture fixation
Cobb Ws et al SCNA 2005
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

3. What are the concerns? Pascal’s principle Does it really help, or ?
Beutner S et al. Surg Endosc 2007
Agarwal BB (2008) JLAST
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

4. What are the concerns? Mass of the mesh
Large port needed - port site hernia (2-22%)
Infection
Open hernial orifice is counter productive
Le Blanc et al. Contemp Surg 2006
Bololo E et al. Surg Endosc 2007
Smietanski M et al (2007) Surg Endosc
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

5. What are the concerns? Transfixation using suture passer Suture hernia
Trauma to parietal wall
Suture site pain
Tip Breakage
Suture hernia
Le Blanc KA Surg Endosc 2007
Chelela et al (2007) Surg Endosc
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

6. Principles of Our Technique
Close the defect: Mayo’s repair
Decreases the mass of mesh
Myofascial continuity
Myofascial barrier between skin / mesh
Decrease dead space
Decrease seroma
Pascal’s principle respected
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

7. Principles of our Technique
Avoid 10 mm port
Mesh introduced through the hernial defect
Mesh introduced through the 10 mm trocar
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

8. Principles of Our Technique
All sutures passed using #18 spinal needles
Hence less trauma
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

9. Watch the video at: www.endosurgeon.org

10. Sutures www.endosurgeon.org
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

11. Results Total patients 37 Defects 46 Comorbidity Male 18 Female 19
Incisional 13
Recurrent 2
Comorbidity
COPD 15
DM 9
HTN 19
Hypothyroid 2
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

12. Results GA 36 Epidural 1 Mean HD length (after closure) 11.5 cms
Mean OT min
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

13. Results No technical difficulty No conversion
No bleeding / use of energy sources
No compression bandage
Only Paracetamol used as Analgesic
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

14. Results Mean follow up 12 months No significant SSP No seroma
No visible bulge
No palpable defect
No re-hospitalization
No early recurrence
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

15. Conclusion
“VOP” closure of HD reinforced by mesh introduced through HD and fixed transfasciallly using spinal needle technique is scientifically appealing
A larger series is required to further evaluate it
Agarwal BB et al, SAGES 2007
Agarwal BB et al, EAES 2007
Agarwal BB et al, ELSA 2007
Agarwal BB et al, JLAST 2008
Agarwal BB et al. Surg Endosc Apr;23(4):900-5.
Agarwal BB et al. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9.

16. Questions or Comments? Thankyou for your kind attention.
Watch the video at:
Thank you Pooja, Krishna Adit & Nayan