The British-Flag Technique of Mesh Insertion in Transabdominal Preperitonial Laparoscopic Inguinal Hernia Repair

Introduction

Imaging of early postoperative complications after mesh repair has shown “foldings” of the prosthetic mesh, leading to displacement and associated hernia recurrence. ¹

A rectangular two-dimensional mesh introduced into the abdomen and fitted into a concave three-dimensional cavity does not lie evenly and is susceptible to crumpling.

Hence, we propose to introduce a geometrically corrected mesh design that would allow easier placement and compliment the anatomic shape of the abdominal cavity.

Methods

The British-flag technique is a simple, easy-to-do method where the mesh is cut (Fig. 1), making the edges overlap to give a uniform curvature, so that the mesh sits in the space without foldings (Fig. 2). The suggested method of cutting the mesh along the lines shown in Figure 2 resembles the British flag. The choice of sides or corners to cut is based on the shape of the space created by the surgeon for the mesh. The most suitable method would be to cut 3 cm along the four corners and one horizontal side, as shown in Figure 1B.

OPEN IN VIEWER

FIG. 1.

(A) Suggested line of cuts. (B) Cuts (2–3 cm) along corners and side.

OPEN IN VIEWER

FIG. 2.

Lay of mesh before and after using British-Flag technique. (A) In vitro. (B) In vivo.

Discussion and Conclusion

Anatomically contoured mesh often requires no fixation, with minimal risk of neuropathy and less than 0.5% patient-year recurrence rate. ² In using our technique, the mesh is more uniformly seated within the cavity, with the cut edges overlapping (Fig. 2B). Our experience with 23 patients has shown that this technique results in quicker, easier mesh placement. Further, the overlapping edges add to the strength of the repair and closure of the peritoneum is not hindered by obstructing folds of mesh.