Surgical Science, 2011, 2, 388-392
doi:10.4236/ss.2011.27085 Published Online September 2011 (
Copyright © 2011 SciRes. SS
A Technique of Bilateral Inguinal Hernia Repair Using
10 mm Single Port Access and Bioresorbable Composite
Mesh Fixed with Endoclose Sutures: Three Cases Reported
Wuttichai Thanapongsathorn
HRH Princess Maha Chakri S i ri nd horn Medical Center , Department of Surgery, Faculty of Medicine,
Srinakharinwirot University, Nakron-Nayok, Thailand
Received April 22, 2011; revised May 3, 2011; accept ed May 24, 2011
Purpose: To report a novel technique of laparoscopic 10 mm Single Port Access IntraPeritoneal Onlay Mesh
(SPA-IPOM) using bioresorbable composite mesh fixed with Endoclose suture (percutaneous subcutaneous
suture) in 3 cases of bilateral inguinal hernia. Methods: Laparoscopic SPA-IPOM is done through a 10 mm
trocar with one 10 mm instrument that has 5 mm optical lens and 5 mm channel for grasper. After inserting
10 mm trocar at umbilicus using semi-open technique, intraperitoneal anatomical landmark of inguinal her-
nia is identified. A 10 × 15 cm pre-tied bioresorbable composite mesh is then placed to cover hernia defect
and all three potential area of indirect, direct and femoral hernia. Using Endoclose™ needle, each pair of
pre-tied sutures is retrieved percutaneously through a needle wound and extracorporeal tied with knot in
subcutaneous space. After the upper half of mesh is sutured to the posterior surface of abdominal wall, the
lower half of mesh is fixed by hernia tacker to Symphysis Pubis, Cooper Ligament and Iliopubic tract. Re-
sults: Three men, average 48 year olds were operated by laparoscopic 10 mm SPA-IPOM for bilateral in-
guinal hernia repair using bioresorbable composite mesh. Average operative time was 36 minutes. No imme-
diate complication. All patients were discharge on the 2nd post-operative day and average 6 months follow up
has no recurrence. Conclusions: Laparoscopic SPA-IPOM is an optional operation and is much easier to be
performed. Benefits include operative time saving, cosmesis, early discharge and early return to work. Bio-
resorbable composite mesh prevents bowel adhesion, however, is much more expensive. Long term follow
up study for complications and recurrence is needed.
Keywords: 10 mm Single Port Access, IntraPeritoneal Onlay Mesh, Percutaneous Subcutaneous Suture,
Bioresorbable Composite Mesh, Bilateral Inguinal Hernia Repair
1. Introduction
Hernias occur fairly frequently and are more common in
adult males. Occasionally these can be life threatening or
more frequently simply a painful nuisance. Nonetheless,
the only true remedy is surgical repair. Over centuries
surgical techniques have evolved until the present
whereby laparoscopic approaches predominate. Several
various methodologies have been introduced [1]. We
now wish to add to this growing laparoscopic experience
and offer three cases of bilateral inguinal hernia repair.
To our knowledge, we are the first to report on utilizing a
10 mm single port access intraperitoneal onlay mesh
[SPA-IPOM] incorporating bioresorbable composite mesh
fixed with Endoclose suture (percutaneous subcutaneous
suture) in bilateral inguinal hernia repair.
2. Cases Report
A total of three Thai men average age 48 years old
[range 32 - 58] presented with symptomatic bilateral in-
guinal hernias. One was a bilateral indirect and the re-
maining 2 bilateral direct inguin al hernias. All u nd erwent
repair using the laparoscopic technique described in the
next section after informed consent was obtained.
The average operative time was 36 minutes [range 28 -
50] without any immediate complications. The patients
have to be admitted due to health in suran ce system of the
hospital and were all discharged on the 2nd post-operative
day. Follow up one week later failed to reveal seroma,
wound infection, nor evidence of gut obstruction, fistula
or pain from mesh related complication. To date [6
months] no recurrence has been noted in any of the pa-
tients and all enjoyed an excellent cosmetic result. (Fig-
ure 1)
3. Operative Technique
Laparoscopic SPA-IPOM was performed via a 10 mm
trocar with the following standard set of instruments
(Figure 2); A 10 mm gynecological instrument that has
5mm optical lens and 5mm channel for grasper, A 43 cm
length of 5mm grasper and An Endoclose™ needle.
Procedure is done under general anesthesia in the fol-
lowing sequence;
1) Inserting a standard 10 mm trocar at umbilicus us-
ing semi-open t echnique.
2) Intraperitoneal anatomical landmarks involved in
inguinal hernia repair were identified; Triangle of Doom
or Square of Doom, Symphysis pubis, Cooper ligament,
Iliopubic tract and Anterior superior iliac spine. There
was no dissection of the peritoneum.
