1. Brij B. Agarwal Presenter Disclosure Slide
I am standing here because of sponsorship by
Elder Pharmaceuticals Ltd.

2. Endoscopic Repair of Abdominal Wall Hernias
Brij B. Agarwal
Consultant Laparoscopic Surgeon
Sir Ganga Ram Hospital , India

3. Endoscopic Repair of Abdominal wall Hernias
Principles of successful repair
Posterior repair- Stoppa’s principle
Tension free reconstruction of the weak part
Mesh / prosthesis, a must to achieve this
Either primary or mesh
Or suture repair reinforced with mesh
Agarwal BB, 2010 (World Congress, Washington)
Agarwal BB, 2009 (European Congress, Parague)
Agarwal BB, 2008 (World Congress, Japan)
Agarwal BB, 2008 (USA Congress, Philadelphia)
Agarwal BB, 2007 (European Congress, Greece
Agarwal BB, 2007 (USA Congress, Las Vegas)
Agarwal BB, 2006 (Asia Pacific, Korea)
Agarwal BB, 2006 (World Congress, Berlin)

4. Essential qualities of Mesh
Should excite an inflammatory response for fibrotic plate
Inflammatory response should stop after plate formation
Should be biologically inert
Should not disturb the tissue compliance
Should leave no foreign body sensation
Agarwal BB, 2010 (World Congress, Washington)
Agarwal BB, 2009 (European Congress, Parague)
Agarwal BB, 2008 (World Congress, Japan)
Agarwal BB, 2008 (USA Congress, Philadelphia)
Agarwal BB, 2007 (European Congress, Greece
Agarwal BB, 2007 (USA Congress, Las Vegas)
Agarwal BB, 2006 (Asia Pacific, Korea)
Agarwal BB, 2006 (World Congress, Berlin)

5. Concerns with Mesh / Prosthesis
None are absolutely bio-inert
Inflammation may lead to adhesions
Causing intestinal obstruction / vas obstruction / fistula / infertility etc
May restrict the tissue compliance and muscle mobility
Cause chronic pain / inguinodynia
Agarwal BB, 2010 (World Congress, Washington)
Agarwal BB, 2009 (European Congress, Parague)
Agarwal BB, 2008 (World Congress, Japan)
Agarwal BB, 2008 (USA Congress, Philadelphia)
Agarwal BB, 2007 (European Congress, Greece
Agarwal BB, 2007 (USA Congress, Las Vegas)
Agarwal BB, 2006 (Asia Pacific, Korea)
Agarwal BB, 2006 (World Congress, Berlin)

6. Indices of mesh Qualities of mesh depend upon Fabric of mesh
Design of mesh
Architecture of mesh
Agarwal BB, Agarwal KA, Sahu T, Mahajan KC. Int J Surg Oct 22. [Epub ahead of print]PMID:
Agarwal BB. Surg Endosc Jul;23(7):
Agarwal BB, Agarwal KA, Mahajan KC. urg Endosc Feb;23(2):242-7
Agarwal BB, Agarwal S, Mahajan KC. Surg Endosc Apr;23(4):900-5.

7. So what is the solution ? Traditional mesh – Polypropylene
Make lighter meshes ; apply adequately large / small mesh
Make meshes with bigger pore sizes
Dual surface meshes
Nano particle coated meshes i.e. titanium mesh
Agarwal BB, 2010 (World Congress, Washington)
Agarwal BB, 2009 (European Congress, Parague)
Agarwal BB, 2008 (World Congress, Japan)
Agarwal BB, 2008 (USA Congress, Philadelphia)
Agarwal BB, 2007 (European Congress, Greece
Agarwal BB, 2007 (USA Congress, Las Vegas)
Agarwal BB, 2006 (Asia Pacific, Korea)
Agarwal BB, 2006 (World Congress, Berlin)

