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Topic:Suture

Sutures are medical devices used to close wounds or surgical incisions in horses. They are typically made from materials such as nylon, polypropylene, or absorbable polymers and are selected based on the specific requirements of the wound or procedure. Sutures serve to approximate tissue edges, promote healing, and reduce the risk of infection. In equine medicine, the choice of suture material, technique, and pattern can significantly affect the healing process and the outcome of surgical interventions. This page compiles peer-reviewed research studies and scholarly articles that examine the types, applications, and outcomes of suture use in equine veterinary practice.
In vitro mechanical testing of braided polyurethane elastic fiber and braided polyester for equine laryngoplasty.
Veterinary surgery : VS    June 5, 2014   Volume 44, Issue 2 223-230 doi: 10.1111/j.1532-950X.2014.12184.x
Willsallen H, Heller J, Kark L, Hilbert BJ.In vitro comparison of the mechanical properties of braided polyurethane elastomer (Lycra®) and braided polyester (Ethibond™) (1) when inserted into the muscular process of the arytenoid cartilage and (2) as suture loops. Methods: Experimental. Methods: Equine cadaver larynges (n = 15). Methods: The muscular processes (n = 30) of the arytenoid cartilages were dissected from each larynx and embedded in a resin base. Lycra® and Ethibond™ prostheses were randomly allocated to the left or right muscular process and each underwent cyclic fatigue (25-50 N) followed by load-to-failure...
Mechanical properties of various suture materials and placement patterns tested with surrogate in vitro model constructs simulating laryngeal advancement tie-forward procedures in horses.
American journal of veterinary research    April 26, 2014   Volume 75, Issue 5 500-506 doi: 10.2460/ajvr.75.5.500
Santos MP, Gutierrez-Nibeyro SD, Horn GP, Johnson AJ, Stewart MC, Schaeffer DJ.To compare the mechanical properties of laryngeal tie-forward (LTF) surrogate constructs prepared with steel fixtures and No. 5 braided polyester or braided polyethylene by use of a standard or a modified suture placement technique. Methods: 32 LTF surrogate constructs. Methods: Surrogate constructs were prepared with steel fixtures and sutures (polyester or polyethylene) by use of a standard or modified suture placement technique. Constructs underwent single-load-to-failure testing. Maximal load at failure, elongation at failure, stiffness, and suture breakage sites were compared among constr...
Biomechanical testing of a novel tendon implant device for the repair of equine flexor tendon lacerations.
Veterinary surgery : VS    April 5, 2014   Volume 43, Issue 6 685-690 doi: 10.1111/j.1532-950X.2014.12181.x
Barrett EJ, Munsterman AS, Hanson RR, Jackson RL.To compare in vitro strength and failure characteristics of a tendon implant against a 3 loop pulley suture pattern for equine superficial digital flexor tendon (SDFT) laceration repair. Methods: Experimental. Methods: Cadaveric equine forelimb SDFT (n = 16). Methods: One tendon of each of 8 pair of SDFT was randomly selected for repair with either the 3-loop pulley (3LP) suture pattern using 2 polydioxanone or with 4 stainless steel suture and anchor implants (SA). Ultimate load to failure, mode of failure, gap at failure, and load to 2 mm gap were obtained using a materials testing sys...
Ex vivo evaluation of 7 polydioxanone for closure of equine ventral midline celiotomies. Anderson SL, Bracamonte JL, Hendrick S.The objective of this study was to compare the bursting strength (BS) and mode of failure (MF) of ventral midline (VM) celiotomies closed with USP 7 polydioxanone (7PD) in 1 or 2 simple continuous sections. A bursting strength model, consisting of inserting and inflating a 200-L polyurethane bladder through a 25-cm VM celiotomy, was used on 15 fresh equine cadavers. Celiotomies were closed using 7PD in 2 separate sections (4 knots), 2 continuous sections (3 knots), or a single section (2 knots) using a simple continuous pattern. The horses' signalment, body weight, number of total knots, MF, a...
Evaluation of the effect of onlay mesenteric flaps on end-to-end jejunojejunostomy healing in horses.
