Absorba tack

A balloon-equipped trocar (Spacemaker Plus; Covidien, Mansfield, MA) was inserted into the preperitoneal space through a small infraumbilical incision and the balloon was inflated for 2 min to allow blunt dissection of the preperitoneal space. After deflating the balloon, pneumoperitoneum was created and maintained at 8 mmHg. Additional 2 ports were inserted in the midline of the lower abdomen, following which the preperitoneal space was dissected and the hernia sac was explored laparoscopically. In indirect inguinal hernia, the hernia sac was dissected from the spermatic sheath and divided after the ligation, whereas in direct inguinal hernia, the hernia sac was reduced immediately after the balloon dissection. The myopectineal orifice was repaired with inlay mesh that was secured with absorbable tacks (Absorba Tack; Covidien).

The meshes were first applied without fixation in both models. In further tests, the meshes were fixed with eight staples (Absorbatack®, Covidien Deutschland, Neustadt a. D., Germany).

Preoperative antibiotic administration was performed to only the strangulated cases. All surgeries were undertaken through three ports using a rigid endoscope (30°) under general anesthesia. A urinary catheter was used only when required. Abdominal CO₂ pressure was established as 10 mmHg during the procedure. We dissected the preperitoneal layer using the Sandwich approach, because it is feasible for patients with prominent adhesion and is able to be safely performed by young surgeons [2 (link)]. We dissected all the hernia sac and did not retract the transversalis fascia. We used two types of mesh: L size 3DMax mesh (Bard, Cranston, RI) and M size Parietex anatomical mesh (Covidien, Mansfield, MA). In strangulated hernias, the same mesh was also used after evaluation as a clean operation. All mesh was fixed with AbsorbaTack (5-mm fixation device; Covidien) at least on the Cooper's ligament and transverse abdominal muscle. After fixation with mesh, we added dissection if needed to reduce the redundant organ incision and the operation time. The peritoneal flap was closed with 3-0 Vicryl in all cases. All surgeries were performed by surgical residents with 3–5 years of experience, and who were supervised by an experienced doctor who also operated as a scopist.