Small Bowel Obstruction Following Robotic Transabdominal Preperitoneal Ventral Hernia Repair (rTAPP) Due to Barbed Suture

Barbed suture is an increasingly popular type of suture used by surgeons across the world. It is an efficient suture that provides several benefits, including better distributed tensile strength, reduced surrounding inflammatory reaction and local tissue hypoxia, and less foreign body exposure. However, there have been a handful of cases of complications with barbed sutures over the past few decades. We present a case of a patient who initially underwent an uncomplicated robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and re-presented postoperative day two with a small bowel obstruction. We demonstrate our operative findings from our return to the operating room with the identification of a barbed suture that had become caught in the mesentery, causing kinking of the bowel.

Barbed suture; V-Loc; rTAPP; robotic ventral hernia repair. 

Symptomatic umbilical hernias are one of the most common issues that general surgeons treat in their clinics daily. With technological advances, multiple surgical approaches range from primary open umbilical hernia repair, open repair with mesh, and laparoscopic intraperitoneal onlay mesh repair (IPOM), to robotic repair options. However, the surgical literature commonly debates and investigates the best repair to prevent recurrence and postoperative complications.

The development of barbed suture (Quill, V-Loc, and STRATAFIX Spiral) to close peritoneal flaps and fascial defects accelerated the adoption of minimally invasive umbilical and ventral hernia repairs as it is now more efficient to tie knots and maintain tension across a suture line.¹ However, there are a growing number of case reports describing postoperative small bowel obstructions (SBO) due to barbed sutures in the literature.^2, 3 We present a case of a patient who underwent a robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and developed an early postoperative SBO due to V-Loc suture and describe how similar complications can be prevented in the future.

We evaluated a 29-year-old healthy male with a symptomatic umbilical hernia. He presented with pain, discomfort, and an incarcerated bulge at his umbilicus but had no obstructive symptoms. He was otherwise a good operative candidate with no prior surgical history, did not use tobacco products, and had a BMI under 30. Prior to his evaluation in the general surgery clinic, he underwent a CT scan of his abdomen, which showed an umbilical hernia with a large amount of incarcerated fat and a 1.2x1.0-cm fascial defect. Given the size of the defect, we counseled him regarding his surgical options, which included an open umbilical hernia repair versus a minimally invasive repair. He ultimately decided to undergo a robotic-assisted umbilical hernia repair with mesh because of his military status and interest in getting a larger mesh overlap of the fascial defect to prevent future recurrence. The operation itself was uncomplicated, and the patient was discharged from our same-day-surgery department without issue.

The patient re-presented on postoperative day two with periumbilical pain starting about 12 hours prior to presentation. The patient additionally reported nausea, multiple episodes of non-bilious non-bloody emesis, and anorexia. He was unable to keep any food or liquids down. He was otherwise recovering well from surgery until his symptoms began. He reported having daily bowel movements up until presentation but was no longer passing flatus.

A patient presenting with a symptomatic umbilical hernia typically complains of pain near or at their umbilicus with an associated bulge at the umbilicus. A focused physical exam consists of palpation of the umbilicus to determine if a hernia is present, if the hernia is reducible, and the size of the fascial defect. It is also important to inspect for surgical scars, especially for scars from prior laparoscopic surgery with trocars near the umbilicus, because this suggests that the umbilical hernia is an incisional hernia from prior surgery. This patient reported his umbilical hernia was initially reducible, but more recently, the hernia had become incarcerated prior to his evaluation in the clinic.

On re-presentation, the patient’s surgical scars were healing as expected with overlying skin glue in place. The patient’s abdomen was distended and diffusely tender to palpation. The patient was guarding to palpation. Otherwise, his physical exam was normal.

Preoperative imaging is not required prior to an umbilical hernia repair unless there is concern for incarceration or strangulation or if the diagnosis is unclear on the physical exam. However, this patient underwent a CT scan of his abdomen prior to his evaluation in the surgery clinic, given that his hernia was incarcerated. His CT scan demonstrated a fat-containing umbilical hernia with a 1.2x1.0-cm fascial defect with no other midline hernias.

When he presented postoperatively with SBO in the emergency room, he underwent a CT scan, demonstrating SBO with a transition point just posterior to the right rectus muscle. However, there were no concerns about free air, free fluid, pneumatosis, or portal venous gas findings.

Umbilical hernias are common, and more than 25% of the population may have occult umbilical hernias identified on screening ultrasound and CT scan.^4, 5 However, the natural history of these asymptomatic hernias has yet to be studied extensively.

Umbilical hernias should be repaired if symptomatic (causing pain or discomfort), incarcerated, or strangulated. For women, elective umbilical hernia repair is typically delayed until female patients are done having children, as pregnancy can stretch the umbilical ring. Preoperative risk stratification of comorbidities is important to reduce the risk of postoperative recurrence and wound complications. Elective hernia repair should be delayed until BMI is below 30 and smoking cessation occurs 4–6 weeks before surgery.⁶

For patients who are poor surgical candidates, watchful waiting appears to be safe.⁷ In a Dutch study following 1,358 patients with incisional, epigastric, and umbilical hernias, 16% of patients with epigastric or umbilical hernias who elected to undergo watchful waiting eventually underwent elective repair, and only 4% required an emergency repair within five years of follow-up.⁸ Watchful waiting may be a better option for asymptomatic patients with significant comorbidities, tobacco users, and a BMI >30.