Veterinary surgery : VS    April 1, 2014   Volume 43, Issue 4 479-486 doi: 10.1111/j.1532-950X.2014.12120.x
Aristizabal FA, Lopes MA, Silva A, Avanza MF, Nieto JE.To evaluate the effect of onlay mesenteric flaps (MFs) with end-to-end jejunojejunostomy on stomal diameter, length of jejunum with reduced stomal diameter, abdominal adhesion formation, and healing. Methods: Experimental study. Methods: Healthy adult horses (n = 6). Methods: Two hand sewn end-to-end jejunal anastomoses using a 1 layer simple continuous serosubmucosal suture pattern were performed in each horse ∼ 2 and 5 m oral to the ileocecal fold. Using a random design for selection anastomosis location (oral or aboral), 1 anastomosis was covered with 2 adjacent onlay MFs secured with int...
In vitro comparison of V-Loc™ versus Biosyn™ in a one-layer end-to-end anastomosis of equine jejunum.
Veterinary surgery : VS    November 20, 2013   Volume 43, Issue 1 80-84 doi: 10.1111/j.1532-950X.2013.12081.x
Nelson BB, Hassel DM.To compare a unidirectional barbed suture (V-Loc™) to its suture material equivalent (Biosyn™) in a single-layer end-to-end anastomosis of equine jejunum. Methods: Experimental in vitro study. Methods: Jejunal sections from adult horses (n = 5) without gastrointestinal disease. Methods: Jejunal end-to-end anastomoses (n = 9) were performed for each group (V-Loc™, Biosyn™) with a continuous Lembert pattern with an interruption every 120°. Anastomosis construction time, luminal diameter, and number of suture bites were recorded. Anastomosis constructs were distended with fluid at 1 L/mi...
Elasticity and breaking strength of synthetic suture materials incubated in various equine physiological and pathological solutions.
Equine veterinary journal    November 20, 2013   Volume 46, Issue 4 494-498 doi: 10.1111/evj.12181
Kearney CM, Buckley CT, Jenner F, Moissonnier P, Brama PA.Selection of suture material in equine surgery is often based on costs or subjective factors, such as the surgeon's personal experience, rather than objective facts. The amount of objective data available on durability of suture materials with regard to specific equine physiological conditions is limited. Objective: To evaluate the effect of various equine physiological and pathological fluids on the rate of degradation of a number of commonly used suture materials. Methods: In vitro material testing. Methods: Suture materials were exposed in vitro to physiological fluid, followed by biomechan...
The influence of suture pattern on the incidence of incisional drainage following exploratory laparotomy.
Equine veterinary journal    July 8, 2013   Volume 46, Issue 2 156-160 doi: 10.1111/evj.12091
Colbath AC, Patipa L, Berghaus RD, Parks AH.Incisional complications following exploratory celiotomy increase morbidity, extend hospitalisation and increase cost. Retrospective studies seek to identify risk factors and measures for prevention of surgical site infection. The relatively high incidence of incisional complications following exploratory laparotomy necessitates identification of ideal surgical closure methods. Objective: The study sought to identify the incidence of incisional drainage within our hospital population, and to identify risk factors for incisional complications while determining surgical practices that reduce the...
Thoracoscopic diaphragmatic hernia repair in a warmblood mare.
Veterinary surgery : VS    April 25, 2013   Volume 42, Issue 5 591-594 doi: 10.1111/j.1532-950X.2013.12009.x
Röcken M, Mosel G, Barske K, Witte TS.To describe successful repair of a diaphragmatic hernia in a standing sedated horse using a minimally invasive thoracoscopic technique. Methods: Clinical report. Methods: Warmblood mare with a diaphragmatic hernia. Results: An 18-year-old Warmblood mare with severe colic was referred for surgical treatment of small intestinal strangulation in a diaphragmatic defect. Twelve days after initial conventional colic surgery, left-sided laparoscopy in the standing sedated mare for diaphragmatic herniorrhaphy failed because the spleen obscured the hernia. One week later, a left-sided thoracoscopy was ...
Ex vivo comparison of 7 polydioxanone, 2 polyglactin 910 for closure of ventral median celiotomy in horses.
