Abstract
Background
Laparoscopic ventral and incisional hernia mesh repair (LVIHR) has become the standard of care due to shorter recovery time, low rate of complication and recurrence. The most common fixation technique for mesh is by tackers but results in patients having more pain in the early postoperative period. One modality to reduce pain has been to use intracorporeal conventional sutures but with the disadvantage of inherent difficulty in handling, suturing and knotting which is obviated by barbed sutures.
Methods
The study was conducted over a period of two years. Sixty patients with primary ventral and incisional hernia were randomized to either fixation of mesh with barbed sutures or to tackers with transfacial sutures. Primary end points were used to evaluate and compare mesh fixation time, early postoperative pain and complications, whereas secondary end points were used to compare the incidence of chronic pain and recurrence.
Results
Of the 60 patients, 51% had primary ventral hernia, and the rest had incisional hernia. Visual Analogue Scale (VAS) pain score for the barbed suture group at all intervals postoperatively was significantly lower than that for tackers. The mean time taken for fixation in the tacker group was significantly lower. Only one patient under the tacker group developed recurrence.
Conclusion
Barbed suture group had significantly less pain and is economical with the same rates of recurrence as compared with tackers. Hence, low pain scores, cost effectiveness and relatively easier intracorporeal suturing make barbed sutures a viable alternative for intracorporeal mesh fixation in LVIHR.
Keywords: Barbed, Ventral hernia, Tackers, Laparoscopic
Introduction
Laparoscopic Ventral and Incisional Hernia Repair (LVIHR) with a dual or composite mesh has become the standard of care in uncomplicated select patients because of low rate of complication, recurrence and shorter recovery time. Various methods have been used for the fixation of mesh in the laparoscopic repair, most commonly using tackers or a combination of tackers and transfascial sutures.1 Along with transfacial sutures at the four corners of the mesh, tackers are used for fixing the margins either singly or in a double crown (DC) method. This reduces the operative time but leads to excessive postoperative pain. Various reasons for this pain include muscle ischaemia, nerve entrapment, relative inflexibility of mesh vis a vis abdominal wall on movement etc.2,3 Intracorporeal fixation by conventional sutures obviates these reasons and can reduce the extent of pain but not preferred because of the increased operative time taken due to inherent disadvantage of handling, suturing and knotting. Barbed sutures have unidirectional or bidirectional barbs that spread pressure equally, prevent slippage and with no requirement of knots can become a viable method of mesh fixation.4
Although barbed sutures have been studied and used extensively in general surgery, urology and gynaecology,5,6 no studies have been carried out comparing tackers and barbed sutures in LVIHR. This randomized controlled pilot study was devised with an aim to study the efficacy and safety of barbed sutures versus standard fixation techniques using tackers in LVIHR in terms of postoperative pain, operative time, complications and recurrence.
Material and methods
This was a prospective randomized controlled parallel group study conducted at a tertiary care centre of the Armed Forces at Pune from July 2015 to July 2017 (with follow-up till July 2018). Ethics clearance was obtained from the Institutional Ethics Committee. The study was also registered with Clinical Trials Registry India (CTRI). Written informed consent was obtained from each subject before the conduct of the study. All the surgeries were performed at a single centre by a single surgeon.
Although there have been no earlier studies with barbed sutures as proposed in this study, a study by Kitamura et al,2 comparing transabdominal suture vs tack fixation was used with the mean pain score difference between the two fixation techniques as 0.7 with 30% expected frequency of postoperative pain. The total sample size came to 57; hence 30 patients were studied in each arm. Therefore, the study population included 60 patients of age more than 18 years with ventral or incisional hernia who underwent elective laparoscopic hernia repair. Patients with chronic cough, active abdominal infection, loss of abdominal domain and ascites were excluded from the study (Fig. 1).
Fig. 1.
Consort diagram.
Patients were randomized by block randomization taking 6 patients using computer generated random number. They were divided into the tacker or the barbed suture arm. All the surgeries were performed under general anaesthesia with prophylactic antibiotics at induction.