Primary umbilical hernias can be repaired using open, laparoscopic, or robotic approaches. Hernias are divided into small (0–2 cm), medium (2–4 cm), and large (>4 cm) based on the size of the fascial defect. An open umbilical hernia repair with mesh is recommended for small hernias with fascial defects less than 2 cm. Primary repair with suture can be considered for defects less than 1 cm, but a direct repair has a significantly higher risk of recurrence with larger defect sizes.⁷

For medium and large hernias, minimally invasive repair with the laparoscopic or robotic approach can decrease the risk of wound complications. Still, it is unclear if there is a significant reduction in hernia recurrence.⁷ The laparoscopic intraperitoneal onlay mesh (IPOM) technique is commonly used, but failure to close the fascial defect can result in seroma formation, bulging of the mesh, recurrence, and adhesions, causing a future SBO. Laparoscopic closure of the fascial defect (IPOM+) may reduce the risk of seroma formation and recurrence, but there is conflicting evidence across studies.⁹

The robotic approach solves these challenges because it is straightforward to close the fascial defect and permits mesh placement in the preperitoneal or rectorectus position. Rapid robotic platform adoption has been for these cases, and retrospective data demonstrated shorter length of stay and decreased surgical site infections compared to laparoscopic IPOM repair.¹⁰ The PROVE-IT is the only randomized study to date comparing robotic ventral hernia repair to laparoscopic IPOM.¹¹ This trial showed no significant difference in outcomes of postoperative pain, patient satisfaction, or complications 30 days after surgery, but the robotic platform required more operating time than laparoscopic IPOM, respectively (146 vs. 94 minutes, p<0.001). However, the study was handicapped by the small sample size (75 patients total), no assessment of hernia recurrence, no evaluation of postdischarge opioid consumption, and no follow-up after 30 days. The key thing to realize is that PROVE-IT compared laparoscopic IPOM+ with fascial closure versus a robotic hernia repair, and thus, we would expect similar outcomes. A randomized trial comparing open umbilical hernia repair with preperitoneal mesh placement to robotic umbilical hernia repair with preperitoneal mesh placement (Robivent Trial) is in process, and this will further clarify what is the best approach for umbilical hernias with a fascial defect greater than 2 cm.¹²

From a surgeon’s perspective, a minimally invasive repair (laparoscopic IPOM+ vs. robotic) should be strongly considered for umbilical hernias with fascial defects greater than 2 cm. The choice of technique should be driven by the surgeon’s experience and learning curve with the platforms available.

The primary indication for surgical repair for an umbilical hernia is to prevent incarceration and strangulation. The second indication is to relieve pain and discomfort associated with the hernia.

Contraindications for robotic hernia repair include the inability to tolerate general anesthesia and/or pneumoperitoneum.

We present a case of a 29-year-old healthy man with a symptomatic umbilical hernia repair who underwent a robotic transabdominal preperitoneal ventral hernia repair (rTAPP) and represented on postoperative day two with SBO. His cross-sectional imaging was concerning for SBO near the site of his surgical repair concerning a complication. Given his benign exam and hemodynamic stability, we planned to return to the operating room for exploration but we wanted to avoid disrupting the patient’s prior repair, if possible, by using a laparoscopic approach. He underwent decompression with a nasogastric tube overnight and returned to his bowel function after receiving a gastrograffin challenge within 12 hours of his re-admission. However, due to the early bowel obstruction near the operative site, the patient would likely benefit from diagnostic laparoscopy with possible lysis of adhesions to rule out a surgical complication. In the operating room, we identified the distal end of the V-Loc suture freely hanging from the anterior abdominal wall, which was adherent to the small bowel mesentery, causing an obstruction. The suture was cut to resolve the obstruction, and the patient recovered without further complications.

V-Loc suture is a commonly used barbed suture in laparoscopic surgeries by general surgeons and other specialties. It has the benefits of decreased operative time, reduced blood loss, increased tensile strength, less foreign body exposure, reduced inflammatory reaction, and reduced tissue hypoxia.¹ There is limited evidence on this specific complication; however, recent literature reviews in 2020 and 2021 present multiple documented cases of bowel obstruction due to barbed suture.^2, 3 All cases were related to exposed intraperitoneal sutures. Some cases of the exposed suture were due to a long exposed tail, and others were due to the exposed suture line. In our case, the suture had come loose in the interval period between the first case and the re-presentation. Techniques to reduce the risk of this complication include throwing two backward stitches when ending the suture to ensure it does not loosen, only using barbed suture where it will not be visibly exposed, using a different non-barbed absorbable suture for exposed areas, cutting tails short, and considering the use of an adhesion barrier device if suture exposure is inevitable.

The da Vinci XI system.

The views presented in this video and manuscript do not represent the views of the U.S. Army, Department of Defense, or Tripler Army Medical Center.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.