Veterinary surgery : VS    February 22, 2013   Volume 42, Issue 4 463-467 doi: 10.1111/j.1532-950X.2013.12002.x
Anderson SL, Bracamonte JL, Hendrick S, Carmalt JL, Wilson DG.To compare bursting strength and failure mode between ventral median celiotomies closed with USP 7 braided polydioxanone (7PD) or USP 2 polyglactin 910 (2PG). Methods: Ex vivo experimental. Methods: Equine cadavers (n = 10). Methods: A 25 cm ventral median celiotomy was created in fresh equine cadavers. A 200 L polyurethane bladder was inserted into the abdomen. Celiotomies were closed in a simple continuous pattern with 2 sections of 7PD or 2PG. The bladder was inflated with compressed air until construct failure. The horses' signalment, body weight, suture type, failure mode (suture or abdom...
Use of a barbed suture for laparoscopic closure of the internal inguinal rings in a horse.
Journal of the American Veterinary Medical Association    January 2, 2013   Volume 242, Issue 2 249-253 doi: 10.2460/javma.242.2.249
Ragle CA, Yiannikouris S, Tibary AA, Fransson BA.A 4-year-old castrated Arabian horse was evaluated for a history of a right-sided nonstrangulating inguinal hernia that was manually reducable. Results: Physical examination revealed a right-sided hydrocele and bilateral enlargement of the inguinal rings detectable by both external digital and rectal palpation. Results: Biportal laparoscopic internal inguinal ring closure was performed with a continuous suture line of unidirectional barbed suture applied with a mechanical suturing instrument. The barbed suture contributed to a secure closure with the added benefit of not requiring knots to be ...
In vitro mechanical testing of an alternate laryngoplasty system (ALPS) for horses.
Veterinary surgery : VS    December 4, 2012   Volume 41, Issue 8 918-923 doi: 10.1111/j.1532-950X.2012.01061.x
Ahern BJ, Boston RC, Parente EJ.Mechanical evaluation of a novel alternate laryngoplasty system (ALPS). Methods: Experimental. Methods: Cadaveric horse larynges (n = 10). Methods: Arytenoid and cricoid cartilages were embedded for testing. A novel laryngoplasty system consisting of a metallic anchor, 2 stands of #2 suture material, and a metallic button were evaluated. A traditional laryngoplasty using a single strand of #5 Ethibond was evaluated in parallel. Constructs were evaluated in cyclic testing oscillating from 30 to 50 N for 3600 cycles. Constructs subsequently underwent a single cycle to failure. Distraction during...
A modified laryngeal tie-forward procedure using metallic implants for treatment of dorsal displacement of the soft palate in horses.
Veterinary surgery : VS    July 23, 2012   Volume 41, Issue 6 685-688 doi: 10.1111/j.1532-950X.2012.01001.x
Rossignol F, Ouachée E, Boening KJ.To describe a modified laryngeal tie-forward procedure (LTFP) using metallic implants. Methods: Retrospective case series. Methods: Twenty-seven horses (including 24 race horses) with dorsal displacement of the soft palate (DDSP) or palatal instability (PI) diagnosed using high-speed treadmill endoscopy (n = 15), history and resting examination (n = 8), or dynamic endoscopy over ground (n = 4). Methods: All horses underwent the modified LTFP. Modifications of the surgical procedure consisted in the use of 3 metallic stents called Suture Button(TM) through which the sutures are threaded and in ...
An ex vivo model for suture-less amniotic membrane transplantation with a chemically defined bioadhesive.
Current eye research    March 29, 2012   Volume 37, Issue 5 372-380 doi: 10.3109/02713683.2012.663853
Tsujita H, Brennan AB, Plummer CE, Nakajima N, Hyon SH, Barrie KP, Sapp B, Jackson D, Brooks DE.Chemically defined bioadhesives (CDB) are "two-component reactive adhesives" made from antibiotic food additives. They contain no animal-derived ingredients and are characterized by a high level of self-degradability, low toxicity, and strong bonding properties. Amniotic membrane (AM) transplantation is used to repair severe ocular surface disease in humans and horses. AM requires meticulous suturing to the injured cornea. The purpose of this study is to determine whether CDB can facilitate the suture-less placement and adherence of equine AM to porcine cadaver cornea. Methods: Prospective stu...
In vitro comparison of three suture techniques for anastomosis of the equine small intestine.
