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In the hernia illustrated, the 10-mm Hasson port for the videoscope was placed in the left lateral abdominal position. This large port site is needed for the difficult passage of the rolled up mesh through the abdominal wall. A useful technique is to pass a grasping forceps through an operating port and then out through the Hasson port (Figure 7). The port tube is removed and the rolled up mesh is grasped with the forceps (Figure 8) and drawn back into the abdomen. The mesh is unrolled and oriented with the smooth expanded PTFE surface down toward the bowel. Getting the mesh into the abdomen and unrolling it in the correct orientation can be quite tedious. The mesh is first secured with one of the preattached sutures at the four quadrants. Most surgeons begin with the 12 or 6 o'clock sutures. The four previously marked skin sites are incised with a No. 11 scalpel blade, which makes a 3-mm skin opening (Figure 9). A special suturing needle is passed perpendicularly through the abdominal wall. The needle tip is opened and one of the suture ends is grasped as it closes. The loose suture end is brought out through the abdominal wall and secured with a hemostat. A special suturing needle is passed again through the abdominal incision, but this time it is aimed to enter the abdominal space about 1 cm away from the first site. The other half of the tied suture is grasped and brought out. The suture is tied down through the skin incision, setting the knot deeply. This secures the mesh to the abdominal wall within (Figure 9). This transabdominal suturing continues with placement of the two lateral sutures and then, last, the opposite (6 o'clock) suture. In general, the mesh should be slightly loose but not wrinkled rather than precisely tight. The exposed perimeter of the mesh is now secured with an endoscopic stapling device. Spiral screws or tacks are preferred.
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These are placed 1 cm apart. It is important that the perimeter be securely attached with closely spaced tacks such that no bowel or omentum can get under the edge of the mesh. Placement of the tacks is facilitated by having the surgeon apply external counterpressure with the hand while the tacking instrument spreads out the mesh in a radial manner (Figure 11). These two actions provide a ...