Operative technique
Port size and placement is as shown in Fig. 2. After entry into the abdomen, maintaining an adequate CO2 pressure of 10–12 mmHg, adhesiolysis with diathermy and scissors was carried out to ascertain the defect size. The mesh size was calculated keeping in mind an overlap of five cm. The mesh used was Intraperitoneal Onlay Mesh (IPOM) 15 × 15, 20 × 15, 20 × 20 cm size, rectangular in shape, with an overlap of 5 cm all around the defect size. To confirm the mesh size and placement, abdomen was desufflated, and mesh size was confirmed by marking over the abdomen.
Fig. 2.
Port placement.
Mesh was placed in the peritoneal cavity through the 10 mm port. Once placed, it was carefully rolled out to keep the soft/biocompatible/collagen side towards the viscera. Four points were then marked on the skin of the anterior abdominal wall surrounding the defect for passing the suture passer and taking the transfascial sutures to tack the mesh. The preplaced sutures were brought to the skin with the help of the suture passer (Fig. 3).
Fig. 3.
Transfascial sutures.
The sutures were held in traction over the anterior abdominal wall. Once the desired method of fixation was carried out (as detailed below), transfascial sutures were either tied (in Tacker method) or simply snipped and removed without knotting to avoid transfascial suturing (in Barbed suture method).
Tacker method
Absorbable 5 mm helical absorbable titanium tackers (15/30 tackers) were used at a distance of 1.5–2 cm using standard single crown (SC) or DC method. The SC method was used for a defect size <4 cm, and the DC method was used for defect size ≥4 cm. No extra ports were required for the mesh fixation all around the perimeter of the mesh.
Barbed suture method
V Loc 180 absorbable 2-0, 37 mm, ½ circle, round body, 45 cm COVIDIEN barbed suture (Wound closure device) was used. Single bite continuous suturing was carried out at 1.5–2 cm distance between bites. Simple sutures akin to the DC method were also taken in suture method. Minimum of two and in some three foils were used depending on the mesh size. The barbed suture has a loop in the end which averts the need of initial knotting, and because of barbs, a simple knot is adequate in the end (Fig. 4). Random simple sutures akin to the double crowning method were taken to prevent sag in >4 cm defects. Separate 5 mm ports as appropriate were used to fix the mesh to the blind corners and sides (Fig. 4, Fig. 5, Fig. 6, Fig. 7). The time taken for mesh fixation using sutures was recorded.
Fig. 4.
First stitch.
Fig. 5.
Threading end.
Fig. 6.
Cannula on the other side.
Fig. 7.
Fixed mesh.
Post operative care
Standard analgesia as per WHO pain ladder was followed. Injection paracetamol was given intravenously at 6–8 hour intervals for the first 24 h. Diclofenac suppository 50 mg/100 mg depending on weight was used for rescue analgesia. Oral analgesics such as tablet paracetamol and tablet tramadol were given after the first 24 h.
Follow-up
Patients were followed up for a minimum of three months and a maximum of two years depending on the time of surgery. Of 60 patients, 18 were followed up for a duration of two years (10 were in the tacker group and 8 in the suture group). Nineteen patients were followed up for a period of eighteen months (10 in the tacker group and 09 in the suture group). Ten patients were followed up for one year (04 tacker, 06 suture). Thirteen patients were followed up for six months (06 tacker, 07 suture).
Outcomes
The postoperative pain score was calculated using Visual Analogue Scale (VAS). Patients tabulated their pain score postoperatively at 6 h, 1st postoperative day (POD), 3rd POD, at the end of two weeks, six weeks and three months on a scale of one to 100 mm with ‘one’ being the least amount of pain and 100 being the maximum. The mean VAS of both the groups was compared immediately postoperatively and three months later to compare chronic postoperative pain. The time taken for mesh fixation using barbed suture and tackers and transfascial sutures was compared. The total time taken for surgery was not compared because that depended and included the time taken for adhesiolysis. Postoperative complications such as seroma or surgical site infection (SSI) were also recorded.
Statistical method
The data were compiled, collated and analysed using softwares IBM SPSS, version 20 and Epi info 7. The results were tabulated, and appropriate statistical tests using Mann-Whitney U test (significance of VAS score), independent t paired test (time taken for mesh fixation) and chi-square test (difference in use of rescue analgesia).