Equine veterinary journal. Supplement    December 7, 2011   Issue 40 46-50 doi: 10.1111/j.2042-3306.2011.00494.x
Auletta L, Lamagna F, Uccello V, Lamagna B, Pasolini MP.The equine small intestine can be affected by a variety of disorders that may require some form of bypass or anastomosis. Many suture patterns have been used in equine anastomoses to minimise post operative complications, which include leakage from the anastomosis site, stenosis and adhesions. Because of the critical condition of horses undergoing colic surgery, it is imperative this is performed as quickly as possible. Objective: To evaluate, in vitro, differences in the time of execution and leakage pressure between the Lembert single layer, Gambee and Lembert double layer suture patterns fo...
Biomechanical testing of a novel suture pattern for repair of equine tendon lacerations.
Veterinary surgery : VS    October 31, 2011   Volume 41, Issue 2 278-285 doi: 10.1111/j.1532-950X.2011.00905.x
Everett E, Barrett JG, Morelli J, DeVita R.To compare in vitro biomechanical properties of a novel suture pattern to a current standard for primary repair of equine superficial digital flexor tendon (SDFT) laceration. Methods: In vitro randomized, paired design. Methods: Cadaveric equine forelimb SDFT (n = 24). Methods: The 3-loop pulley (3LP) and 6-strand Savage (SSS) suture patterns were applied to transected equine SDFT. Ultimate failure load, stiffness, mode of failure, and load required to form a 3-mm gap were obtained using a materials testing system and synchronized high-speed video analysis. Statistical comparisons were made us...
Ex vivo comparison of three hand sewn end-to-end anastomoses in normal equine jejunum.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 76-80 doi: 10.1111/j.2042-3306.2011.00423.x
Sherlock C, Lee W, Mueller PO, Eggleston R, Epstein K.Although single layer techniques are preferred in man and small animals for small intestinal end-to-end anastomoses, double layer techniques are more popular in equine surgery. This study was undertaken to evaluate the ex vivo characteristics of 2 single layer anastomoses in comparison to the traditionally performed double layer anastomosis in equine jejunum. Objective: To compare ex vivo: 1) construction time; 2) bursting pressure; and 3) lumen size reduction of 3 suture patterns (double layer simple continuous/Cushing pattern [2C]; single layer Lembert pattern [1L]; and single layer Cushing ...
An ex vivo biomechanical study comparing strength characteristics of a new technique with the three-loop pulley for equine tenorrhaphy.
Veterinary surgery : VS    July 19, 2011   Volume 40, Issue 6 768-773 doi: 10.1111/j.1532-950X.2011.00856.x
Smith RL, Murphy DJ, Day RE, Lester GD.To test single cycle to failure tensile strength characteristics of 6 suture material-pattern combinations in equine superficial digital flexor (SDF) tenorrhaphy, specifically to compare a 10-strand modification of the Savage core suture technique with the 3-loop pulley technique. Methods: Ex vivo mechanical experiment comparing 3 different suture patterns with 2 different materials. Methods: Forelimb and hindlimb SDF tendons (n=48) harvested from adult Thoroughbred and Standardbred horses of mixed age and gender. Methods: Six suture material-pattern combinations were evaluated: (1) 10-strand ...
Technical note: a 2-stage cecal cannulation technique in standing horses.
Journal of animal science    March 18, 2011   Volume 89, Issue 8 2425-2429 doi: 10.2527/jas.2010-3718
Beard WL, Slough TL, Gunkel CD.Cecal cannulation is necessary for sampling of intestinal contents for a variety of nutritional or digestive physiology studies. This report describes a 2-stage technique for permanent cecal cannulation in standing horses. For the first procedure, a right flank laparotomy is performed and a small pouch of the cecal base exteriorized and sutured to the body wall. The second procedure is performed approximately 1 wk later. During the second procedure, the exposed cecal pouch is removed and the cannula inserted. Ten horses were cannulated using this technique. After the first procedure, 1 horse d...
Equine laryngoplasty sutures undergo increased loading during coughing and swallowing.
Veterinary surgery : VS    November 2, 2010   Volume 39, Issue 8 949-956 doi: 10.1111/j.1532-950X.2010.00742.x
Witte TH, Cheetham J, Soderholm LV, Mitchell LM, Ducharme NG.To report (1) the force required on a single laryngoplasty suture to achieve optimal abduction of the left arytenoid cartilage, (2) peak forces experienced by the suture during induced swallowing and coughing, and during 24-hour resting activity in a stall, and (3) peak forces during induced swallowing and coughing after left recurrent laryngeal nerve blockade. Methods: Experimental study. Methods: Horses (n=8). Methods: Each laryngoplasty suture was instrumented with an E-type buckle force transducer to measure the force required for optimal intraoperative left arytenoid cartilage abduction. ...
