Optimum mesh and port sizes for laparoscopic incisional hernia repair

Since incisional hernia repair was introduced into laparoscopic surgical practice it has been recognized that larger meshes can be problematic to successfully insert through laparoscopic ports. This study aims to facilitate the choice of mesh and port by documenting the minimum port sizes realistically needed for insertion of different types and sizes of onlay mesh. It also aims to evaluate the optimal insertion techniques.

Using four specified insertion techniques--simple roll, a tight roll along the longest edge; diagonal roll, a tight roll along the longest axis; roll and bind, the optimal roll with an additional vicryl tie as binding; and unprepared, grasped by the corner, the diagonal length of the mesh is presented head-on to the port--two independent investigators attempted insertion of different sizes of four onlay meshes--DualMesh (1 mm and 1.5 mm), Surgisis Gold, and Permacol--down 10- to 18-mm Endopath and Versaport ports positioned within a sham abdomen. The maximum mesh sizes used were DualMesh, 34 x 26 cm; Surgisis Gold, 22 x 13 cm; and Permacol, 10 x 10 cm. Two types of ports were used, Endopath ports which have an integral seal and Versaport ports with a removable seal.

The largest mesh widths successfully passed down 18-, 12-, 11-, and 10-mm ports, respectively, were: DualMesh 1 mm--26, 17, 15, and 13 cm; Surgisis Gold--13, 13, 13, and 10 cm; DualMesh 1.5 mm--26, 15, 12, and 9 cm; and Permacol--10, 10, 10, and 7 cm. The novel roll and bind insertion technique showed improved insertion than the simple roll technique alone for the biological meshes.

Small differences in mesh size and type can lead to marked changes in optimal port size. The availability of a guide such as the one produced by this study in the operating room will help surgeons to plan and select appropriate combinations of ports and meshes, potentially reducing intraoperative delays.