Results
Patient and hernia characteristics are as shown in Table 1. Both the groups were matched with regard to age, gender, comorbidities and body mass index (BMI). The number of patients with primary ventral hernias and incisional hernias were also evenly distributed among the two groups. Maximum number of patients (24) (12 in each group) had a central defect followed by lower midline defect (10 in suture arm and 6 in tacker arm). Maximum number of patients had a defect size ranging between 2.1 and 3 cm (17 patients) followed by 1–2 cm (14 patients). Eleven patients in the tacker group and 13 patients in the suture group had defect sizes more than 4 cm (Table 1).
Table 1.
Baseline characteristics of patients & operative procedures.
| Characteristics | Surgical method |
|
|---|---|---|
| Tackers N = 30 (%) |
Sutures N = 30 (%) |
|
| Patient characteristics | ||
| Mean age (years) | 42.73 ± 7.59 | 43.63 ± 9.10 |
| Gender | ||
| Male | 18 (60.0) | 14 (46.7) |
| Female | 12 (40.0) | 16 (53.3) |
| BMI (kg/m2) | ||
| Underweight (<18.5) | 01 (3.30) | 00 (00.0) |
| Normal (18.5–24.99) | 26 (86.7) | 27 (90.0) |
| Overweight (>24.99) | 03 (10.0) | 03 (10.0) |
| Type of co-morbidity | ||
| Hypertension | 06 (20.0) | 06 (20.0) |
| Diabetes mellitus | 04 (13.3) | 04 (13.3) |
| COPD | 04 (13.3) | 02 (6.6) |
| Defect location | ||
| Central | 12 (40.0) | 12 (40.0) |
| Lower midline | 10 (33.3) | 06 (20.0) |
| Upper midline | 02 (6.60) | 03 (10.0) |
| Others | 06 (20.0) | 09 (30.0) |
| Type of hernia | ||
| Primary ventral | 15 (50.0) | 14 (46.7) |
| Incisional | 15 (50.0) | 16 (53.3) |
| Defect size (cm) | ||
| 1–3 | 16 (53.3) | 15 (50.0) |
| 3.1–6 | 14 (46.7) | 13 (43.3) |
| >6 | 00 (00.0) | 02 (6.70) |
| Operative characteristics | ||
| Priority of Surgery | ||
| Elective | 27 (90.0) | 28 (93.3) |
| Emergency | 03 (10.0) | 02 (6.70) |
| Mesh fixation time, Mean ± SD | 22.1 ± 4.1 min | 43.4 ± 11.6 min |
| Total operative time, Mean ± SD | 61.5 ± 12.2 min | 83.2 ± 21.7 min |
| Surgical Site Infection | ||
| Present | 04 (13.3) | 03 (10.0) |
| Absent | 26 (86.7) | 27 (90.0) |
BMI, body mass index.
The operative characteristics are shown in Table 1. Of a total of 60 patients, 55 patients (27 patients in the tacker group and 28 patients in suture group) underwent elective surgery, whereas 5 patients were operated as emergency cases. All the emergency cases were due to sub-acute intestinal obstruction failing conservative management. Pneumoperitoneum was created in 51 patients with veress needle, whereas in 9 patients via Hasson technique (where complicated entry was anticipated). Mesh fixation time was defined as the time taken to place the last tack or tying of the final knot in the suture group measured from the time the mesh was placed inside the abdomen. The time taken for adhesiolysis and final closure varied depending on each case. The mean mesh fixation time was higher in the suture fixation group (43.4 ± 11.6 min vs 22.1 ± 4.1 min). However, as the experience of the operating surgeon improved, the time reduced considerably for barbed suture group to a minimum of 22 min. The total mean operative time (which included time for adhesiolysis and closure) was also higher in the suture group (83.2 ± 21.7 min vs 61.5 ± 12.2 min). Four patients in the tacker group and 3 patients in the suture group had SSI. All resolved with no sequel. There were no cases of intraoperative haemorrhage, bowel injury or persistent postoperative ileus. Only one patient in the tacker group developed a recurrence.