3) Each hernia opening was strengthened with a 10 ×
15 cm pre-tied bioresorbable composite mesh (Parietex™
composite mesh). (Figure 3) Preparation of the mesh
involved placing three 2/0 vicryl sutures ~1 cm from the
superior edge. After wetting for 30 seconds with sterile
water, the mesh was rolled in cigarette fashion enabling
passage through th e 10 mm port into the perito neal space.
Unrolling the mesh allowed coverage of all 3 potential
inguinal hernia areas (indirect, direct and femoral hernia).
This form of mesh is two-sided with a bioresorbable col-
lagen side to preclude visceral organ adhesion and an-
other side to promote tissue in-growth for enhanced fixa-
tion against posterior abdomin a l wall.
4) The upper half of mesh is fixed with percutaneous
subcutaneous suture at the level of 2 cm above trans-
verses abdominis arch, medially at abdominal midline,
laterally near anterior superior iliac spine and the middle
at between the medial and lateral suture. The Endo-
close™ needle pass through abdominal wall into perito-
neal cavity under direct vision, grasp and pull out one
end of vicryl pre-tied suture outside abdominal wall, then
insert Endoclose™ needle through previous needle
wound, grasp and pull out another end of vicryl pre-tied
suture, extracorporeal tied with knot in subcutaneous
space (Figure 4). So, the upper half of mesh is fixed to
posterior abdominal wall firmly.
5) Fixation of the lower half of the mesh was done by
using hernia tacker at Symphysis pubis (medial side),
Cooper ligament (lower side), Iliopubic tract (lateral
Figure 1. Postopertive cosmetic result.
Figure 2. 10 mm gynecological instrument and Endoclose™
Figure 3. Pre-tied bioresorbable composite mesh.
Figure 4. Endoclose™ needle and extracorporeal knot ty-
Copyright © 2011 SciRes. SS
side). Care was taken not to place hernia tacker at Trian-
gle of Doom or Square of Doom.
6) Remove trocar and closure of umbilical wound.
Dress needle wounds without suture.
4. Discussion
By definition a hernia is a protrusion of an internal organ
through a tear, hole or defect in the wall of a body cavity.
Most often it is the abdominal wall which is defective
and hernias are classified anatomically with inguinal
hernias being the most prevalent. Groin hernias were
depicted as far back as 1552 BC in ancient Egyptian
writing and there are even some findings in mummies
that surgery was attempted. For many centuries the
anatomic detailing greatly improved but concrete and
feasible surgical technique lagged. Despite these impor-
tant advances in the knowledge of anatomy and the in-
troduction of anesthesia in 1846, surgery on hernias
made little progress during the first half of the nineteenth
century, as any attempt to open the inguinal canal was
followed by severe sepsis and had a near 100% recur-
rence rate of the hernia.
Traditional surgical technique used for decades did an
open approach with basic simple suture closure of the
anatomic defect without addressing or reinforcing the
surrounding thinned and weakened hernia-prone tissue
layer. These older methods of repair however were asso-
ciated with significant tension leading to poor wound
healing, suture line disruption and hernia recurrence.
This paved the way for the development of mesh repair
in a truly tension-free fashion as popularized by Lichen-
Minimally invasive surgery or Keyhole surgery utiliz-
ing laparoscopy is a pro cedure conceptualized to provide
effective standard surgical treatment inside the human
body yet decreasing access-related morbidity to abdomi-
nal wall. The potential advantages that have been re-
ported are less postoperative pain, decrease blood loss,
quicker recovery, superior cosmetic results, less surgical
trauma to unrelated organ and surrounding tissue with
decreased immunological and metabolic trauma to the
patient. In the short ~20 year history of laparoscopic
surgery we have seen an increased worldwide acceptance
and progression from multi-port (4 incisions) to single
port (one incision). Concurrent with this trend has been
improvement in equipment allowing for smaller sized
entry sites ranging from 25 mm to 2 mm port and placing
the incision wound into anatomic hidden areas for im-
proved cosmetic results. Thus leading to the terms “hid-
den scar” or “scar less surgery”.
