Laparoscopic incisional hernia repair in a porcine model: What do transfixion sutures add?

Background: The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh. Methods: Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean ± standard deviation. Results: The mean hernia size was 8.5 ± 0.5 cm by 5.5 ± 0.7 cm, with no difference between groups. The operative time was significantly longer (p = 0.006) for the Sutured group (62.1 ± 16.8 min) than for the Tacks group (32.3 ± 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly (p ≤ 0.05) higher adhesion score (5.4 ± 3.3) than the Tacks group (2.0 ± 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 ± 1.5 N/cm, Tacks 3.8 ± 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 ± 0.6, Tacks 0.2 ± 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 ± 0.3 mm, Tacks 3.9 ± 0.4 mm). Conclusions: In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.