The association of various variables in the study with the method of surgery used was assessed using independent ‘t’ test. Statistically significant association was found between the method of surgery used with the time taken to fix the mesh (p value < 0.001), indicating that the time taken for fixation of mesh is significantly less with tackers as compared with Barbed sutures. However, no statistically significant association was found between the methods of surgery and variables such as age, BMI, and defect size (Table 2).
Table 2.
Multivariate analysis 1: Association of variables with the method of surgery used.
| Variables | Surgery technique | Total frequency(N) | Mean | Standard deviation | p-value∗ |
|---|---|---|---|---|---|
| Age | Tackers | 30 | 43.63 | 9.10 | 0.679 |
| Sutures | 30 | 42.73 | 7.59 | ||
| BMI | Tackers | 30 | 22.57 | 5.92 | 0.722 |
| Sutures | 30 | 23.50 | 6.20 | ||
| Defect size | Tackers | 30 | 3.65 | 1.40 | 0.770 |
| Sutures | 30 | 3.76 | 1.66 | ||
| Time for mesh | Tackers | 30 | 22.1 | 4.1 | <0.001 |
| Sutures | 30 | 43.4 | 11.6 |
BMI, body mass index, ∗Independent ‘t’ test applied.
Pain and VAS scores
Of the 60 patients, 32 (26 patients in the tacker group and six patients in the suture group) required rescue analgesia. This was found to be statistically significant (p < 0.001) (Table 3). The mean VAS score for patients undergoing surgery by either method at 6 h after surgery was 6.33/10, whereas it was 7.53/10 and 5.13/10 for tacker and suture method, respectively. Further as the postoperative period increased, the VAS score chronologically fell and was found to be 2.13/10 and 0.40/10 for tackers and sutures method at 3 months (Table 4). The association between VAS score and the method of mesh fixation at various postoperative intervals was assessed using Mann-Whitney U test and was found to be highly significant (p < 0.001) at all periods postoperatively (Table 5).
Table 3.
Multivariate analysis 2: Association of variables with the method of surgery used.
| Variables | Technique of surgery |
p-value∗ | ||
|---|---|---|---|---|
| Tackers | Sutures | |||
| Type of surgery | Emergency | 4 | 9 | 0.209 |
| Elective | 26 | 21 | ||
| Entry technique | Hasson | 9 | 10 | 0.999 |
| Veress | 21 | 20 | ||
| SSI | Yes | 4 | 3 | 0.606 |
| No | 26 | 27 | ||
| Rescue analgesia | Yes | 26 | 6 | <0.001 |
| No | 4 | 24 | ||
| Mesh size | 10 × 10 | 4 | 6 | 0.027 |
| 10 × 15 | 12 | 18 | ||
| 15 × 15 | 14 | 4 | ||
| 20 × 15 | 0 | 2 | ||
SSI, surgical site infection, ∗Chi squared test applied.
Table 4.
Distribution of mean VAS score for postoperative pain.
| Postoperative period | Mean VAS for all patients | Mean VAS: tackers | Mean VAS: barbed sutures |
|---|---|---|---|
| At 6 h postoperative | 6.33 | 7.53 | 5.13 |
| 1st POD | 4.86 | 6.33 | 3.40 |
| 3rd POD | 4.00 | 5.40 | 2.60 |
| At 2 weeks postoperative | 2.83 | 3.73 | 1.93 |
| At 6 weeks postoperative | 2.10 | 2.93 | 1.26 |
| At 3 months | 1.27 | 2.13 | 0.40 |
POD, postoperative day.
Table 5.
Association of VAS score with methods of mesh fixation at various intervals in the postoperative period.
| Postoperative period | Surgery technique | Minimum | Maximum | Median | p-value∗ |
|---|---|---|---|---|---|
| 6 h | Tackers | 6 | 9 | 8 | <0.001 |
| Sutures | 3 | 7 | 5 | ||
| 1st POD | Tackers | 5 | 8 | 6 | <0.001 |
| Sutures | 2 | 6 | 3 | ||
| 3rd POD | Tackers | 4 | 7 | 5 | <0.001 |
| Sutures | 2 | 5 | 2 | ||
| 2 weeks | Tackers | 2 | 6 | 3 | <0.001 |
| Sutures | 1 | 5 | 2 | ||
| 6 weeks | Tackers | 1 | 5 | 3 | <0.001 |
| Sutures | 0 | 3 | 1 | ||
| 3 months | Tackers | 1 | 4 | 2 | <0.001 |
| Sutures | 0 | 1 | 0 |
POD, postoperative day, ∗Mann-Whitney U test applied.