Laparoscopic hernia surgery has many subtle varia-
tions usually reflective of the technique, anatomic ap-
proach, materials and means of fixation. A thorough
comparative review is beyond the scope of this article
but will be roughly outlined. Laparoscopic inguinal her-
nia repair technique has 3 main modifications in ap-
proach; TAPP (Trans Abdominal PrePeritoneal repair)
TEP (Totally ExtraPeritoneal repair) and IPOM (IntraP-
eritoneal Onlay Mesh repair). The type of approach se-
lected by surgeons is based on personal preference and
individual skills. For minimizing surgical trauma to ab-
dominal wall and cosmetics, some surgeon use a single
incision to perform laparoscopic inguinal hernia repair
by inserting either three separate 5 mm trocars through
one skin incision or one special trocar that has 3 - 4
channels. There are favorable published reports for both
laparoscopic Single Port Access Trans Abdominal
PrePeritoneal (SPA-TAPP) inguinal hernia repair [2-4]
and laparoscopic Single Port Access Totally ExtraPeri-
toneal (SPA-TEP) inguinal hernia repair [5-7]. SPA has
been reported successful in many various laparoscopic
- SPA-laparoscopic cholecystectomy [8]
- SPA-laparoscopic appendectomy [9]
- SPA-laparoscopic nephrectomy [10]
- SPA-laparoscopic prostatectomy [11]
- SPA-laparoscopic sigmoidectomy [12]
- SPA-laparoscopic placement of an adjustable gastric
band [13]
As mentioned the trend has been from multiple ports
to single port laparo scopic surg ery. Single port surger y is
known by a multitude of names with associated acro-
nyms. Let us clarify some further terminology for dis-
Single Incision Lapa rosco pi c Sur gery (SILS)
Single Access Laparoscopic Surgery (SALS)
Single Access Surgery (SAS)
One Port Umbilical Surgery (OPUS)
Single Port Incisionless Conventional Equipment-
utilizing Surg ery (SPICES)
Natural Orifice TransUmbilical Surgery (NOTUS)
Embryonic Natural Orifice Transluminal Endoscopic
Surgery (E-NOTES)
LaparoEndoscopi c Si n gle-si te Surgery(LESS)
All of these incorporate a single incision (10 - 25 mm)
usually at the umbilicus minimizing the number of inci-
sions and improved cosmetic results. There are three
1) One standard 10 mm port with one 10 mm instru-
ment that has 5 mm optical lens and 5 mm channel for
instrument. (10 mm SPA).
2) One special 15 - 25 mm port that has 3 - 4 channels
for 5 - 10 mm telescope and hand instruments [14].
(Special SPA: -TriPort®, R-port®, Endocone®, X-cone®,
SILS port®, Uni-X single port®, GelPort®, SITRACC
Copyright © 2011 SciRes. SS
3) Two or three 5 mm port into single incision. One
port for 5mm telescope, others port for 5 mm hand in-
struments. (SI-MPA: Single Incision-Multiple Ports Ac-
All three approaches are single incision that will give
better cosmetic results than multiple incision procedure.
However, specialized trocars are very expensive, require
more special hand instruments and demand higher skills
and trainings to perform the operation. Our technique of
10 mm SPA-IPOM using a standard trocar and gyneco-
logical instruments which are present in most operating
rooms can be performed by those surgeons who possess
standard laparoscopic surgical skills.
There are many reports using bioresorbable composite
mesh for standard incisional hernia repair [15]. Pa-
rietex™ Composite Mesh was introduced in 1999 with a
resorbable collagen barrier on one side to limit visceral
adhesion and a three-dimensional polyester knit structure
on the other to promote tissue in growth.
The assurance of mesh fixation is still a problem for
some surgeons. Olmi in 2007 [16] reported on laparo-
scopic repair of inguinal hernia using an intraperitoneal
onlay mesh (IPOM) technique fixed with fibrin glue
(Tissucol). To combat this potential problem we
strengthened the mesh fixation both by suturing to the
abdominal wall and utilizing tacker to the bony and fas-
cia parts (Symphysis pubis, Cooper ligament, Iliopubic
tract). This assured that the mesh will not displace during
postoperative activity.
Granted, that any bioresorbable composite mesh is
more expensive 3 - 5 times than prolene mesh. One must
consider overall benefit to the patient and more efficient
hospitalization costs. Laparoscopic repair incorporates
all or some of the following advantages:
1) less postope rat i ve pai n
2) decrease blood loss
3) less surgical trauma to unrelated organ and sur-
rounding tissue
4) decrease immunological and metabolic trauma to
the patient
5) strengthen all three potential inguinal hernia in
same procedure (prophylactic ro le)
6) operative time saving
7) superior cosmetic wound
8) quicker recovery and early discharge
9) early return to work
To date no report has utilized suture for mesh fixation
under one 10mm trocar SPA-IPOM technique. Our re-
port shows personal technique using 10mm-Single-Port
Access IntraPeritoneal Onlay Mesh (SPA-IPOM) tech-
nique with bioresorbable composite mesh (Parietex™
composite mesh) fixed in place with suture and hernia
5. Summary
Our experience showed that 10mm SPA-IPOM for bilat-
eral inguinal hernia repair fixed with su ture and tacker, is
an optional operation and easier to perform than TAPP or
TEP technique. But prospective randomized controlled
trial should be done for long term benefit and cost effec-
tiveness to the patient and health care system. In our ap-
proach of Laparo-Endoscopic Single Site Surgery [LESS]
and Mesh Onlay Reinforced with Endoclose suture
[MORE] perhaps the architects of modern surgery will
find like Ludwig Mies van der Rohe that “less is more”.
6. Author’s Declaration
Open Access
This article is distributed under the terms of the Creative
Commons Attribution Noncommercial License which
permits any noncommercial use, distribution and repro-
duction in any medium, provided the original author and
source are credited.
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