Risk factors for incisional complications after exploratory celiotomy in horses: do skin staples increase the risk?
Veterinary surgery : VS    July 20, 2010   Volume 39, Issue 5 616-620 doi: 10.1111/j.1532-950X.2009.00636.x
Torfs S, Levet T, Delesalle C, Dewulf J, Vlaminck L, Pille F, Lefere L, Martens A.To assess risk factors for celiotomy incisional infection in horses, especially the use of staples for skin closure. Methods: Case series. Methods: Horses (n=356) that had 1 exploratory celiotomy for colic and survived >2 weeks after surgery between March 1, 2004 and December 31, 2007. Methods: Incisions were classified as "normal" (no complication, only edema, serous drainage lasting <24 hours) or as "surgical site infection (SSI)" (persistent serosanguinous drainage or purulent drainage with or without positive bacterial culture). All possible risk factors, including method of skin closure (...
Difference in incisional complications following exploratory celiotomies using antibacterial-coated suture material for subcutaneous closure: Prospective randomised study in 100 horses.
Equine veterinary journal    June 9, 2010   Volume 42, Issue 4 304-309 doi: 10.1111/j.2042-3306.2009.00020.x
Bischofberger AS, Brauer T, Gugelchuk G, Klohnen A.Incisional complications are a major post operative challenge following ventral midline exploratory celiotomy for abdominal pain in horses. They lead to discomfort, prolonged hospitalisation, longer recovery times and increased cost; therefore, investigation of preventative procedures are warranted. Objective: To determine the clinical effect of antibacterial (triclosan) coated 2-0 polyglactin 910 suture material on the likelihood of incisional infections when used for closure of subcutaneous tissue following ventral midline celiotomies in horses. Methods: One hundred horses undergoing explora...
Mechanical evaluation of the equine laryngoplasty.
Veterinary surgery : VS    April 29, 2010   Volume 39, Issue 6 661-666 doi: 10.1111/j.1532-950X.2010.00701.x
Ahern BJ, Parente EJ.Mechanical evaluation of the equine laryngoplasty. Methods: Experimental. Methods: Cadaveric cricoid (n=36) and arytenoid (46) cartilages. Methods: Arytenoid and cricoid cartilage specimens were embedded for testing. Suture material (2 Ethilon, 5 Ethibond, or 5 Fiberwire) was inserted simulating laryngoplasty procedures. Constructs were evaluated in single or cyclic loading. Single cycle tests recorded load at failure and stiffness. Cyclical tests recorded displacement after 10,000 cycles. ANOVA and t-tests were used (significance P<.05). Results: The arytenoid Ethibond (241.10+/-47.67 N) cons...
A non-invasive technique for standing surgical repair of urinary bladder rupture in a post-partum mare: a case report.
Irish veterinary journal    November 1, 2009   Volume 62, Issue 11 734-736 doi: 10.1186/2046-0481-62-11-734
Stephen J, Harty M, Hollis A, Yeomans J, Corley K.An 11-year-old mare presented 36 hours after foaling with a ruptured bladder. Uroperitoneum was diagnosed on ultrasound and from the creatinine concentration of the peritoneal fluid. Bladder endoscopy demonstrated tissue necrosis and a rent in the dorsocranial aspect of the bladder. Following stabilisation, including abdominal drainage and lavage, the mare was taken to standing surgery. Under continuous sedation and epidural anaesthesia, and after surgical preparation, a Balfour retractor was placed in the vagina. Using sterile lubricant and moderate force, it was possible to insert a hand int...
Suture exostosis causing obstruction in the nasolacrimal duct in three horses.
New Zealand veterinary journal    August 4, 2009   Volume 57, Issue 4 229-234 doi: 10.1080/00480169.2009.36907
Carslake HB.Three horses were presented with facial swelling and epiphora. Results: All horses had facial swellings and radiographic findings consistent with exostosis at the lacrimomaxillary suture, and ipsilateral epiphora. Positive contrast dacryocystorhinography demonstrated that the site of obstruction of the nasolacrimal duct was located where the duct traverses the lacrimomaxillary suture. Methods: Lacrimomaxillary suture exostosis. Conclusions: Lacrimomaxillary suture exostosis should be considered as a differential diagnosis in cases of epiphora in horses. Dacryocystorhinography, preferably retro...
