Ask 10 general surgeons about which mesh material is best and how it's best attached to the abdominal wall during laparoscopic hernia procedures and you'll get 10 different answers. Ask the same group of docs if advances in fixation devices, mesh designs and deployment systems help plug hernias more efficiently and you'll get more of a consensus. Here's what a few experts had to say about reducing OR times with the latest hernia-repair technologies.

Fixation options
"Nations have gone to war with less passion than manufacturers who argue about who makes the best hernia tack," says Patricia L. Turner, MD, FACS, an assistant professor of surgery at the University of Maryland School of Medicine and a general surgeon at the University of Maryland Medical Center in Baltimore.

She's only half kidding. The choices seem endless, consisting of permanent and absorbable styles that resemble staples, thumbtacks, straps, wire spirals, screws, hooked daggers and arrows. All are effective, points out Dr. Turner, who says like most anything else, surgeons often set their preferences based on experience and training.

She currently uses absorbable tacks, after making the switch from permanent titanium models. Both styles work well, but if the tacks aren't needed beyond 6 months post-op, why risk avoidable complications? "The strength of the repair is where the mesh grows into the abdominal wall," explains Dr. Turner, who didn't see a jump in hernia recurrence rates after switching to absorbable fasteners. "The tacks just hold it in place while it grows." She prefers screw-style fixation devices, believing the beveled heads result in more secure mesh placement.

What happens if a tack isn't placed exactly where a surgeon wants or needs it? Can it be moved quickly so cases keep progressing smoothly? Surgeons must also consider how easily tacks are removed and replaced. "Those are the little things I worry about," admits Dr. Turner.

Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Medical Group in Memphis and past president of the American Hernia Association, uses fixation fibrin glue to keep meshes in place, an option that does away with the need for mechanical tacking. He says multiple clinical trials have shown glue to be just as effective as tacks for securing mesh.

Some surgeons opt to use no fixation at all, which is very efficient but could lead to hernia recurrence problems (see "Does Applying Mesh Without Fixation Save Time?"). "Studies show that mesh migrates and can protrude through holes," he explains, adding that the efficacy of repairing hernias without tacks or glue is likely limited to defects smaller than 2cm in diameter.

Dr. Turner is a self-described "minimalist tacker." Her wide dissection at the hernia site lets her place hernia mesh right where she wants to and requires only 2 tacks to secure it. But Robert Baxt, MD, a general surgeon specializing in hernia repair and abdominal wall reconstruction in Reisterstown, Md., says most surgeons place tacks every 2 or 3cm along a mesh's edge and some add more around the hernia site. "If you're working on a 5cm defect, that's a lot of tacks," he explains. Newer stapling devices have the capacity to fire more fasteners than previous designs, letting surgeons secure mesh without having to exchange instruments and disrupt case flow. Dr. Baxt also points to scalpels that employ ultrasonic energy to cut and coagulate, which let surgeons grab and dissect tissue around the defect without exchanging instruments.

Switching instruments mid-procedure breaks a surgeon's concentration and forces him to refocus and recalibrate once a freshly loaded applicator or tissue grasper is slid back into the abdomen, says Dr. Baxt. Those precious seconds wasted during instrument exchanges add up, leading to longer, less efficient cases.

Dr. Turner finds it harder to fire fixation devices that place absorbable tacks. She recommends surgeons assess which type of device works best for them. Spring-loaded? Pneumatically powered? How much force is needed to fire it and at what angle is it applied? Dr. Turner admits that she's broken her fair share of handpeices trying to amp up the torque needed to fire in various positions, but would rather have devices fall apart in her hands than misfire inside the patient. Still, broken instruments don't do much for case efficiencies, so have your surgeons trial various fixation devices to determine which firing mechanism matches their approach and operating style.

Mesh materials
David Renton, MD, MPH, assistant professor of surgery at Ohio State University in Columbus, says the degree of difficulty in placing mesh depends largely on the type of hernia being repaired and the patient's medical history. Is there mesh from a previous operation already in place? Is the hernia recurrent or a relatively recent onset? Is it inguinal, umbilical or incisional? Is it within the site of a previous surgery and dissection?

Mesh material might also play a role in how easily patches are placed. Dr. Voeller says a mesh that's too stiff is difficult to maneuver around the many nooks and crannies of the preperitoneal space; a mesh that's too soft, on the other hand, is simply too difficult to manipulate and place.

All of the experts we spoke to touted specialty-designed anatomic meshes that are easier for surgeons to fit and place than meshes that need to be cut to size. "That doesn't mean you can't perform repairs with standard meshes," says Dr. Voeller. "You just have to fiddle with them a little more."

Positioning aids
Self-fixating meshes backed with a Velcro-like substance are easy to place, says Dr. Voeller, but not so easy to shift once they're set in position. For that reason he's involved in the development of a mesh deployment system for inguinal hernias that will let surgeons load mesh on the end of a stick-like device, place it just so and unfold it over the defect.

Dr. Baxt shies away from using meshes that incorporate expanding rings and other similarly designed placement aids. He acknowledges that the features might improve handling of the mesh and save surgeons time in the OR, but warns against potential complications they might cause down the road: Built-in placement aids make mesh stiffer, which leads to a loss of compliance and increased risk of scar tissue developing as it grows into the abdominal wall. Patients might feel a pulling sensation when they cough or sneeze and think something has gone awry with the repair, even though nothing has. "They need to understand that their natural tissues stretch, but mesh does not," explains Dr. Baxt. "Thicker mesh doesn't help with the ultimate outcome of the procedure."

Dr. Renton prefers a macroporous, lightweight and strong mesh, but admits placing large pieces can be challenging. He saw a mesh fixation system designed for incisional hernias on display at this year's annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in San Antonio, Texas. Surgeons use a syringe to inflate the system, which holds mesh in place, then deflate and remove the system once the mesh has been secured. It's a neat concept, says Dr. Renton, but he relies more on his experience and ingenuity to solve mesh-placement challenges. After tying 4 sutures to hold mesh in place — 2 placed laterally, 1 placed superiorly and 1 placed inferiorly — Dr. Renton fires 2 to 4 tacks just inside the suture ties to tent the center of the mesh, which helps spread it out.

Economy of motion
Dr. Voeller believes all factors contributing to efficient hernia repair take a back seat to surgeon expertise. Dr. Baxt agrees, claiming efficient laparoscopic hernia repair is a skill that takes about 50 cases to develop. "You go faster, but not because you're rushing," he says. "Speed is not your goal, it's your accomplishment. As you perform more repairs, the movements become smoother and you'll get quicker." It's hardly surprising that surgeons think surgeons have the biggest impact on case times. But based on the proven efficacy of the myriad meshes and instruments currently on the market, maybe surgeon-skill does determine which devices lead to faster, safer outcomes. "The fact that we have so many products to choose from should tell you that there's no clear winner," says Dr. Turner. "If there were, we'd all be using the same thing."