8. Size does matter
Mesh should overlap the repair by at least 3 cm and >5 cm of BMI >30
Should be properly centered
Should stay in place ??Pascal’s principle
Agarwal BB, 2010 (World Congress, Washington)
Agarwal BB, 2009 (European Congress, Parague)
Agarwal BB, 2008 (World Congress, Japan)
Agarwal BB, 2008 (USA Congress, Philadelphia)
Agarwal BB, 2007 (European Congress, Greece
Agarwal BB, 2007 (USA Congress, Las Vegas)
Agarwal BB, 2006 (Asia Pacific, Korea)
Agarwal BB, 2006 (World Congress, Berlin)

9. What are the concerns? Pascal’s principle Does it really help, or ?
Beutner S et al. Surg Endosc 2007
Agarwal BB (2008) JLAST

12. Based upon my international Publications / Presentations
Agarwal BB. Journey of Carbon literate and climate conscious endosurgeon having Head, Heart, Hands & Holistic sense of responsibility. Surg Endosc 2008;22(12):
Agarwal BB. Laparoscopic Surgeon and Basics of Technology- Is There a Need to Revisit the Classrooms? JIMSA 2007;20(3) 183.
Agarwal BB. Inguinal hernia repair – Challenges beyond zero recurrence. Saudi J Gastroenterol Jan-Mar;16(1):1-2.
Agarwal BB. Women in surgery- From kitchen to clinic. Arch Surg. (Ahead of Publication)
Agarwal BB. Use of ultrasonic shears in thyroidectomy – a note of caution. ANZ J Surg. (Ahead of Publication)
Agarwal BB, Agarwal KA, Sahu T, Mahajan KC.Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy. Int J Surg Oct 22. [Epub ahead of print]PMID:
Agarwal BB, Sharma S. Geek-speak on "peek port": hybridizing a hybrid technique not Geeks peak. Surg Endosc Jan;24(1): PMID:
Agarwal BB. Umbilicus, navel, belly button-Vitruvian guide for esthetic cosmetics: a Da Vinci code for beautiful informed consent. Surg Endosc Jan;24(1): PMID:
Agarwal BB. Patient safety in laparoscopic cholecystectomy. Arch Surg Oct;144(10):979; author reply 979. PMID:
Agarwal BB. Letter 3: Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients (Br J Surg 2009; 96: ). Br J Surg Oct;96(10):1225. PMID:
Agarwal BB, Mahajan KC. Laparoscopic biliary tract injury prevention: zero tolerance, error free performance. Surg Endosc Jul 25. [Epub ahead of print] PMID:

13. Based upon my international Publications / Presentations
Agarwal BB, Sarangi R, Mahajan KC. Outcomes with thyroidectomy: what are they?-patient-reported voice quality, not merely nerve preservation. Surg Endosc Jul 25. [Epub ahead of print] PMID:
Agarwal BB, Mahajan KC. Nomenclature of abbreviated acronyms (Naa...)-caveamus surgeones. Surg Endosc Jul 16. [Epub ahead of print] PMID:
Agarwal BB, Agarwal S. Recurrent laryngeal nerve, phonation and voice preservation-energy devices in thyroid surgery-a note of caution. Langenbecks Arch Surg Sep;394(5):911-2; author reply
Agarwal BB, Manish K. Endoscopic varicocelectomy by extraperitoneal route: a novel technique. Int J Surg Aug;7(4): Epub 2009 Jun 21.PMID:
Agarwal BB. A self-tailored hernia mesh using lightweight material: a note of caution-res ipsa loquitur. Surg Endosc Jul;23(7):
Agarwal BB. Informed consent in an era of informed socio-political landscape – a disclaimer? An empowering tool! or our Savior. Surg Endosc May;23(5):
Agarwal BB. Tattoo – a navigational tool, a lighthouse for biomolecular level precision in Surgical Endoscopy – Newton’s Apple or Eve’s. Surg Endosc May;23(5):
Agarwal BB, Agarwal KA, Mahajan KC. Prospective double blind randomized controlled study comparing heavy weight and lightweight polypropylene mesh in totally extra-peritoneal repair of inguinal hernia – early results. Surg Endosc Feb;23(2):242-7
Agarwal BB, Agarwal S, Mahajan KC. Laparoscopic Ventral Hernia Repair: Innovative Anatomical Closure, mesh insertion without 10 mm trans-myofascial port and atraumatic mesh fixation – a preliminary experience of a new technique. - Surg Endosc Apr;23(4):900-5.