Effect of prosthesis number and position on rima glottidis area in equine laryngeal specimens.
Veterinary surgery : VS    June 23, 2009   Volume 38, Issue 4 452-456 doi: 10.1111/j.1532-950X.2009.00525.x
Dart A, Tee E, Brennan M, Dart C, Perkins N, Chapman S, Debney S.To assess the effect of 1 or 2 laryngeal prosthetic sutures on rima glottidis areas in equine laryngeal specimens. Methods: Experimental, randomized design. Methods: Cadaveric equine larynges (n=16). Methods: Larynges were collected from 10 horses; 2 sutures each were preplaced in the right and left sides of each larynx. A dorsal suture (DS) was placed through the caudal rim of the dorsal midline of the cricoid cartilage, under the cricopharyngeus muscle and through the proximal and rostral aspect of the muscular process. A lateral suture (LS) was placed 1.5 cm lateral to the DS and through th...
In vitro model for testing novel implants for equine laryngoplasty.
Veterinary surgery : VS    January 13, 2009   Volume 37, Issue 6 588-593 doi: 10.1111/j.1532-950X.2008.00424.x
Cheetham J, Witte TH, Soderholm LV, Hermanson JW, Ducharme NG.To develop an in vitro laryngeal model to mimic airflow and pressures experienced by horses at maximal exercise with which to test laryngoplasty techniques. Methods: Randomized complete block. Methods: Cadaveric equine larynges (n=10). Methods: Equine larynges were collected at necropsy and a bilateral prosthetic laryngoplasty suture was placed with #5 Fiberwire suture to achieve bilateral maximal arytenoid abduction. Each larynx was positioned in a flow chamber and subjected to static flow and dynamic flow cycling at 2 Hz. Tracheal pressure and flow, and pressure within the flow chamber were ...
Biomechanical comparison of six suture configurations using a large diameter polyester prosthesis in the muscular process of the equine arytenoid cartilage.
Veterinary surgery : VS    January 13, 2009   Volume 37, Issue 6 580-587 doi: 10.1111/j.1532-950X.2008.00423.x
Kelly JR, Carmalt J, Hendrick S, Wilson DG, Shoemaker R.To compare biomechanical properties of 6 suture configurations using a large diameter polyester prosthesis in the muscular process (MP) of the arytenoid cartilage and to determine failure mode. Methods: Experimental study. Methods: Cadaveric equine larynges (n=121). Methods: Suture configurations (4 single, 2 double) were inserted, and then constructs were tested in a single-cycle to failure at a 100 mm/min distraction. Load deformation curves were generated to assess the biomechanical properties of each construct. A 1-way ANOVA was used to compare the mean differences in construct failure for...
Management of equine skull fractures using fixation with polydioxanone sutures.
Australian veterinary journal    December 17, 2008   Volume 86, Issue 12 481-485 doi: 10.1111/j.1751-0813.2008.00369.x
Schaaf KL, Kannegieter NJ, Lovell DK.Ten horses presented with severe distortion of the facial contour, crepitus on palpation and mild to moderate epistaxis. Individual horses also showed ocular damage, ptosis, severe dyspnoea and movement of the facial bones concurrent with respiration. The fracture fragments were exposed using a large curvilinear incision and elevated using a retractor, periosteal elevator, chisel or Steinmann pin. The fracture fragments were unstable following reduction and fixation was necessary. Stabilisation was achieved with polydioxanone sutures placed through holes drilled in opposing sides of the fractu...
Repair of abdominal wall hernias in horses using primary closure and subcutaneous implantation of mesh.
The Veterinary record    December 9, 2008   Volume 163, Issue 23 677-679 
Kelmer G, Schumacher J.Abdominal incisional hernias in over 40 horses were repaired by exposing the hernial sac and ring and closing the ring with absorbable, interrupted, inverted, cruciate sutures after inverting the hernial sac into the peritoneal cavity. A mesh was sutured, under tension, over the closed ring. Placing the mesh subcutaneously, rather than in the retroperitoneal space, simplified the dissection and minimised the likelihood of penetrating the peritoneal cavity, a problem common to techniques of hernia repair in which the mesh is implanted into the retroperitoneal space. Implanting the mesh subcutan...