Discussion
The most common method of mesh fixation in laparoscopic repair of ventral and incisional hernias is by fixation by tackers or by transfascial sutures (transabdominal sutures) or a combination of both. These methods have a proven record with many studies showing low incidences of recurrence over a prolonged follow-up period. However, one of the most vexatious issues with laparoscopic repair is the excessive postoperative pain which can persist for upto three months and sometimes till six months affecting quality of life.3
The main reason of pain post-LVIHR is still vague. Carbajo et al, and Bageacu et al, in their studies have found persistent severe pain due to tacks.7,8 Tackers fix the mesh to the parieties by compression and contortion of tissues.9,10 The length of the tacker depends on thickness of abdominal wall, age, gender, and BMI because the tacker should at least reach the posterior rectus sheath for adequate fixation and not be too long to reach the skin in thin individuals. Moreover, the other disadvantages of metal tacks are adhesion formation (in animal models), bowel injury (colo-cutaneous fistula), pain and ‘Tack hernia’.11 Similarly, transfascial sutures have been speculated to cause increased postoperative pain as the sutures penetrate through several layers of muscle and fascia.2 They may cause local ischaemia of the muscle7 or trap intercostal nerve fibres, causing chronic neuropathic pain.12
This cause of the pain can be negated by using only intracorporeal sutures, fixing the margins of the mesh without use of transfascial sutures or tackers. Easier said than done, this method is not preferred because of the inherent difficulty in handling, knotting and keeping the tension of the suture in place to ensure a tight and well apposed closure. Monofilament, non-braided, non-absorbable polypropylene and absorbable, monofilament polydioxanone could not be used because of long memory and continuous requirement of traction intraoperatively. Absorbable, braided polygalactic acid also did not provide adequate tension while suturing.
The requirement therefore is of a suture that would not require traction by the assistant would hold on to the previous stitch without knots and at the same time require less time to suture. Barbed sutures have the unique capabilities of fulfilling the above needs. Dr. John Alcamo was a general surgeon and is credited with the US patent for barbed sutures (unidirectional) in 1964. They are already being used in dermal closure, laparoscopic myomectomy, hysterectomy, breast augmentation, abdominoplasty, radical prostatectomy, total hip and knee replacement, and so on. Unidirectional barbs distribute tension across the wound and anchor tissue at numerous points and eliminate the need for knots.13 However, no study has been carried out to use barbed suture as an intracorporeal suture to fix the margins of the mesh in repairs of ventral hernias laparoscopically. Therefore, the aim of this pilot study was to provide an insight into the feasibility of using these sutures to assess ease of handling, operative time and effect on postoperative pain as compared with use of tackers along with transfascial sutures.
There have been a few studies comparing the main mesh fixation techniques such as absorbable trans-abdominal sutures, non-absorbable trans-abdominal sutures and tackers with primary outcomes being postoperative pain scores. Nguyen et al compared transabdominal sutures with tacks and found no significant difference in pain scores.14 Wassenaar et al, are credited with publishing the largest RCT with 199 patients and three arms namely absorbable sutures, non-absorbable sutures, and tacks (double crowned).1 No significant difference was found in the pain scores between the three arms. However, Eriksen et al published in 2009 a prospective study comparing preoperative and postoperative pain in 35 patients undergoing LVIHR using DC method and found considerable postoperative pain at the end of first month affecting general well being.3 Similar results were published by Le Blanc differentiating early and late postoperative pain15 Bansal et al, in 2012 also found transabdominal suture fixation to be more cost effective, causing less pain though taking greater time than tackers.16
In the present study, the mean VAS score for patients undergoing surgery after 6 h was 7.53/10 and 5.13/10 for tackers and sutures method respectively. Further as the postoperative period increased, the VAS score chronologically fell and was found to be 2.13/10 and 0.40/10 for tackers and sutures method respectively at 3 months. The association between VAS score and the method of mesh fixation at various postoperative intervals was assessed using Mann Whitney U test and was found to be highly significant (p < 0.001) at all periods postoperatively. This decrease in pain in the intracorporeal barbed suture arm is likely due to the avoidance of all the factors responsible for increased pain with tackers and transabdominal sutures enumerated earlier.