14. Agarwal BB, Sinha BK, Mahajan KC
Agarwal BB, Sinha BK, Mahajan KC. Risk of communicating “TEP related infertility risk” is an opportunity and not a ‘Cinderella concern’ any more. Surg Endosc Jun;22(6):
Agarwal BB, Agarwal S, Gupta MK, Mishra A, Mahajan KC. Laparoscopic ventral hernia meshplasty with ‘Double breasted’ fascial closure of hernial defect – A new technique. J Laparoendosc Adv Surg Tech A Apr;18(2):222-9
Agarwal B, Agarwal S, Gupta M, Mahajan K. Transaxillary endoscopic excision of benign breast lumps: a new technique. Surg Endosc Feb;22(2):
Agarwal BB, Gupta MK, Agarwal S, Mahajan KC. Spontaneous rupture of iatrogenic (postinguinal herniorrhaphy) venovenous malformation managed endoscopically. J Laparoendosc Adv Surg Tech A Feb;18(1):80-3.
Agarwal BB, Agarwal S. Surgical pilgrimage - the need to avoid navigation through drains, medicine or 'medisin': our notes on NOTES. Surg Endosc Jan;22(1):271-2.
Agarwal BB, Gupta M, Agarwal S, Mahajan K. Anatomical footprint for safe laparoscopic cholecystectomy without using any energy source: a modified technique. Surg Endosc Dec;21(12):
Agarwal BB, Agarwal S. The man-machine interface, a paradox of technology. Is the black box (BB) concept an angel or a demon? Surg Endosc Sep;21(9):1680.
Agarwal BB, Gupta M, Agarwal S, Mahajan KC. Laparoscopic cholecystectomy without using any energy source. J Laparoendosc Adv Surg Tech A Jun;17(3):
Agarwal BB. Are energy sources required in laparoscopic cholecystectomy? Or should they be standby? Surg Endosc Jun;21(6):1042.
Sarin D, Agarwal BB, Rao BK. Ethics for surgeons: the role of trainees, surgical innovations and the informed consent. JIMSA 2007;20(3),

15. Agarwal BB, Agarwal S, Sinha BK, Mahajan KC
Agarwal BB, Agarwal S, Sinha BK, Mahajan KC. New inventions and innovations in Endoscopic Surgery. JIMSA ;20(3)
Agarwal BB. Electrocautery In Laparoscopic Cholecystectomy Leads To Unfavorable Outcome: Results Of A Comparative Study. JIMSA ;20(3)200-08
Mishra AK, Sood J, Agarwal BB. Fast Track Surgery: Current Concepts. JIMSA ;20(3)
 Kaur B, Gogia A, Kakar A, Byotra SP, Aggarwal BB. Large Gall Bladder Stone Causing Mid Small Bowel Obstruction with Cholecystoduodenal Fistula. J Assoc Physicians India. 2008;56:914
Agarwal BB, Mahajan KC. Effect of yoga exercises on outcome of stapled hemorrhoidectomy: results of a prospective randomized controlled study Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008, Surg Endosc (2008) 22:S150
Agarwal BB. Polypropylene mesh (PPM) or light weight mesh (LWM) in inguinal hernia surgery (TEP)- results of a prospective randomized controlled study Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008 , Surg Endosc (2008) 22:S148
 Agarwal BB, Agarwal S. Laparoscopic surgery videos as a 'visual aid' improve medical student’s learning of anatomy (MSLA): a randomized controlled study Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008 , Surg Endosc (2008) 22:S229
Agarwal BB, Agarwal S, Mahajan KC Totally extraperitoneal (TEP) bilateral varicocelectomy (BLV) – a comparative study of collateral venous channels in left and right varicocele and their accessibility by TEP route Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008 , Surg Endosc (2008) 22:S280.
Agarwal BB, Mahajan KC. Minimally traumatic suture transfixation can decrease suture site pain (SSP) and inflammation (SSI) in laparoscopic ventral hernia repair (LHVR) – a randomized controlled study Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008 , Surg Endosc (2008) 22:S276.
Agarwal BB. Outcomes in laparoscopic cholecystectomy (LS) done with or without using energy sources (ES): results of a prospective randomized controlled study Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 9–12 April 2008 , Surg Endosc (2008) 22:S224.
Agarwal BB, Gupta M, Agarwal S, Laddha A, Agarwal D, Mahajan KC. A prospective comparative study of traditional polypropylene and newer light weight meshes in totally extraperitoneal (TEP) inguinal hernia surgery. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S5

