腹腔鏡下鼠径ヘルニア根治術（TAPP法）における再発予防のメッシュ固定の工夫—吸収性Barbed sutureを滑り止め材として使う

A novel procedure for preventing postoperative migration of mesh after transabdominal preperitoneal hernia repair

◆要旨：TAPP法におけるメッシュ固定（タッキング法）では，慢性神経疼痛予防のため背外側のタッキングが禁忌である．しかし，この部分のメッシュが逸脱し再発することもあるため，われわれは神経損傷の危険が少ない吸収性Barbed sutureを滑り止め材として使用し，背外側のメッシュのずれを予防している．この滑り止め材は吸収性Barbed sutureをバーブの方向が交互になるように2本束ねて吸収性縫合糸で両端を結紮したもので，剝離面とメッシュの間に留置して使用する．術後は腹圧によりメッシュが押さえつけられるため，この滑り止め材の使用により，メッシュと剝離面の摩擦力が高まり固定力は増す．一方，吸収性の材料を置くだけであるため，神経を障害するリスクは少ないと考えられる．これまで40例使用し，再発や慢性疼痛は経験していない．

　In laparoscopic transabdominal preperitoneal（TAPP）hernia repair, tack fixation of the mesh on the trapezoid of disaster（TD）is restricted to avoid postoperative pain. However, mesh migration in this area and recurrence after TAPP occur in some cases. Hence, we thought it was necessary to fix the mesh in this area and we created an absorbable anti-slip material, partially fixating for mesh on the TD to prevent mesh migration and to avoid postoperative pain. The anti-slip material that we created was as follows : Absorbable barbed suture was cut into a 2 cm length, and two threads were tied up opposite the barb with absorbable suture. During TAPP, the mesh was fixed with absorbable tacks into Cooper's ligament, the abdominal rectus muscle, the aponeurosis of the transverse abdominal muscle, and medial and lateral to the epigastric vessels. The mesh was then turned over, and the four anti-slip materials were arranged on the TD toward the hernia orifice. Finally, the mesh was returned, and the peritoneum was closed with a suture. We used these materials for 40 patients with inguinal hernia, and there was no postoperative chronic pain or hernia recurrence after a postoperative period of 26 months. When the mesh is pushed against the abdominal wall by intraabdominal pressure after the operation, the friction force between the mesh and the abdominal wall increases, and the mesh is securely fixed in place. On the other hand, there is little risk of neuropathic pain because the materials are just put on the tissue.