The time taken for mesh fixation using barbed sutures had gradually decreased over thirty patients from a maximum of 55 min–22 min (mean: 43.4 min) as experience of the surgeon increased. This was in contrast to a mean of 22.1 min for tacking which included transfascial fixation. The added time was also determined by the necessity to introduce one or two 5 mm ports on the opposite side of the abdomen to cater for the ‘blind ends’. Nevertheless, as truly stated for any laparoscopic procedure, the ease of operating after the initial few compensated for the learning curve. The total mean operative time was higher in the suture group (83.2 ± 21.7 min vs 61.5 ± 12.2 min) compared with the tacker group. This total operative time included different components of surgery such as entry in the abdomen, adhesiolysis, closure of defect, and so on and thus were not taken into consideration since these varied between patients. However, the total operative time using tackers was not significantly different from other studies. Wassenaar et al1 also reported a mean of 60.3 min for the abdominal suture group. In an earlier study in 2005, Nguyen et al, had reported 132 min for sutures and 122 min for tackers in a study with 50 patients each.14
Overall, seven patients had SSI. Four patients in the tacker group (three patients had grade I and one patient with grade II SSI) and three patients in the suture group (two with grade I and one with grade II) had SSI. All apart from one (which resulted in a recurrence) resolved with no sequelae. There was one recurrence. The patient, a 35-year-old obese women, in the tacker group developed grade II SSI. The defect was 5.5 cm midline infraumbilical for which a mesh of size 20 × 15 cm was used. Managed conservatively initially, the sinus persisted with discharge from the umbilicus for nine months. She underwent excision of the local abscesses a year later after LVIHR (Fig. 8). Intraoperatively, there were two abscesses on the right of midline, connected to each other with a sinus tract to the skin. Although she improved and mesh extraction was not required, she developed infraumbilical recurrence after 18 months. This rate of complication is comparable to many other studies in literature. Kitamura et al published a retrospective study comparing tacks versus sutures in 86 patients of umbilical hernia, where recurrence was the primary outcome. In this study, there were a total of five recurrences (three sutures, two tacks) and all the five patients were obese with the same initial defect size.2
Fig. 8.
Excision of local abscesses in the case of recurrence after laparoscopic repair with tacks.
A pack of absorbable 15 tacks/5 mm cost Rs. 20,000–25,000 and 25,000–30,000 for a pack of 30 tacks/5 mm. On the other hand, barbed sutures cost approx. Rs. 2000 per suture. A single procedure would utilize on an average two barbed sutures of 45 cm length each, which proves more economical.
Conclusion
Use of barbed sutures as a means of intracorporeal mesh fixation in ventral hernias is a viable alternative to tackers and transfascial sutures in ventral hernias. Even though the time taken for suturing in barbed sutures is relatively more as compared to tackers, it more than compensates with its low pain scores, cost-effectiveness and easy intracorporeal suturing and handling. To conclude, barbed suture group had significantly less pain and is economical with almost the same recurrence rate as tackers.
Although this pilot randomized controlled trial has shown the efficacy of this method, more studies are required with larger numbers to validate and establish the efficacy and safety of primary fixation with barbed sutures over other methods of mesh fixation.
Disclosure of competing interest
The authors have none to declare.
Acknowledgements
(a) This paper is based on Armed Forces Medical Research Committee Project No. 4645/2015 granted and funded by the office of the Directorate General Armed Forces Medical Services and Defence Research Development Organization, Government of India.
(b) The authors convey their heartfelt gratitude and acknowledge the support and cooperation from the O/o DGAFMS and also thank all the healthcare workers for their contribution towards the study.