16. Agarwal BB, Gupta M, Agarwal S, Mahajan KC, Garg R, Agarwal D
 Agarwal BB, Gupta M, Agarwal S, Mahajan KC, Garg R, Agarwal D. Laparoscopic ventral hernia repair (LVHR): innovative anatomical closure, mesh insertion without 10mm transmyofascial port (P10) & atraumatic fixation. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S11
Agarwal BB, Agarwal S, Gupta M, Mahajan KC. Anatomical footprint for endoscopic varicocelectomy by extraperitoneal route (EVE) without using any energy source (ES). 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S47
Agarwal BB, Agarwal S, Gupta M, Mahajan KC, Agarwal D. Totally extraperitoneal (TEP) inguinal hernia repair without using energy sources. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S50
Agarwal S, Agarwal BB, Agarwal KA, Agarwal N, Mahajan KC, Gupta M. Redefined endoscopic vascular anatomy as applicable to laparoscopic cholecystectomy (LC) done without using energy sources (ES15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S58
Agarwal BB, Agarwal S, Gupta M, Dhamija N, Mahajan KC. Endoscopic excision (EE) of benign breast lump (BBL) using two ports. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S58
Agarwal BB, Agarwal S, Gupta M, Dhamija N, Ladha A, Mahajan KC. Cholecystogastric fistulae (CGF) myths/reality, our dissection technique avoiding use of energy sources, experience and review of literature. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S73
Agarwal BB, Gupta M, Agarwal S, Laddha A, Agarwal D, Mahajan KC Agenesis of gall bladder (AGB): a laparoscopic perspective a first such case reported with review of literature. 15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S88
Agarwal S, Agarwal BB, Gupta M, Laddha A, Mahajan KC. Injury to tributaries of middle hepatic vein (MHV), the only source of bleeding in separation of gall bladder (GB) from liver bed (LB15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July Surg Endosc (2008) 22:S89
Agarwal BB, Agarwal S, Gupta MK, Saggar VR, Mahajan KC. Endoscopic excision of fibroadenoma breast Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Las Vegas, Nevada, USA, 18–22 April Surg Endosc (2007) 21: S329.
Agarwal BB, Gupta MK, Agarwal S, Mahajan KC. Avoiding any energy source for a safe & better laparoscopic cholecystectomy 2007 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Las Vegas, Nevada, USA, 18–22 April Surg Endosc (2007) 21: S.
Agarwal BB, Agarwal S, Gupta MK, Saggar VR, Mahajan KC Laparoscopic technique of mayo’s repair for ventral hernia with meshplasty Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Las Vegas, Nevada, USA, 18–22 April Surg Endosc (2007) 21: S.
Agarwal BB, Gupta MK, Agarwal S, Mahajan KC. Varicocoelectomy by endoscopic extraperitoneal route (VEER) 2007 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Las Vegas, Nevada, USA, 18–22 April Surg Endosc (2007) 21: S.
Agarwal BB, Agarwal S, Gupta MK, Mahajan KC. Laparoscopic cholecystectomy with pure sharp dissection, without using any energy source. 10th World Congress of Endoscopic Surgery 14th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.) Berlin, Germany, 13–16 September 2006 Surg Endosc (2007) 21: S280
Agarwal BB, Agarwal S, Gupta MK, Mahajan KC. Endoscopic management of subcutaneous venovenous malformation in ileo-inguinal region following open inguinal hernia repair 10th World Congress of Endoscopic Surgery 14th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.) Berlin, Germany, 13–16 September 2006 Surg Endosc (2007)

17. Thankyou for your kind attention
Thank you Pooja, Krishna Adit & Nayan