References
- 1.Wassenaar E., Schoenmaeckers E., Raymakers J., van der Palen J., Rakic S. Mesh-fixation method and pain and quality of life after laparoscopic ventral or incisional hernia repair: a randomized trial of three fixation techniques. Surg Endosc. 2010;24(6):1296–1302. doi: 10.1007/s00464-009-0763-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kitamura R.K., Choi J., Lynn E., Divino C.M. Suture versus tack fixation of mesh in laparoscopic umbilical hernia repair. J Soc Laparoendosc Surg. 2013;17(4):560–564. doi: 10.4293/108680813X13693422520044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Eriksen J., Bisgaard T., Assaadzadeh S., Jorgensen L., Rosenberg J. Fibrin sealant for mesh fixation in laparoscopic umbilical hernia repair: 1-year results of a randomized controlled double-blinded study. Hernia. 2013;17(4):511–514. doi: 10.1007/s10029-013-1101-z. [DOI] [PubMed] [Google Scholar]
- 4.V Loc – Knotless wound closure device – clinical and economical value. http://www.medtronic.com/content/dam/covidien/library/us/en/product/wound-closure/v-loc-knotless-wound-closure-device-vac-pack.pdf.
- 5.Umranikar S.A., Ubee S.S., Selvan M., Cooke P. Barbed suture tissue closure device in urological surgery–a comprehensive review. J Clin Urol. 2017;10(5):476–484. [Google Scholar]
- 6.Greenberg J.A. The use of barbed sutures in obstetrics and gynecology. Rev Obstet Gynecol. 2010;3(3):82. [PMC free article] [PubMed] [Google Scholar]
- 7.Carbajo M., Del Olmo J.M., Blanco J., et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13(3):250–252. doi: 10.1007/s004649900956. [DOI] [PubMed] [Google Scholar]
- 8.Bageacu S., Blanc P., Breton C., et al. Laparoscopic repair of incisional hernia: a retrospective study of 159 patients. Surg Endosc. 2002;16(2):345–348. doi: 10.1007/s00464-001-0018-2. [DOI] [PubMed] [Google Scholar]
- 9.Greenstein A.J., Nguyen S.Q., Buch K.E., Chin E.H., Weber K.J., Divino C.M. Recurrence after laparoscopic ventral hernia repair: a prospective pilot study of suture versus tack fixation. Am Surg. 2008;74(3):227–231. doi: 10.1177/000313480807400310. [DOI] [PubMed] [Google Scholar]
- 10.Reynvoet E. Ghent University; 2015. Mesh Fixation Techniques in Laparoscopic Ventral Hernia Repair.https://biblio.ugent.be/publication/6868915/file/6868919 [Google Scholar]
- 11.LeBlanc K.A. Tack hernia: a new entity. J Soc Laparoendosc Surg. 2003;7(4):383. [PMC free article] [PubMed] [Google Scholar]
- 12.Heniford B.T., Park A., Ramshaw B.J., Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190(6):645–650. doi: 10.1016/s1072-7515(00)00280-5. [DOI] [PubMed] [Google Scholar]
- 13.Ahmed O., Jilani D., Funaki B., et al. Comparison of barbed versus conventional sutures for wound closure of radiologically implanted chest ports. J Vasc Intervent Radiol. 2014;25(9):1433–1438. doi: 10.1016/j.jvir.2014.04.024. [DOI] [PubMed] [Google Scholar]
- 14.Nguyen D., Szomstein S., Ordonez A., et al. Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair. Surg Endosc. 2016;30(2):764–769. doi: 10.1007/s00464-015-4275-x. [DOI] [PubMed] [Google Scholar]
- 15.LeBlanc K. Laparoscopic incisional and ventral hernia repair: complications—how to avoid and handle. Hernia. 2004;8(4):323–331. doi: 10.1007/s10029-004-0250-5. [DOI] [PubMed] [Google Scholar]
- 16.Bansal V.K., Misra M.C., Babu D., et al. Comparison of long term outcome and quality of life after laparoscopic repair of incisional and ventral hernias with suture fixation and without tacks: a prospective, randomized, controlled study. Surg Endosc. 2012;26(12):3476–3485. doi: 10.1007/s00464-012-2390-5. [DOI] [PubMed] [Google Scholar]